Exhibits

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Nurses' Notes

1400:

Upon admission assessment, client is lying in the fetal position. Client reports abdominal pain as a 10 on a 0 to 10 scale and radiating to right shoulder. Abdomen is distended and rigid. During assessment, client vomited moderate amount bright red emesis.

Vital Signs

1400:

Temperature 36.5° C (97.7" F)

Heart rate 120/min

Respiratory rate 20/min

Blood pressure 70/49 mm Hg

SpO2 95% room air

Rationales for Correct Findings:

• Client lying in the fetal position; This position often indicates severe abdominal pain and discomfort, signaling peritoneal irritation or acute abdomen. It helps reduce tension on the abdominal muscles, which suggests significant underlying pathology such as peritonitis or perforation.
• Abdominal pain rated 10 radiating to right shoulder: Shoulder pain, especially the right side, can be referred pain from diaphragmatic irritation caused by blood or gastric contents in the peritoneal cavity. This suggests a perforated ulcer or ruptured viscus, making it an alarming symptom requiring immediate attention.
• Abdomen distended and rigid: Abdominal rigidity and distension are classic signs of peritonitis, which may result from gastrointestinal perforation or severe intra-abdominal infection. This indicates an emergency, as the patient may require surgery to address the underlying cause.
• Vomited moderate amount bright red emesis: Bright red emesis indicates active upper gastrointestinal bleeding, which can lead to hypovolemia and shock. This finding requires prompt stabilization and diagnostic evaluation to control bleeding and prevent further deterioration.
• Heart rate 120/min: Tachycardia is an early compensatory response to hypovolemia or pain and can be a sign of shock or sepsis. It indicates the body is under stress, and immediate monitoring and intervention are essential to prevent further cardiovascular compromise.
• Blood pressure 70/49 mm Hg: Hypotension with a low systolic pressure indicates significant circulatory compromise, likely from blood loss or septic shock. This requires urgent fluid resuscitation and advanced cardiac monitoring to prevent organ failure.

Rationale for Incorrect Findings:

• Temperature 36.5° C (97.7° F): The temperature is within normal limits, and the absence of fever does not rule out serious abdominal pathology. Fever may develop later in peritonitis or infection, so normal temperature should not delay intervention but does not require immediate follow-up alone.
• Respiratory rate 20/min: This respiratory rate is within normal to mildly elevated range and may reflect mild distress but is not critical at this time. Oxygen saturation is adequate, and the patient is breathing without significant difficulty, so no urgent intervention based solely on this is needed.
• SpO2 95% room air: Oxygen saturation at 95% on room air is borderline but generally acceptable in adults without respiratory disease. It does not indicate respiratory failure and is not the priority concern in this clinical scenario.