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Chapter 23: Problem 32

A client presents to the emergency room with a sudden onset of abdominal pain. Nursing assessment reveals a bluish discoloration around the umbilicus. What initial action is most appropriate? A. Notify the charge nurse B. Assess the distal pulses C. Elevate the head of the bed D. Perform a complete head-to-toe assessment

Short Answer

Expert verified
Answer: The most appropriate initial action for a nurse in this scenario is to perform a complete head-to-toe assessment.

Step by step solution

01

Understand the scenario and symptoms

First, we need to understand the scenario presented to us. A client has arrived at the emergency room with sudden abdominal pain and a bluish discoloration around the umbilicus. The bluish discoloration could be a sign of various medical conditions, such as internal bleeding (e.g., Cullen's sign) or a sign of hypoxia. Identifying the most appropriate initial action is important in properly addressing the patient's needs and facilitating timely and appropriate care.
02

Evaluate option A - Notify the charge nurse

Notifying the charge nurse can be helpful in a situation where it is necessary to escalate the level of care or gather additional support from the healthcare team. However, this option may not be the most appropriate initial action, as the nurse should first assess the patient's condition and gather more information.
03

Evaluate option B - Assess the distal pulses

Assessing the distal pulses may be useful in determining if there is a vascular issue or if the patient's circulation is affected. However, this option may not be the most appropriate initial action for the specific symptoms presented.
04

Evaluate option C - Elevate the head of the bed

Elevating the head of the bed can help in cases of respiratory distress or when the patient has difficulty breathing. However, it may not be the most appropriate initial action in response to abdominal pain and bluish discoloration around the umbilicus.
05

Evaluate option D - Perform a complete head-to-toe assessment

Performing a complete head-to-toe assessment is a systematic approach to gather critical information about the patient's overall condition. This assessment enables a nurse to obtain a better understanding of the patient's condition, which would help guide subsequent actions and appropriate interventions.
06

Choose the most appropriate initial action

Given the options and the patient's symptoms — abdominal pain and bluish discoloration around the umbilicus — D. Perform a complete head-to-toe assessment is the most appropriate initial action. This assessment will allow the nurse to gather relevant information and provide adequate care based on the findings.

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