# A nurse is caring for a client with a history of peptic ulcer disease who presents to the emergency department with sudden onset of severe abdominal pain, rigid abdomen, and signs of shock. Which nursing action should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=177300 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with a history of peptic ulcer disease who presents to the emergency department with sudden onset of severe abdominal pain, rigid abdomen, and signs of shock. Which nursing action should be the priority? ## 보기 1. Prepare the client for surgical intervention **✔ 정답** 2. Administer prescribed analgesics for pain relief 3. Insert a nasogastric tube for gastric decompression 4. Obtain a complete set of vital signs and monitor closely **정답: 1** ## 해설 Classic signs of perforation with shock require immediate surgical preparation to prevent peritonitis and sepsis. Other actions are supportive but secondary. ## 심화 해설 Clinical Priority in Suspected Perforated Peptic Ulcer The client's presentation—sudden onset of severe abdominal pain, a rigid (board-like) abdomen, and signs of shock—is a classic triad for a perforated peptic ulcer. This is a surgical emergency. The rigid abdomen indicates peritonitis caused by the spillage of gastric or duodenal contents into the sterile peritoneal cavity. The signs of shock are a direct consequence of the massive inflammatory response and fluid shifts (third-spacing) that occur with chemical and subsequent bacterial peritonitis. In the hierarchy of nursing priorities, addressing the underlying, life-threatening cause takes precedence over all other interventions. According to the WSES guidelines, complicated peptic ulcer disease, particularly perforation, requires a time-sensitive, definitive intervention to control the source of contamination [1]. While the guidelines discuss a spectrum of management strategies, the immediate priority for a patient with generalized peritonitis and hemodynamic instability is source control, which is most commonly achieved through surgical intervention. Preparing the client for surgery is the most critical nursing action because it directly facilitates the definitive treatment that will stop the ongoing contamination and reverse the pathophysiological cascade of shock. **Analyzing the Options Based on Clinical Urgency** - **Option 1: Prepare the client for surgical intervention.** This is the correct priority. The definitive management for a perforated ulcer with generalized peritonitis is surgical repair. The nurse's role is to act as a patient advocate and coordinator, immediately initiating preoperative protocols (informed consent, IV access, fluid resuscitation as prescribed, NPO status, and notification of the surgical team). Delaying this preparation directly delays life-saving treatment [1]. - **Option 2: Administer prescribed analgesics for pain relief.** While pain management is an important nursing responsibility, it is not the priority in this acute scenario. Administering analgesics before a surgical diagnosis is confirmed can mask the abdominal examination findings, potentially delaying the diagnosis. Furthermore, pain relief does not address the source of the contamination causing the shock. - **Option 3: Insert a nasogastric tube for gastric decompression.** Gastric decompression is a key supportive measure for a perforated ulcer, as it helps reduce further spillage of gastric contents. However, this is a temporizing measure, not the definitive treatment. It is typically performed as part of the preoperative preparation or as a non-operative management strategy in select, stable patients. In a client with frank shock and a rigid abdomen, preparing for the operating room is the more urgent priority. - **Option 4: Obtain a complete set of vital signs and monitor closely.** Vital sign monitoring is a fundamental part of the assessment. However, the nurse already has critical assessment data: severe pain, rigid abdomen, and signs of shock. The assessment phase has identified a life-threatening problem. The priority now shifts to the *intervention* phase of the nursing process. Simply monitoring vital signs without acting on the clear clinical picture of a surgical abdomen would constitute a failure to escalate care appropriately. The nursing process (Assessment, Analysis, Planning, Implementation, Evaluation) guides this decision. The assessment data points unequivocally to an acute abdomen requiring surgical source control. The priority implementation is therefore to prepare the client for that definitive procedure. The WSES guidelines underscore that successful management of complicated peptic ulcer disease hinges on a multidisciplinary approach where timely recognition and intervention are paramount to reducing mortality [1]. References (research sources) - [1]Perforated and bleeding peptic ulcer: WSES guidelines.GuidelineTarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber DG, Abu-Zidan FM, Campanile FC, Di Saverio S, Baiocchi GL, Casella C, Kelly MD, Kirkpatrick AW, Leppaniemi A, Moore EE, Peitzman A, Fraga GP, Ceresoli M, Maier RV, Wani I, Pattonieri V, Perrone G, Velmahos G, Sugrue M, Sartelli M, Kluger Y, Catena F. (2020) · DOI: 10.1186/s13017-019-0283-9 ## 임상 시나리오 Perforated Peptic Ulcer: Emergency ResponseRecognizing the Surgical Triad and Nursing Priority The classic presentation of a perforated peptic ulcer involves a triad: sudden, severe abdominal pain; a rigid, board-like abdomen; and signs of shock. This indicates peritonitis from gastric contents spilling into the peritoneal cavity. The immediate priority is source control. Definitive treatment is surgical repair. The nurse's critical action is to prepare the client for the operating room, ensuring IV access, NPO status, and preoperative checklists are completed without delay. CautionDo not administer analgesics before a surgical evaluation is complete, as this can mask the abdominal exam. A nasogastric tube provides decompression but does not stop the ongoing leak. Continuous monitoring of vital signs is essential but does not replace the need for definitive intervention. ## 핵심 개념 - **Perforated Peptic Ulcer** — A life-threatening complication where an ulcer erodes through the stomach or duodenal wall, spilling contents into the peritoneal cavity. - **Peritonitis** — Inflammation of the peritoneum, often caused by bacterial or chemical contamination, presenting with a rigid, board-like abdomen. - **Third-spacing** — The shift of fluid from the vascular space into interstitial or body cavities, contributing to hypovolemia and shock. - **Source Control** — A critical principle in sepsis management involving physical measures to eliminate the focus of infection or contamination, such as surgery. - **Rigid Abdomen** — Involuntary reflex contraction of abdominal muscles over an area of peritoneal inflammation, a classic sign of peritonitis. ## 같은 주제 문제 - [A nurse is assessing a 45-year-old male client with epigastric pain. 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