# A nurse is caring for a 65-year-old male client with a peptic ulcer who is receiving proton pump inhibitor therapy and reports new-onset dizziness and fatigue. Which assessment finding would be the priority concern requiring immediate nursing intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=540516  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a 65-year-old male client with a peptic ulcer who is receiving proton pump inhibitor therapy and reports new-onset dizziness and fatigue. Which assessment finding would be the priority concern requiring immediate nursing intervention?

## 보기

1. Client reports mild nausea after meals
2. Blood pressure reading of 128/82 mmHg
3. Sudden onset of severe abdominal pain with rigid abdomen **✔ 정답**
4. Heartburn symptoms occurring 2 hours after eating

**정답: 3**

## 해설

Sudden severe abdominal pain with rigidity indicates perforation, a life-threatening emergency requiring immediate surgical intervention. Other findings are less urgent.

## 심화 해설

Understanding the Priority Concern

This question tests your ability to recognize a surgical emergency in a patient with a known peptic ulcer. While proton pump inhibitor (PPI) therapy is a standard treatment to reduce gastric acid secretion and promote healing, it does not eliminate the risk of a life-threatening complication: perforation. The client’s new-onset dizziness and fatigue may suggest anemia from slow, chronic blood loss, but the assessment finding that demands immediate intervention is the one that signals an acute abdominal catastrophe.

Analyzing the Correct Answer: Option 3

Sudden onset of severe abdominal pain with a rigid abdomen is the classic presentation of a perforated peptic ulcer. When an ulcer erodes completely through the wall of the stomach or duodenum, gastric contents, including acid and digestive enzymes, spill into the sterile peritoneal cavity. This causes immediate, intense chemical peritonitis, which rapidly progresses to bacterial peritonitis. The physical hallmark of this condition is a “board-like” or rigid abdomen, resulting from involuntary reflex muscle guarding over the inflamed peritoneum. This is a surgical emergency requiring immediate notification of the provider, preparation for emergency surgery, and initiation of interventions like intravenous fluids, antibiotics, and nasogastric tube placement. The provided evidence supports that duodenal perforation is a life-threatening condition requiring prompt surgical repair [3]. In a prospective cohort study of patients presenting with non-traumatic abdominal pain, such acute presentations with signs of peritonitis would be categorized as a high-acuity emergency requiring immediate intervention .

Why the Other Options Are Lower Priority

-   Option 1: Client reports mild nausea after meals. Nausea is a common, non-emergent symptom associated with peptic ulcer disease and can also be a side effect of PPI therapy. While it requires nursing assessment and comfort measures, it does not indicate a life-threatening change in the client’s condition.

-   Option 2: Blood pressure reading of 128/82 mmHg. This is a normal blood pressure reading for an adult. Even in the context of the client’s reported dizziness and fatigue, a stable, normotensive reading is a reassuring sign that the client is not currently in hypovolemic shock from an acute, massive gastrointestinal bleed. It does not warrant immediate intervention over a rigid, painful abdomen.

-   Option 4: Heartburn symptoms occurring 2 hours after eating. This is a classic symptom of a peptic ulcer, often related to the buffering effect of food wearing off and acid coming into direct contact with the ulcer crater. While uncomfortable, it is an expected finding in the disease process and is not an immediate priority when compared to signs of peritonitis.

Applying the Nursing Process and Clinical Judgment

In an NCLEX-RN prioritization question, you must use a systematic approach. The ABCs (Airway, Breathing, Circulation) are not directly compromised by the perforation itself, but the condition leads to third-spacing of fluid, sepsis, and potential hypovolemic shock, which will rapidly affect circulation. More directly, the principle of Maslow’s Hierarchy of Needs places physiological integrity and safety as the highest priority. A rigid, painful abdomen is a cue for acute peritonitis, a direct threat to the client’s physiological survival. Using the “acute vs. chronic” framework, a sudden onset of severe pain is an acute change that takes precedence over chronic or expected symptoms like nausea or heartburn. The nurse’s immediate action is to stop any oral intake, assess vital signs for signs of shock (tachycardia, hypotension), and prepare the client for urgent diagnostic tests and surgical intervention [3].References (research sources)

- [3]Laparoscopic Repair of Duodenal Perforation Using the Falciform Ligament: A Cross-Sectional Study.Research articleReddy GPS, Mecheri Antony A, Venkateswaran R. (2024) · DOI: 10.7759/cureus.73576

## 임상 시나리오

Recognizing Perforated Peptic UlcerKey assessment findings and immediate nursing actions
A patient with a known peptic ulcer reporting new dizziness and fatigue may have chronic blood loss, but the priority is always assessing for an acute abdomen. The hallmark of a perforation is sudden, severe epigastric pain that rapidly becomes generalized, accompanied by a rigid, board-like abdomen.

This presentation indicates chemical peritonitis from gastric contents spilling into the peritoneal cavity. Immediate nursing actions include notifying the provider, keeping the patient NPO, initiating IV fluid resuscitation, and preparing for nasogastric tube insertion and emergency surgery.

CautionDo not rely on the absence of fever or guarding early on; rigidity is a late, critical sign. Pain medications should be withheld until a surgical evaluation is complete to avoid masking the diagnostic examination.

## 핵심 개념

- **Perforated Peptic Ulcer** — A full-thickness erosion through the gastric or duodenal wall, allowing luminal contents to spill into the peritoneal cavity, causing acute peritonitis.
- **Board-like Rigidity** — Involuntary reflex contraction of the abdominal muscles overlying an area of severe peritoneal inflammation, a classic sign of an acute abdomen.
- **Chemical Peritonitis** — Initial inflammation of the peritoneum caused by the irritation of sterile gastric acid and bile, which rapidly progresses to bacterial infection.

## 같은 주제 문제

- [A nurse is assessing a 45-year-old male client with epigastric pain. Which assessment find…](https://mymerci.kr/pages/nclex_q.php?qn_id=540487)
- [A nurse is assessing a client with suspected peptic ulcer disease. Which assessment findin…](https://mymerci.kr/pages/nclex_q.php?qn_id=540488)
- [A nurse is assessing a client with suspected peptic ulcer disease. Which assessment findin…](https://mymerci.kr/pages/nclex_q.php?qn_id=540489)
- [A nurse is conducting an emergency assessment on a 60-year-old client with a known history…](https://mymerci.kr/pages/nclex_q.php?qn_id=540512)
- [A nurse is caring for a client with a newly diagnosed peptic ulcer. Which nursing interven…](https://mymerci.kr/pages/nclex_q.php?qn_id=540513)
- [A nurse is caring for a 30-year-old client with a newly diagnosed duodenal peptic ulcer, p…](https://mymerci.kr/pages/nclex_q.php?qn_id=540514)
- [A nurse is caring for a 52-year-old female client who presents to the emergency department…](https://mymerci.kr/pages/nclex_q.php?qn_id=540515)
- [A nurse is caring for a client with a history of peptic ulcer disease who presents to the …](https://mymerci.kr/pages/nclex_q.php?qn_id=540517)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._