Question

A 55-year-old female is admitted to the emergency room complaining of indigestion and back and shoulder pain. She tells the nurse that she has taken several antacids for the past two days without relief of her symptoms. Which action would be most appropriate at this time? A. Ask the client if she has a history of gastric ulcers B. Allow the client to rest undisturbed C. Take the client's vital signs and contact the physician D. Obtain a history to rule out a hiatal hernia

Short answer

Answer: Take the client's vital signs and contact the physician.

Step-by-step solution

Understanding the patient's situation

We have a 55-year-old female patient who has been experiencing indigestion, back and shoulder pain for the past two days. She has taken several antacids without relief.

Analyzing the options

We need to choose the most appropriate action at this time among the given options: A. Ask the client if she has a history of gastric ulcers B. Allow the client to rest undisturbed C. Take the client's vital signs and contact the physician D. Obtain a history to rule out a hiatal hernia

Evaluating Option A

Asking the client about a history of gastric ulcers might be relevant, but not the most immediate concern as it doesn't address the current symptoms or potential risks.

Evaluating Option B

Allowing the client to rest undisturbed may not be the most appropriate action at this time, as it doesn't address any potential causes or complications of her symptoms.

Evaluating Option C

Taking the client's vital signs and contacting the physician is a proactive approach that addresses the seriousness of the client's ongoing symptoms and ensures appropriate medical intervention in case of critical issue.

Evaluating Option D

Obtaining a history to rule out a hiatal hernia might be a useful step, but it doesn't directly address the current symptoms or offer any immediate relief or solutions.

Choosing the best option

After evaluating all the options, the most appropriate action at this time is: C. Take the client's vital signs and contact the physician

Key concepts

Nursing Assessment

The foundation of any effective nursing care begins with a thorough nursing assessment. This evaluation includes gathering comprehensive information about a patient's physical, psychological, social, and spiritual health. For the 55-year-old female patient admitted with indigestion and back and shoulder pain, a complete nursing assessment would involve a detailed health history, a physical examination, and a review of her symptoms.

During the health history, it is vital for the nurse to inquire about past medical issues, current medications, and lifestyle factors that may contribute to or aggravate her condition. While the patient's report of indigestion and persistent pain despite taking antacids could signal a variety of issues, such as gastric ulcers or even cardiac problems, what's paramount is addressing her immediate distress. Subsequently, the physical exam—which includes inspecting, palpating, percussing, and auscultating—can offer clues that may indicate the cause of the discomfort.

Emergency Patient Care

Emergency patient care demands swift and decisive actions to manage acute and potentially life-threatening situations. In the context of the 55-year-old female with unresolved indigestion and pain, emergency care protocols stipulate the importance of recognizing serious signs that could indicate a cardiac event, such as a myocardial infarction (heart attack), rather than assuming the issue is purely gastrointestinal.

Thus, even though a detailed medical history is important, the urgency of her symptoms combined with her age suggests a need for rapid assessment and intervention. The primary goal in emergency patient care is to stabilize the patient while determining the cause of their distress. In this case, taking the patient's vital signs—such as blood pressure, pulse, respiratory rate, and temperature—is crucial, as they can help detect life-threatening conditions that require immediate medical attention. Contacting the physician without delay ensures the patient is assessed and treated promptly.

Vital Signs Monitoring

Vital signs monitoring plays a critical role in assessing the health status of a patient, providing clues to possible medical conditions. Vital signs include blood pressure, heart rate, respiratory rate, and body temperature; they act as the body's fundamental health indicators. For our emergency room patient, monitoring her vital signs is a critical step not just in the initial stages, but continuously over time to detect any trends or changes in her condition.

Abnormal vital signs could suggest several health emergencies, including a cardiac event, infection, or other acute health issues. In an emergency scenario, deviations from normal ranges may warrant immediate interventions. By choosing to take the patient's vital signs and notifying the physician, the nursing staff act appropriately, ensuring that the patient receives the timely, prioritized care that her symptoms warrant.