A nurse is assisting with the care of a client in an emergency department (ED). Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Nurses' Notes Day 1,2130: Client presents to ED with reports of abdominal distention, feelings of fullness. belching, and flatulence, along with right upper quadrant abdominal pain. Client reports manifestations worsened after large meal for dinner and that they felt a burning sensation in their upper chest. Reports frequent loose stools with episodes of nausea. Client rates pain as 7 on a scale of 0 to 10. Brought in by partner. Client is alert and oriented to person and place. Appears restless. 51. 52 heard, no murmur detected. Lungs clear bilaterally. Skin turgor is less than 2 seconds. Peripheral catheter inserted in left forearm. Provider notified.

Rationale for correct choices • Right upper quadrant abdominal pain rated 7/10: Severe pain in the right upper quadrant may indicate acute cholecystitis, cholangitis, or hepatitis, which can rapidly progress if untreated. The intensity and location of pain require immediate evaluation and possible imaging or intervention. • Abdominal distention and feeling of fullness: These symptoms can signal biliary obstruction or gastrointestinal compromise. When present with severe pain, nausea, and elevated WBC, they support the need for urgent assessment and diagnostic testing. • Manifestations worsened after a large meal: Pain or discomfort exacerbated by food intake is a key indicator of hepatobiliary or gastrointestinal pathology, such as gallstones or gastritis, requiring prompt evaluation. • Nausea: Persistent nausea, especially with abdominal pain and distention, may indicate acute inflammation, obstruction, or infection, warranting timely intervention to prevent further complications. • Appears restless: Restlessness may be an early sign of pain, hypoxemia, infection, or worsening metabolic state, indicating the client’s condition is unstable and needs rapid assessment. Rationale for incorrect choices • Skin turgor less than 2 seconds: Mild dehydration is present but not an immediate threat; it can be corrected with IV fluids and ongoing monitoring.