# A nurse is assessing a 38-year-old patient who presents to the emergency department with severe abdominal pain. Which assessment finding should be the nurse's highest priority to report immediately to the healthcare provider?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=540499  
> language: ko  
> subject: Adult Health

## 문제

A nurse is assessing a 38-year-old patient who presents to the emergency department with severe abdominal pain. Which assessment finding should be the nurse's highest priority to report immediately to the healthcare provider?

## 보기

1. Nausea and vomiting for the past 6 hours
2. Temperature of 100.2°F (37.9°C)
3. Rigid abdomen with rebound tenderness (반발 압통) **✔ 정답**
4. Patient rating pain as 8/10 on the pain scale

**정답: 3**

## 해설

Rigid abdomen with rebound tenderness suggests peritonitis, a surgical emergency requiring immediate reporting. Nausea, low-grade fever, and severe pain are less urgent findings.

## 심화 해설

Clinical Reasoning and Priority Setting in Acute Abdomen

The patient presents with severe abdominal pain, and the nurse must identify the finding that indicates the most life-threatening condition requiring immediate intervention. In the context of an acute abdomen, the highest priority is recognizing signs of peritonitis, which strongly suggest a surgical emergency such as a perforated viscus.

Analysis of the Correct Answer

Rigid abdomen with rebound tenderness (Option 3) is the correct priority finding. This combination represents classic peritoneal signs. A rigid, board-like abdomen indicates involuntary guarding of the abdominal muscles, a protective reflex to prevent movement of an inflamed peritoneum. Rebound tenderness—pain upon sudden release of pressure rather than during palpation—is a cardinal sign of peritoneal inflammation. These findings collectively point to peritonitis, which in the setting of an acute abdomen, is most commonly caused by a perforated peptic ulcer or other gastrointestinal perforation leading to pneumoperitoneum (free air in the peritoneal cavity) [1]. The presence of peritoneal signs signals a potential surgical abdomen that requires immediate notification of the healthcare provider for urgent evaluation and likely emergency surgery . The cited case of a perforated peptic ulcer confirmed at operation highlights that such clinical signs are critical triggers for escalating care and arranging definitive imaging or surgical consultation [1].

Analysis of Incorrect Options

Option 1, nausea and vomiting for 6 hours, is a common but nonspecific symptom in many abdominal conditions. While it contributes to the clinical picture and can lead to fluid and electrolyte imbalances, it does not immediately indicate a life-threatening surgical pathology in the same way peritoneal signs do. It is a lower priority for immediate reporting compared to a rigid, tender abdomen.

Option 2, a temperature of 100.2°F (37.9°C), is a low-grade fever. While it may indicate an infectious or inflammatory process, it is not a specific marker for a surgical emergency. Many self-limiting conditions can cause a mild temperature elevation. In contrast, the absence of fever does not rule out a perforation, as demonstrated by a case of large-volume idiopathic pneumoperitoneum where the patient remained afebrile and without peritoneal signs . Therefore, the presence or absence of a specific physical sign like rebound tenderness is far more critical than a mildly elevated temperature.

Option 4, a pain rating of 8/10, is a significant subjective finding that requires prompt analgesic intervention and further assessment. However, pain severity alone does not differentiate between a benign and a life-threatening cause. The objective physical finding of a rigid abdomen with rebound tenderness provides specific pathophysiologic evidence of peritoneal irritation, which is a more reliable and urgent indicator of a condition like a perforated organ [1,4]. A patient can have severe pain from renal colic without having a surgical abdomen, making the physical assessment finding the higher priority for immediate reporting.References (research sources)

- [1]Diagnosis of Pneumoperitoneum Using POCUS.Research articleMaya Jaramillo MP, Ocampo AC. (2026) · DOI: 10.24908/pocusj.v11i01.19753

## 임상 시나리오

Recognizing the Acute Surgical AbdomenPrioritizing Peritoneal Signs in Emergency Assessment
A rigid, board-like abdomen with rebound tenderness is the hallmark of peritonitis and indicates a potential surgical emergency. This finding should be reported immediately before other symptoms like pain score or nausea.

Rebound tenderness is elicited by pressing deeply and then suddenly releasing the abdominal wall; pain on release is a more specific indicator of peritoneal inflammation than pain on palpation. This often signals a perforated viscus leading to pneumoperitoneum.

CautionDo not repeatedly test for rebound tenderness as it causes unnecessary pain. Once identified, notify the provider immediately and prepare the patient for urgent imaging or surgical consultation. Maintain NPO status.

## 핵심 개념

- **Rebound Tenderness** — Pain upon sudden release of deep palpation pressure, a cardinal sign of peritoneal inflammation.
- **Peritonitis** — Inflammation of the peritoneum, often caused by a perforated viscus, requiring emergency surgery.
- **Rigid Abdomen** — Involuntary, board-like guarding of abdominal muscles, a protective reflex indicating peritoneal irritation.
- **Surgical Abdomen** — An acute abdominal condition requiring urgent surgical intervention, often indicated by peritoneal signs.
- **Pneumoperitoneum** — Free air in the peritoneal cavity, commonly resulting from a perforated peptic ulcer.

## 같은 주제 문제

- [A nurse is assessing a 12-year-old child who presents to the emergency department with sev…](https://mymerci.kr/pages/nclex_q.php?qn_id=540494)
- [A nurse is assessing a 70-year-old client who reports chronic abdominal pain and changes i…](https://mymerci.kr/pages/nclex_q.php?qn_id=540495)
- [A 30-year-old patient presents to the emergency department with sudden onset of severe epi…](https://mymerci.kr/pages/nclex_q.php?qn_id=540496)
- [A nurse is assessing a 45-year-old patient admitted with acute abdominal pain. Which asses…](https://mymerci.kr/pages/nclex_q.php?qn_id=540497)
- [A nurse is caring for a 58-year-old patient hospitalized for suspected gastrointestinal bl…](https://mymerci.kr/pages/nclex_q.php?qn_id=540498)

---

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

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