# A nurse is assessing a 58-year-old client who was recently diagnosed with colorectal cancer. Which assessment finding would be most concerning and require immediate nursing intervention?

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> subject: Adult Health

## 문제

A nurse is assessing a 58-year-old client who was recently diagnosed with colorectal cancer. Which assessment finding would be most concerning and require immediate nursing intervention?

## 보기

1. Complaint of mild abdominal cramping after meals
2. Report of fatigue and weakness over the past month
3. Presence of bright red blood in stool with severe abdominal pain **✔ 정답**
4. Weight loss of 10 pounds over the past 3 months

**정답: 3**

## 해설

Bright red blood with severe pain indicates acute bleeding or complications like obstruction/perforation requiring immediate intervention, while other findings are less urgent.

## 심화 해설

Correct Answer: 3. Presence of bright red blood in stool with severe abdominal pain

Clinical Priority and Pathophysiology

The combination of bright red blood in stool (hematochezia) and severe abdominal pain in a client with colorectal cancer signals a potential surgical emergency, specifically bowel perforation or significant hemorrhagic complication. This assessment finding cluster takes immediate priority because it indicates a rapid deterioration in the integrity of the gastrointestinal tract. In the context of a known obstructing or locally advanced tumor, severe pain suggests peritoneal irritation from a perforation, while frank bleeding indicates erosion into a major vessel or friable tumor tissue. The case report by Mishina et al. illustrates this exact clinical urgency, describing a patient with an obstructing sigmoid colon tumor who presented with abdominal pain and was found to have a mesocolic abscess with suspected proximal perforation, necessitating an emergency Hartmann procedure [1]. This demonstrates that such symptoms are not manageable with routine nursing measures and require immediate escalation for surgical evaluation and intervention to prevent peritonitis, sepsis, and hemorrhagic shock.

Analysis of Incorrect Options

Option 1: Complaint of mild abdominal cramping after meals is a common and expected finding in colorectal cancer due to partial luminal obstruction by the tumor mass. While it requires assessment and comfort measures, it does not represent an acute, life-threatening change in condition. It lacks the indicators of a catastrophic event like perforation or active hemorrhage.

Option 2: Report of fatigue and weakness over the past month is a classic manifestation of chronic disease and cancer-related anemia, often due to slow, occult blood loss from the tumor. This is a significant finding that requires ongoing management, including monitoring hemoglobin levels and energy conservation strategies, but it is a chronic issue, not an immediate emergency.

Option 4: Weight loss of 10 pounds over the past 3 months is a cardinal sign of cancer cachexia and altered metabolism. This finding is critical for nutritional assessment and long-term care planning. However, the time frame of "over the past 3 months" indicates a gradual process, distinguishing it from an acute condition requiring immediate intervention over other more urgent presentations.

NCLEX-RN Application: Triage and Prioritization

This question tests the critical nursing skill of differentiating between chronic, expected disease manifestations and acute, emergent complications. The NCLEX-RN exam consistently prioritizes assessment findings that suggest an immediate threat to airway, breathing, or circulation. In this scenario, the client's presentation aligns with a high-risk situation for rapid circulatory compromise from hemorrhage and systemic infection from perforation. The clinical decision-making process involves recognizing that severe pain with bright red blood is a "red flag" symptom cluster. The referenced case supports this by showing that a patient with an obstructing tumor and abdominal pain was managed as a surgical emergency due to suspected perforation [1]. The nurse's priority is to stop the ongoing assessment, ensure the client's safety by maintaining NPO status, establish intravenous access, and immediately notify the healthcare provider for urgent surgical consultation.References (research sources)

- [1]Successful emergency Hartmann procedure for perforated sigmoid colon cancer requiring splenic flexure mobilization under combined spinal-epidural anesthesia: a case report.Case reportMishina T, Yamada A, Kobayashi S, Sekimura A, Takagi T, Maeda T, Hori A. (2026) · DOI: 10.2185/jrm.2026-023

## 임상 시나리오

Recognizing Acute Abdomen in Colorectal CancerPrioritizing Hemorrhage and Perforation Over Chronic Symptoms
In a client with known colorectal cancer, the combination of bright red blood per rectum and severe abdominal pain is a critical red flag. This presentation suggests a surgical emergency such as bowel perforation or erosion into a major vessel.

Severe pain indicates peritoneal irritation from leaking luminal contents, while frank hematochezia signals active hemorrhage. Immediate nursing action includes withholding oral intake, establishing IV access, and notifying the provider for urgent surgical evaluation to prevent sepsis and hemorrhagic shock.

CautionDo not dismiss these symptoms as routine cancer progression. Chronic findings like mild cramping, fatigue, or gradual weight loss do not take priority over acute peritoneal signs or active bleeding.

## 핵심 개념

- **Hematochezia** — The passage of bright red blood from the rectum, often indicating lower gastrointestinal bleeding.
- **Bowel Perforation** — A full-thickness defect in the intestinal wall allowing luminal contents to leak into the peritoneal cavity, causing peritonitis.
- **Hartmann Procedure** — A surgical operation involving resection of the rectosigmoid colon with closure of the rectal stump and creation of an end colostomy.
- **Peritoneal Irritation** — Inflammation of the peritoneum characterized by severe abdominal pain, rebound tenderness, and guarding.
- **Oncologic Emergency** — An acute, potentially life-threatening condition caused by cancer or its treatment requiring immediate intervention.

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