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

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## 문제

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

## 보기

1. Mild abdominal cramping after meals
2. Change in bowel habits with alternating constipation and diarrhea
3. Fatigue and weakness during daily activities
4. Severe abdominal pain with rigid abdomen and absent bowel sounds **✔ 정답**

**정답: 4**

## 해설

Severe abdominal pain with rigidity and absent bowel sounds indicates life-threatening complications like obstruction or perforation requiring immediate intervention. Other findings are common in colorectal cancer but not emergent.

## 심화 해설

Clinical Reasoning and Priority Setting

The assessment finding that is most concerning and requires immediate nursing intervention is severe abdominal pain with a rigid abdomen and absent bowel sounds. This combination of signs is a classic presentation of an acute surgical abdomen, specifically suggesting bowel perforation with subsequent peritonitis.

In a client with colorectal cancer, a tumor can grow to obstruct the bowel lumen completely. As intraluminal pressure builds proximal to the obstruction, the bowel wall's perfusion becomes compromised, leading to ischemia, necrosis, and ultimately perforation [1]. When bowel contents spill into the sterile peritoneal cavity, a massive inflammatory response is triggered, resulting in chemical and bacterial peritonitis. The clinical hallmarks of this life-threatening progression are a rigid, board-like abdomen (involuntary guarding due to peritoneal inflammation) and an absence of bowel sounds (paralytic ileus), accompanied by severe, diffuse pain. Without immediate intervention, this condition rapidly progresses to sepsis and septic shock.

The critical nature of this finding is underscored by the high risk of postoperative sepsis in patients undergoing emergency colon surgery, a context directly linked to complications like perforation. A multicenter study identified that emergency surgery itself is a high-risk scenario for developing postoperative sepsis, emphasizing that the preoperative physiological insult from an acute abdomen significantly worsens outcomes [2]. The study highlights the role of systemic inflammation in these patients, a process that begins the moment perforation occurs. Therefore, recognizing the rigid, silent abdomen is the nurse's highest priority, as it signals a transition from a chronic oncologic condition to an acute, time-sensitive surgical emergency where delays directly increase mortality risk.

The other options represent common, non-emergent manifestations of colorectal cancer. Mild postprandial cramping (Option 1) and changes in bowel habits (Option 2) are classic symptoms associated with a partially obstructing mass, while fatigue (Option 3) is often related to chronic, occult blood loss from the tumor leading to anemia. These are important to document and address but do not indicate an immediate threat to the client's life.References (research sources)

- [1]National Health Commission guidelines for diagnosis and treatment of colorectal cancer in China (2025 edition, English version).GuidelineRepublic Of China Chinese Medical Association Oncology Branch DOMANHCOTP. (2025) · DOI: 10.21147/j.issn.1000-9604.2025.06.07

- [2]Machine learning-based multicenter prediction of postoperative sepsis in emergency colon cancer: role of surgical approach and inflammatory markers.Research articleDu W, Sun T, Chen W, Sun M, Shi C, Jiang C, Zhan F, Zhang Y. (2026) · DOI: 10.3389/fonc.2026.1845236

## 임상 시나리오

Recognizing an Acute Abdomen in Colorectal CancerBowel Perforation & Peritonitis Assessment
In a client with colorectal cancer, the combination of severe abdominal pain, a rigid, board-like abdomen, and absent bowel sounds is a classic triad for bowel perforation and generalized peritonitis.

This is a life-threatening emergency. A tumor causing complete obstruction leads to increased intraluminal pressure, bowel wall ischemia, and perforation. Spillage of contents triggers chemical and bacterial peritonitis, rapidly progressing to sepsis and septic shock without immediate surgery.

CautionDo not delay intervention for diagnostic tests. The nurse's priority is to notify the provider immediately, keep the patient NPO, initiate IV fluids, and prepare for emergency laparotomy. Do not administer oral medications or apply heat to the abdomen.

## 핵심 개념

- **Peritonitis** — Inflammation of the peritoneum, often due to bacterial or chemical contamination from a perforated viscus, presenting with a rigid abdomen and severe pain.
- **Paralytic Ileus** — A functional obstruction of the bowel due to cessation of peristalsis, often caused by peritoneal irritation, leading to absent bowel sounds.
- **Acute Surgical Abdomen** — A sudden onset of severe abdominal pain requiring urgent surgical evaluation, often characterized by guarding, rigidity, and rebound tenderness.
- **Bowel Perforation** — A full-thickness hole in the intestinal wall allowing luminal contents to leak into the peritoneal cavity, a life-threatening complication of obstruction or tumor invasion.
- **Involuntary Guarding** — Reflexive tensing of abdominal muscles over an inflamed area, a key physical sign of peritoneal irritation.

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