# Situation: A 72-year-old woman has had a small, soft bulge just below the right inguinal ligament for a year; it used to disappear when she lay down. She is admitted with 8 hours of severe right groin pain, and the bulge is now tense, tender, and cannot be pushed back. The nurse compares two assessments. On arrival: bulge tense and tender; pain 7/10, cramping, comes in waves; vomited once; heart rate 94/min; temperature 37.2 °C Three hours later: bulge tense and tender; pain 9/10, constant; vomited three times, no flatus; heart rate 116/min; temperature 38.3 °C; serum lactate 3.8 mmol/L (normal below 2.0) Which conclusion does the later assessment BEST support?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630388  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 72-year-old woman has had a small, soft bulge just below the right inguinal ligament for a year; it used to disappear when she lay down. She is admitted with 8 hours of severe right groin pain, and the bulge is now tense, tender, and cannot be pushed back.

The nurse compares two assessments.
On arrival: bulge tense and tender; pain 7/10, cramping, comes in waves; vomited once; heart rate 94/min; temperature 37.2 °C
Three hours later: bulge tense and tender; pain 9/10, constant; vomited three times, no flatus; heart rate 116/min; temperature 38.3 °C; serum lactate 3.8 mmol/L (normal below 2.0)
Which conclusion does the later assessment BEST support?

## 보기

1. Incarcerated hernia causing a bowel obstruction
2. Groin abscess forming around the trapped hernia
3. Paralytic ileus from low potassium after vomiting
4. Strangulated hernia with loss of blood supply **✔ 정답**

**정답: 4**

## 해설

Both assessments show an irreducible (incarcerated) hernia with obstruction. The later one adds a change from waves of cramping to constant severe pain, fever, tachycardia, and a raised lactate — signs that the trapped bowel's blood supply is compromised. Skin discoloration may appear late; its absence does not rule out strangulation, which is a surgical emergency.

## 심화 해설

What the later assessment shows
Both assessments show an irreducible, incarcerated hernia with signs of bowel obstruction: a tense, tender bulge and vomiting. The later assessment adds a decisive set of changes. Pain has shifted from waves of cramping to constant severe pain, and fever, tachycardia, and a raised serum lactate have appeared; together these show that the trapped bowel's blood supply is compromised. This is a strangulated hernia, a surgical emergency.

Reading the two assessments side by side
Cramping pain that comes in waves is typical of mechanical obstruction: the bowel above the trapped loop contracts against a blockage. Constant pain means something different. It reflects ischemia of the bowel wall, which hurts continuously rather than with peristaltic waves. The heart rate rising from 94 to 116/min and the temperature rising from 37.2 to 38.3 °C reflect inflammation and early systemic response. A serum lactate of 3.8 mmol/L (normal below 2.0) indicates tissue hypoperfusion, because ischemic bowel shifts to anaerobic metabolism. Increasing vomiting with no flatus confirms that the obstruction persists.

| Finding | On arrival | Three hours later |
| --- | --- | --- |
| Pain | 7/10, cramping, in waves | 9/10, constant |
| Vomiting / flatus | Vomited once | Vomited three times, no flatus |
| Heart rate | 94/min | 116/min |
| Temperature | 37.2 °C | 38.3 °C |
| Lactate | Not reported | 3.8 mmol/L |

Why the other conclusions are incomplete or wrong
Incarceration with obstruction explains the vomiting and absent flatus, but it does not account for constant pain, fever, tachycardia, and a raised lactate; stopping at this conclusion would miss the ischemia. A groin abscess can cause fever but does not explain obstruction with rising lactate. Paralytic ileus from low potassium causes diffuse distension and reduced bowel activity, not constant localized pain over a trapped hernia with fever and lactate rise.

Nursing priority
The nurse reports the findings to the surgeon at once, keeps the client NPO, maintains IV fluids, and prepares her for emergency surgery. Skin discoloration over the hernia may appear late, and its absence does not rule out strangulation. Waiting for color change would delay surgery while the bowel dies.

Exam takeaway
Key point Cramping in waves suggests obstruction; constant pain with fever, tachycardia, and raised lactate suggests ischemia. When a trend question shows this shift, choose strangulation.

## 임상 시나리오

From Incarceration to StrangulationTrending the assessment
Both checks show an incarcerated hernia with obstruction. The later one shows pain changing from waves of cramping to constant severe pain, with fever, tachycardia of 116/min, and lactate of 3.8 mmol/L.

Constant pain and a raised lactate reflect ischemia of the trapped bowel. This is a strangulated hernia and needs emergency surgery.

CautionDo not wait for skin discoloration over the bulge. It may appear late, and its absence does not rule out strangulation.

## 핵심 개념

- **Strangulation** — Loss of blood supply to trapped bowel in a hernia, causing ischemia and possible necrosis.
- **Serum lactate** — A blood marker that rises when tissues are poorly perfused and shift to anaerobic metabolism.
- **Mechanical bowel obstruction** — Blockage of the bowel lumen causing cramping pain, vomiting, distension, and absent flatus.
- **Ischemic pain** — Constant pain caused by inadequate blood flow to tissue.

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