A patient with appendicitis has a rigid (board-like) abdomen, fever, tenderness, and hypotension. Which action taken by a student nurse should be intervened (stopped) by the senior nurse?

Appeared in: NORCET 10 Mains

Explanation

The patient's signs (rigid abdomen, fever, hypotension) indicate peritonitis, likely from a ruptured appendix.
Administering a rectal enema increases intra-abdominal pressure and stimulates bowel motility.
This action can cause a contained abscess to rupture or spread existing infection throughout the peritoneal cavity.
Spreading the infection can rapidly lead to widespread sepsis and septic shock, which is a life-threatening emergency.
Therefore, any intervention that increases peristalsis or abdominal pressure is strictly contraindicated.

Option B: This is a correct and essential action. The patient has signs of a severe infection (fever) and potential sepsis.
Option C: This is a correct and priority action. The patient is hypotensive, which is a sign of circulatory collapse or septic shock.
Option D: This is a correct and standard nursing action. Pain is a key indicator of the patient's status.

Visual 1: Diagram - An illustration showing the progression from simple appendicitis to a ruptured appendix, with spillage of infectious material into the peritoneal cavity, causing peritonitis.
Visual 2: Flowchart - A decision-making flowchart for a patient with abdominal pain, showing how signs like rigidity and hypotension lead to a diagnosis of peritonitis and emergency intervention.

Clinical Relevance

Nursing practice connection: Use the key finding related to Nursing management of complicated appendicitis (peritonitis) to guide bedside assessment, documentation, and the next nursing action.
A key nursing responsibility is to recognize the signs of peritonitis (rigid abdomen, high fever, tachycardia, hypotension) as a surgical emergency and immediately notify the physician.
Nurses must prepare the patient for emergency surgery, which includes maintaining NPO status, ensuring IV access, administering fluids and antibiotics as ordered, and providing emotional support.
Patient education is critical: the nurse must instruct the patient and family not to apply heat to the abdomen, as this can increase inflammation and the risk of rupture.

How to Approach the Question

Step 1: Analyze the patient's clinical presentation. Identify the key signs and symptoms: rigid (board-like) abdomen, fever, tenderness, and hypotension in a patient with appendicitis.
Step 2: Synthesize these findings to form a clinical picture. These are hallmark signs of a ruptured appendix leading to peritonitis and potential septic shock.
Step 3: Understand the question's objective. It asks which action is incorrect or harmful and should be stopped ('intervened').
Step 4: Evaluate each option based on the pathophysiology of peritonitis. Ask, 'Does this action help or harm a patient with a potential bowel perforation?'
Step 5: Rule out the beneficial actions. Antibiotics fight infection. IV fluids treat shock. Pain assessment monitors the patient's condition. These are all correct.
Step 6: Identify the harmful action. A rectal enema increases intra-abdominal pressure and motility, which can spread the infection. This is the action to be stopped.

Concept Tested & Keywords

Concept Tested: Nursing management of complicated appendicitis (peritonitis)
Stem keywords: appendicitis, rigid (board-like) abdomen, fever, tenderness, hypotension
Lead-in keywords: action...should be intervened (stopped)
Clinical cues: The combination of a rigid abdomen and hypotension strongly suggests a ruptured appendix and peritonitis, which is a surgical emergency.
Negative lead-in flag: The question asks the nurse to identify an incorrect or harmful action that must be stopped, which is a negative framing.

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