Question

Three hours later, Claudine's husband calls the nurse, stating that she is reporting increased abdominal pain. The nurse asks Claudine where she is experiencing pain and she points to her right lower abdomen.

When completing the pain assessment, how should the nurse assess for rebound tenderness?

- Position the client on her right side.
- Lightly palpate over the painful area.
- Ask the client to describe the pain.
- Push down on the left side of the abdomen.

Answer 1

To assess for rebound tenderness, the nurse should palpate deeply and then quickly release the pressure on the side opposite the pain, observing if pain increases upon release. This is an important indicator of conditions like appendicitis.

Step-by-step explanation:

To assess for rebound tenderness, which may indicate peritonitis or another inflammatory condition such as appendicitis, the nurse should deeply palpate the abdomen away from the painful area (typically the left side if the pain is on the right) and then quickly release the pressure. If the pain worsens upon release, this indicates rebound tenderness. It's important to perform this assessment gently and to monitor the client's comfort level closely due to the potential for this maneuver to cause significant discomfort.

Furthermore, it is essential to ask Claudine to describe the pain, including its characteristics, onset, duration, and any associated symptoms to get a comprehensive understanding of her condition. Lightly palpating over the painful area and positioning the client appropriately can also provide valuable information regarding the nature and source of the pain.