Question

A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?

a. Obtain vital sign measurements.
b. Measure capillary glucose level.
c. Encourage ambulation in the room.
d. Monitor for bloody diarrheal stools.

Answer 1

The nurse should first obtain vital sign measurements because a rigid abdomen with rebound tenderness may indicate a serious condition, such as bowel perforation or peritonitis, necessitating immediate assessment and action.

Step-by-step explanation:

If a client hospitalized with an Inflammatory Bowel Disease (IBD) exacerbation develops a rigid abdomen with rebound tenderness while being treated with a corticosteroid, the nurse should first obtain vital sign measurements. This presentation could indicate a serious and emergent condition such as perforation of the bowel or peritonitis, which requires immediate medical attention.

Monitoring vital signs is essential for assessing the client's hemodynamic status and for detecting signs of shock or acute deterioration. This information can guide further diagnostic and therapeutic interventions. While monitoring for bloody diarrheal stools can also provide important information regarding the client's IBD status, the presence of life-threatening abdominal signs such as rebound tenderness and rigidity necessitates prompt vital signs assessment and reporting to the care team.