A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

Choice A: “You shouldn’t feel any pain since the local area is anaesthetized.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not tell the client that they will not feel any pain, as this may create unrealistic expectations and increase anxiety if they do experience discomfort. The nurse should also not tell the client that the local area is anaesthetized, as this is not true. The client does not receive local anesthesia for a colonoscopy, but rather sedation and pain medication.

Choice B: “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not tell the client not to worry, as this may sound dismissive and insensitive to their concerns. The nurse should also not tell the client that they will not remember anything about the procedure, as this is not true. The client may receive conscious sedation for a colonoscopy, which means that they are awake but drowsy and relaxed. They may have some memory loss of the procedure, but they are not completely unconscious.

Choice C: “Most clients report more discomfort from the preparation than from the procedure itself.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not compare the client’s experience to other clients, as this may minimize their feelings and individual differences. The nurse should also not focus on the preparation, which involves drinking a large amount of liquid laxative to empty the colon, as this may increase anxiety and dread for the client. The nurse should instead focus on providing information and support for both the preparation and the procedure.

Choice D: “You may feel some cramping during the procedure.” This is a response that the nurse should make to the client who is scheduled for a colonoscopy, which is a diagnostic test that uses a flexible tube with a camera to examine the colon and rectum. The nurse should inform the client that they may feel some cramping during the procedure as the tube is inserted and moved through the colon. The nurse should also reassure the client that they will receive sedation and pain medication to make them comfortable and relaxed.

Choice A: Check for bleeding on the dressing at the back of the client’s neck. This is an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy, which is a surgical removal of part of the thyroid gland. The nurse should check for bleeding on the dressing at the back of the client’s neck because this is where blood can pool and go unnoticed. Bleeding can cause hematoma, compression of the airway, and respiratory distress.

Choice B: Ensure that acetylcysteine IV is readily available. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Acetylcysteine IV is an antidote for acetaminophen overdose, which can cause liver damage, but it is not related to thyroid surgery.

Choice C: Place the client in a side-lying position. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. The nurse should place the client in a semi-Fowler’s position, which is a position with the head of the bed elevated to 30 to 45 degrees. This position can facilitate breathing, reduce edema, and prevent aspiration.

Choice D: Check the client for asterixis. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Asterixis is a sign of hepatic encephalopathy, which is a condition caused by liver failure, but it is not related to thyroid surgery.