[Solved]: A 45-year-old male client sustained a spinal cord…

A 45-year-old male client sustained a spinal cord injury at T6 as a result of a gunshot wound. Surgery was performed 4 days ago to remove the bullet. Today the client is transferred to the neurosurgical unit from critical care. During hand-off report, the nurse is told that the client is a high-level paraplegic. The client is currently alert and oriented and able to describe how his injury occurred. Psychosocial assessment reveals anxiety and fear about his prognosis. He states, “I can’t feel or move anything below my waist and I’m worried about what this means. I’m still single and only 45 years old and don’t have any kids yet.” Additional assessment findings include: • Temperature = 98.8°F (37.1°C) • Pulse = 82 beats/min • Respirations = 20 breaths/min • Oxygen saturation = 93% (on room air) • Blood pressure = 122/82 mm Hg • Pain level = 0/10 (states: “I can’t feel my legs”) • Skin integrity intact • Breath sounds = fine crackles in the right lower lobe • Abdomen is distended and firm • Bowel sounds present × 4 The client states he is not sure when he had his last bowel movement (BM) and there is no documentation of a BM postoperatively. He has an indwelling urinary catheter that is draining clear, yellow urine. 1. which client assessment findings require immediate follow-up by the nurse at this time. A 45-year-old male client sustained a spinal cord injury at T6 as a result of a gunshot wound which was surgically treated 4 days ago. He was transferred from the critical care unit to the neurosurgical unit this morning. He has an indwelling urinary catheter draining clear, yellow urine, but has not yet had a postoperative bowel movement (BM). The nurse enters the client’s room to set up lunch and notes that the client’s face is very flushed. He reports having a “terrible throbbing headache” at a 10/10 on a 0 to 10 pain intensity scale and nasal congestion. The nurse quickly checks the client’s vital signs and documents: T = 99.0°F (37.2°C), P = 58 beats/min, R = 20 breaths/min oxygen saturation = 90% (on room air [RA]), and BP = 210/120 mm Hg. Breath sounds reveal fine crackles in the right lower lobe. 2. Which symptoms are associated with pneumonia or autonomic dysreflexia? 3. Which client assessment findings are a priority concern for the nurse? 4. Name of the appropriate nursing Interventions to manage and treat the patient Condition. 5. The first action that the nurse would take is to _________1_________ to _________2_________. 6. After implementing appropriate interventions, the nurse reassesses the client. Which of the following client assessment findings indicate that this complication has been adequately managed? Select all that apply. a. Vision is clear b. Pulse = 70 beats/min c. BP = 130/88 mm Hg d. Oxygen saturation = 92% (on RA) e. Headache is 2/10 f. Breath sounds = fine crackles g. Temperature = 99.2°F (37.1°C) h. Facial color pink i. Skin warm and dry