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 × 4The 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.
which client assessment findings require immediate follow-up by the nurse at this time