A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury. Select 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing ______ due to _______. Nurses' Notes 07.00: Client alert and oriented x 3. Denies pain. Client unable to move lower extremities. Urinary catheter draining clear amber urine. Client turned to right. 08.05: Client alert and oriented x 3. Denies pain. Client unable to move lower extremities. Urinary catheter draining clear amber urine. Client turned to left. 09.10: Client reporting headache as a 9 on 0 to 10 pain scale. Client is diaphoretic with flushed skin. Alert and oriented x 3. Client appears agitated with labored breathing. Urinary output diminished Medication Administration Record 07.00: Enoxaparin 40 mg subcutaneous daily 08.45: Dexamethasone 4 mg IV every 12 hr Lactated Ringers solution IV 150 mL/hr Gabapentin 300 mg PO twice daily I&O 07.00: Input: 150 mL Output: 60 mL 08.00: Input 150 mL Output 40 mL 09.00: Input 180 mL Output 10 mL

A is incorrect because the completion of the incident report should not be documented in the client's medical record, but in a separate file for quality improvement purposes.

B is correct because the time the medication was given is an essential fact related to the incident that should be documented in the client's medical record.

C is incorrect because the reason for the medication error should not be documented in the client's medical record, but in the incident report for analysis and prevention of future errors.

D is incorrect because the notification of the pharmacist should not be documented in the client's medical record, but in the incident report for follow-up and corrective actions.

A. Flexing the client's neck forward can increase intracranial pressure by impeding venous drainage from the brain and increasing cerebral blood volume. Therefore, this choice is incorrect.

B. Grouping several nursing activities to be completed at one time can increase intracranial pressure by stimulating the client and causing fluctuations in blood pressure and heart rate. Therefore, this choice is incorrect.

C. Limiting suctioning the client's airway to 30 seconds at a time can reduce intracranial pressure by minimizing hypoxia and hypercarbia, which can cause cerebral vasodilation and increased cerebral blood volume. However, this intervention alone is not sufficient to prevent increased intracranial pressure, and suctioning should be done only when necessary and with caution. Therefore, this choice is partially correct but not the best answer.

D. Placing the client in a quiet environment can reduce intracranial pressure by minimizing sensory stimulation and promoting relaxation, which can lower blood pressure and heart rate and decrease cerebral metabolic demand. Therefore, this choice is correct and the best answer.