The nursing assistant’s training and education include taking and recording the patient’s vital signs.

Option A: Assessing the patient’s respiratory status would require the knowledge of a registered nurse.
Option C: Monitoring patients requires additional education and is appropriate for the scope of practice for professional nurses.
Option D: The nursing assistant may assist with turning and repositioning the patient and may remind the patient to cough and deep breathe but does not teach the patient how to perform these actions.

All of the strategies, except straight catheterization, may stimulate voiding in patients with SCI.
Option C: Intermittent bladder catheterization can be used to empty the patient’s bladder, but it will not stimulate voiding.

Option A: Checking for signs of pressure within the scope of practice of the LPN/LVN.
Option C: Observing for signs of an infection is within the scope of practice of the LPN/LVN.
Option D: The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide.
Option B: Neurologic examination requires additional education and skill appropriate to the professional RN.

The patient’s statement indicates impairment of adjustment to the limitations of the injury and indicates the need for additional counseling, teaching, and support.

Option A: The patient may have a risk for injury due to SCI, but it is not related to the statement. The spinal cord can be injured by transection, distraction, compression, bruising, hemorrhage or ischemia of the cord or by injury to blood vessels supplying it. These injuries can all result in permanent cord injury and may be complete or incomplete.
Option B: A client with SCI may have imbalanced nutrition because of a lesser appetite for eating, but it is not directly related to the statement. Refer to a Dietician early to ensure adequate nutrition, fluid & fiber in the feeds.
Option D: This nursing diagnosis may be appropriate to the patient with SCI, but it is not related to the patient’s statement.

The traveling nurse is relatively new to neurologic nursing and should be assigned to patients whose conditions are stable and not complex.

Option A: The newly diagnosed patient will need to be transferred to the ICU. Multiple sclerosis (MS) is an immune-mediated inflammatory disease that attacks myelinated axons in the central nervous system, destroying the myelin and the axon in variable degrees and producing significant physical disability within 20–25 years in more than 30% of patients. The hallmark of MS is symptomatic episodes that occur months or years apart and affect different anatomic locations.
Option C: The patient with GBS is in respiratory distress and should be assigned to an experienced neurological nurse. Guillain-Barré syndrome (GBS) is a rare disorder in which a person’s own immune system damages their nerve cells, causing muscle weakness and sometimes paralysis. GBS can cause symptoms that usually last for a few weeks.
Option D: The patient with C4 SCI is at risk for respiratory arrest. A C4 spinal cord injury occurs when damage is dealt about mid-way down the cervical spinal cord — the topmost portion of the spinal cord that is located in the neck and upper shoulders.