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Urinary Incontinence and Employee Health Nurse. âA nurse is caring for a client with a spinal cord injury. What are possible causes of autonomic dysreflexia that the nurse should monitor for? distended bladder (most common), fecal impaction, cold stress or drafts on lower part of body, tight clothing, undiagnosed injury or illness.
Box 3-1 NURSEâS RESPONSIBILITY IN DELEGATION. 1  1. Prior to delegating a nursing task, the nurse shall determine the nursing care needs of the patient. The nurse shall retain responsibility and accountability for the nursing care of the patient, including nursing assessment, planning, evaluation, and nursing documentation.