When should the nurse remove a cervical collar from a head injury patient?
When patient no longer has numbness in extremities
When patient states they have no pain in the neck
When doctor has cleared patient following a cervical X-ray
All of the above
The Correct Answer is C
Choice A: When patient no longer has numbness in extremities is incorrect because it is not a reliable indicator of cervical spine injury or recovery. Numbness in extremities can be caused by various factors such as nerve compression, inflammation, or medication. It can also persist or recur after the cervical collar is removed. The nurse should assess the patient's neurological status but should not remove the cervical collar based on this symptom alone.
Choice B: When patient states they have no pain in the neck is incorrect because it is also not a reliable indicator of cervical spine injury or recovery. Pain in the neck can be subjective, variable, or masked by other factors such as analgesics, shock, or distraction. It can also be absent or delayed after the cervical collar is removed. The nurse should assess the patient's pain level but should not remove the cervical collar based on this symptom alone.
Choice C: When doctor has cleared patient following a cervical X-ray is correct because it is the safest and most accurate way to determine if the patient has a cervical spine injury or not. A cervical X-ray can show any fractures, dislocations, or other abnormalities in the cervical vertebrae that may require immobilization or surgery. The nurse should follow the doctor's orders and remove the cervical collar only after the doctor has confirmed that there is no risk of further damage to the spinal cord or nerves.
Choice D: All of the above are incorrect because only choice c) is sufficient and necessary to remove the cervical collar from a head injury patient. Choices a) and b) are not valid criteria and may expose the patient to potential harm or complications. The nurse should use evidence-based practice and follow the protocols for head injury management and care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Frequent monitoring of respiratory status and lung sounds and measures to maintain a patent airway is the first priority, as it can prevent hypoxia, hypercapnia, and increased ICP that can lead to brain herniation and death.
Choice B: Maintain a calm, quiet atmosphere and protect patient from stress is not the first priority, but rather a supportive measure to reduce stimuli and agitation that can increase ICP.
Choice C: Use strict aseptic technique for management of ICP monitoring system is not the first priority, but rather a preventive measure to avoid infection and meningitis that can worsen ICP.
Choice D: Position with head in neutral position and elevation of HOB 0 to 60 degrees to promote venous drainage is not the first priority, but rather a therapeutic measure to facilitate blood flow and reduce ICP.
Correct Answer is D
Explanation
Choice A: Sepsis is a serious infection that occurs when the body's immune system overreacts to an injury or illness. It can cause organ failure and death. People with spinal cord injury are more prone to sepsis because they may have impaired bladder and bowel function, skin breakdown, or reduced sensation that can lead to infections.
Choice B: Pulmonary embolism is a blockage of an artery in the lungs by a blood clot. It can cause chest pain, shortness of breath, and death. People with spinal cord injury are more at risk of pulmonary embolism because they may have reduced mobility, blood circulation, or breathing capacity that can promote blood clot formation.
Choice C: Pneumonia is an inflammation of the lungs caused by bacteria, viruses, or fungi. It can cause fever, cough, and difficulty breathing. People with spinal cord injury are more susceptible to pneumonia because they may have weakened cough reflex, impaired lung function, or aspiration of food or saliva into the lungs.
Choice D: All of the above are major causes of death related to spinal cord injury. They can occur separately or together and can be prevented or treated with proper medical care and lifestyle modifications.
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