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: Inability to move or respond except for eye movements due to a lesion affecting the pons is a description of locked-in syndrome, as it is a state of complete paralysis and preserved consciousness caused by damage to the brainstem.
Choice B: Unconsciousness, unarousable unresponsiveness is not a description of locked-in syndrome, but rather a description of coma, as it is a state of complete loss of consciousness and reflexes caused by severe brain injury.
Choice C: Unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes is not a description of locked-in syndrome, but rather a description of akinetic mutism, as it is a state of severe apathy and reduced motor activity caused by damage to the frontal lobes or basal ganglia.
Choice D: Devoid of cognitive function but has sleep-wake cycles is not a description of locked-in syndrome, but rather a description of persistent vegetative state, as it is a state of minimal awareness and responsiveness caused by widespread brain damage.
Correct Answer is B
Explanation
Choice A: When patient is fully oriented is incorrect because it is a positive sign of recovery from a concussion. It means that the patient is aware of their person, place, time, and situation. The nurse should monitor the patient's orientation status but does not need to report it to the doctor immediately.
Choice B: Difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety are correct because they are signs of worsening brain injury or complications from a concussion. They may indicate increased intracranial pressure, bleeding, swelling, or infection in the brain. The nurse should report these symptoms to the doctor immediately and prepare for further diagnostic tests or interventions.
Choice C: When patient is easy to arouse is incorrect because it is also a positive sign of recovery from a concussion. It means that the patient responds quickly and appropriately to verbal or physical stimuli. The nurse should monitor the patient's level of consciousness but does not need to report it to the doctor immediately.
Choice D: All of the above are incorrect because only choice b) requires immediate reporting to the doctor. Choices a) and c) are normal or expected outcomes of a concussion and do not indicate any danger or complication. The nurse should use clinical judgment and follow the guidelines for concussion management and care.
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