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 C
Explanation
Choice A: Moving patient in a fast abrupt manner is incorrect because it can cause further damage to the spinal cord or other organs. It can also increase the risk of complications such as pressure ulcers, contractures, or fractures. The patient should be moved gently and carefully with proper alignment and support.
Choice B: Using neck brace or collar at patient's discretion is incorrect because it can cause skin irritation, infection, or pressure injuries. The neck brace or collar should be used only as prescribed by the physician and adjusted regularly to ensure a good fit and comfort.
Choice C: Repositioning patient if spine is stable and as indicated by physician is correct because it can prevent complications such as pressure ulcers, contractures, or respiratory infections. The patient should be repositioned every two hours or more frequently if needed, using pillows, wedges, or other devices to maintain proper alignment and relieve pressure.
Choice D: All of the above are incorrect because they do not follow the best practices for nursing intervention for patients with spinal cord injury. They can cause harm or discomfort to the patient and worsen their condition. The nurse should follow the physician's orders and the standards of care for spinal cord injury patients.
Correct Answer is C
Explanation
Choice A: Paralysis of the joints is not a description of dysarthria, but rather a possible complication of stroke or other neurological disorders.
Choice B: Blindness over half the field of vision is not a description of dysarthria, but rather a sign/symptom of hemianopia or visual field loss.
Choice C: Difficult or unclear articulation of speech is a description of dysarthria, as it is a motor speech disorder caused by weakness or paralysis of the muscles involved in speech production.
Choice D: Paralysis of one side of the body is not a description of dysarthria, but rather a sign/symptom of hemiplegia or unilateral weakness.
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