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: Corticosteroids is correct, as they can reduce inflammation and swelling in the brain by suppressing the immune system and decreasing the permeability of blood vessels.
Choice B: Antibiotics is not correct, as they are used to treat bacterial infections, not cerebral edema.
Choice C: Tylenol is not correct, as it is a pain reliever and fever reducer, not an anti-inflammatory agent.
Choice D: All of the above is not correct, as only corticosteroids can be used to reduce cerebral edema.
Correct Answer is D
Explanation
Choice A: Ethnicity is not a modifiable risk factor of strokes, as it is determined by genetic and cultural factors that cannot be changed.
Choice B: Gender is not a modifiable risk factor of strokes, as it is determined by biological and hormonal factors that cannot be changed.
Choice C: Age is not a modifiable risk factor of strokes, as it is determined by chronological factors that cannot be changed.
Choice D: Obesity is a modifiable risk factor of strokes, as it can be reduced by lifestyle changes such as diet and exercise. Obesity can increase the risk of strokes by causing high blood pressure, diabetes, and heart disease.
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