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ANCC Medical-Surgical Nursing Exam Prep

Category - Medical-Surgical Nursing Practice Test

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Levin, age 27, was driving home when his car collided with another moving vehicle. He obtained multiple injuries and a concussion. The paramedics placed a hard neck brace to immobilize the spine. Upon arriving at the hospital, X-rays are inconclusive because of swelling. To assess and care for the skin under the collar, the nurse should:
  1. Place the client flat and supine; remove the anterior section of the collar, turning the head to the right or left to remove the back section.
  2. Have the client sit up in a chair to remove the front and back sections without turning the head from side to side.
  3. Have at least one nurse stabilize the head in line with the torso, while the other nurse removes the collar sections.
  4. Wait until the X-rays are conclusive for any trauma before assessing the skin or providing skin care under the collar.
Explanation
Answer - C - The head and neck are maintained in an aligned position at all times and supported. The collar is hard and can cause skin breakdown. The collar liner should be changed daily and the underlying skin cleansed. Turning the head from side to side may cause injury to the spine (Choice A). Choice B is incorrect because the client may be experiencing weakness and there is no support for the neck if the collar is removed. The collar liner must be changed and the skin cleaned daily to prevent breakdown (Choice D). The presence or absence of a spinal injury may not be determined in less than 24 hours.
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