A nurse in an emergency department is assessing a client who has a basilar skull fracture and serosanguineous nasal discharge following a motor vehicle crash. Which of the following findings should the nurse identify as reliable for determining that the discharge is cerebrospinal fluid?

Papilledema.

Halo sign.

Racoon's eyes.

Elevated WBCs.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Papilledema refers to swelling of the optic disc in the eye, which can occur due to increased intracranial pressure. While it may be present in cases of basilar skull fracture, it is not a reliable finding for determining the discharge of cerebrospinal fluid (CSF).
Choice B rationale:
The halo sign is a reliable finding for determining that the nasal discharge is cerebrospinal fluid. The halo sign is characterized by a ring of blood surrounded by a clear or yellowish fluid (CSF) on a dressing or tissue. This occurs because blood from the fracture mixes with the clear CSF, creating a distinct appearance.
Choice C rationale:
Racoon's eyes, also known as periorbital ecchymosis, is a term used to describe bruising around the eyes. While it can be seen in basilar skull fractures, it is not specific to cerebrospinal fluid leakage and, therefore, not reliable for identifying the nasal discharge as CSF.
Choice D rationale:
Elevated white blood cells (WBCs) in the nasal discharge can indicate infection, inflammation, or an immune response. However, it does not provide direct evidence that the discharge is cerebrospinal fluid, so this is not a reliable finding for determining the nature of the nasal discharge in this context.

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Correct Answer is B

Explanation

Choice A rationale:

Scheduling the client for the last surgery of the day is not directly related to the client's latex allergy. Proper planning for surgery in a latex-allergic client involves addressing potential exposures to latex-containing products and minimizing the risk of allergic reactions.

Choice B rationale:

Placing monitoring cords and tubes in a stockinette can help create a barrier between the client's skin and the latex-containing products. This measure helps reduce the risk of direct contact with latex, which could trigger an allergic reaction in a latex-sensitive individual.

Choice C rationale:

Choosing rubber injection ports for fluid administration is not appropriate for a client with a latex allergy. Rubber products often contain latex, which can lead to an allergic reaction in susceptible individuals.

Choice D rationale:

Having phenytoin IV readily available is not directly relevant to a client with a latex allergy. Phenytoin is an antiepileptic medication and should be available for clients who require it, but it does not address the specific concern of latex exposure.

A. Fluticasone. B. Albuterol. C. Salmeterol. D. Beclomethasone.

Correct Answer is B

Explanation

Choice A rationale:
(Fluticasone) Fluticasone is a corticosteroid inhaler used for the long-term management of asthma symptoms and prevention of asthma attacks. It is not suitable for treating acute asthma

attacks. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
Choice B rationale:
(Albuterol) Albuterol is a short-acting beta-agonist bronchodilator and the preferred medication for relieving acute asthma symptoms and treating asthma attacks. It works by quickly relaxing the airway muscles, making it easier to breathe during an asthma attack. Therefore, this is the correct choice for medications to treat an acute asthma attack.
Choice C rationale:
(Salmeterol) Salmeterol is a long-acting beta-agonist bronchodilator used for the prevention of asthma symptoms but should not be used for treating acute asthma attacks. It has a slower onset of action compared to short-acting beta-agonists like albuterol. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
Choice D rationale:
(Beclomethasone) Beclomethasone is a corticosteroid inhaler used for long-term asthma management and prevention of asthma symptoms but is not appropriate for treating acute asthma attacks. Therefore, this is not the correct choice for medications to treat an acute asthma attack.

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A nurse in an emergency department is assessing a client who has a basilar skull fracture and serosanguineous nasal discharge following a motor vehicle crash. Which of the following findings should the nurse identify as reliable for determining that the discharge is cerebrospinal fluid?

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