A patient presents to the emergency department after a fall. The nurse notes raccoon eyes and rhinorrhea. The healthcare provider suspects a skull fracture. Which of the following nursing interventions is most appropriate?

Instill normal saline into the nose to clear any possible obstructions.

Use a sterile dressing to collect the nasal drainage and send it for testing

Apply ice packs to the nose to reduce swelling and drainage.

Instruct the patient to cough to clear nasal passages.

Answer and Explanation

The Correct Answer is B

A. Instill normal saline into the nose to clear any possible obstructions: Flushing the nasal passages could increase intracranial pressure or dislodge clots, potentially worsening a skull fracture or causing CSF leakage. This intervention is unsafe in suspected basilar skull fractures.

B. Use a sterile dressing to collect the nasal drainage and send it for testing: Raccoon eyes and clear rhinorrhea suggest a possible basilar skull fracture with cerebrospinal fluid (CSF) leakage. Collecting drainage on a sterile dressing and testing for glucose or beta-2 transferrin confirms the presence of CSF. This intervention protects the patient from infection and provides diagnostic information safely.

C. Apply ice packs to the nose to reduce swelling and drainage: While ice may reduce swelling in minor facial injuries, it does not address the risk of CSF leakage or confirm the diagnosis of a skull fracture. Applying ice does not take priority over diagnostic assessment and infection prevention.

D. Instruct the patient to cough to clear nasal passages: Coughing increases intracranial pressure and may exacerbate CSF leakage or worsen the fracture. Patients with suspected basilar skull fractures should avoid actions that increase pressure in the skull.

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Correct Answer is B

Explanation

A. Escape of red blood cells through damaged glomeruli: Hematuria can occur in some kidney diseases, but the loss of red blood cells through glomerular damage is usually minimal and does not account for the chronic anemia seen in CKD. This mechanism is not the primary cause of anemia in these patients.

B. Minimal production of erythropoietin by the kidney: The kidneys produce erythropoietin, a hormone that stimulates bone marrow to produce red blood cells. In CKD, damaged renal tissue reduces erythropoietin synthesis, leading to decreased red blood cell production and anemia. This is the most common and primary cause of anemia in CKD patients.

C. Decrease absorption of Vitamin B12 and folic acid: Vitamin B12 and folate deficiencies can contribute to megaloblastic anemia, but absorption is usually unaffected by CKD. Nutritional deficiencies are secondary contributors and not the main cause of anemia in chronic kidney disease.

D. Interference with transportation of iron to bone marrow: While CKD may cause functional iron deficiency due to inflammation and hepcidin elevation, iron transport interference is a contributing factor, not the primary cause. The key driver of anemia in CKD remains low erythropoietin production.

A. Explain ROM therapy B. Delay therapy until pain improves C. Manage pain prior to therapy D. Stop therapy permanently

Correct Answer is C

Explanation

A. Explain ROM therapy: Educating the patient about the purpose and benefits of range-of-motion (ROM) therapy is important for cooperation and understanding. However, patient education alone does not address the immediate barrier of pain, which can prevent participation and limit the effectiveness of therapy.

B. Delay therapy until pain improves: Postponing therapy may reduce immediate discomfort but can lead to joint stiffness, contractures, and decreased functional outcomes. Burn rehabilitation requires timely, consistent ROM exercises to maintain mobility, so delaying therapy is not ideal.

C. Manage pain prior to therapy: Administering analgesics before ROM exercises allows the patient to participate more comfortably and effectively. Preemptive pain control reduces muscle guarding, facilitates full joint movement, and improves compliance, directly supporting the goal of preserving function and preventing contractures.

D. Stop therapy permanently: Discontinuing ROM therapy permanently would result in progressive joint contractures, decreased mobility, and long-term functional deficits. Pain management strategies should be used to enable continued participation rather than abandoning therapy altogether.

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A patient presents to the emergency department after a fall. The nurse notes raccoon eyes and rhinorrhea. The healthcare provider suspects a skull fracture. Which of the following nursing interventions is most appropriate?

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Naxlex Comprehensive Predictor Exams

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