In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding?

(Click the chosen location. To change, click on the new location.)

Rationale

A. Blood cultures are typically obtained to identify the causative organism of the liver abscess and to monitor the effectiveness of antimicrobial therapy. While repeat blood cultures may be considered if there is concern for ongoing infection or antimicrobial resistance, they may not be the immediate priority in the context of new-onset jaundice.

B. Jaundice indicates possible liver dysfunction, which can occur due to various reasons including progression of the liver abscess, obstruction of the bile ducts, or drug-induced liver injury from antimicrobial therapy. Evaluating liver function tests (such as serum bilirubin, liver enzymes) is essential to assess the extent of liver damage and guide further management.

C. Increasing protein intake is generally not indicated as the immediate response to jaundice. While adequate nutrition is important, specific dietary adjustments should be based on comprehensive assessment findings and medical recommendations.

D. Emergency transport to an inpatient facility may be necessary if the client shows signs of severe complications such as hemodynamic instability, worsening symptoms, or acute liver failure. However, this decision should be based on a thorough assessment of the client's condition and the availability of resources at the community clinic.

Rationale

A. Dill pickles and black olives are typically high in sodium due to the pickling process. High sodium intake can exacerbate hypertension by increasing fluid retention and raising blood pressure.

B. Canned chicken broth often contains a high amount of sodium unless it is specifically labeled as low sodium or reduced sodium. Barley itself is a nutritious whole grain, but the sodium content in canned broth might counterbalance its benefits.

C. Tomato juice can be a good choice for someone with hypertension as long as it is low in sodium or sodium-free. Tomatoes are rich in potassium and other nutrients beneficial for heart health. Gluten-free crackers can be a healthy addition if they are low in sodium and made from whole grains.

D. Sweet potatoes are a nutrient-dense food high in potassium, fiber, and various vitamins and minerals. They are naturally low in sodium and are considered heart-healthy due to their potassium content, which helps counteract the effects of sodium on blood pressure.