The emergency room nurse notes clear drainage dripping from the nose of a newly admitted patient with a head injury after diving into shallow water. Which initial intervention should the nurse perform?

Choice A reason: Completing a halo test with the fluid is the initial intervention that the nurse should perform, as it can help to determine if the fluid is cerebrospinal fluid (CSF) or not. CSF is the fluid that surrounds and protects the brain and spinal cord, and it can leak from the nose or ears after a head injury. A halo test involves placing a drop of the fluid on a piece of filter paper or gauze and observing the color and shape of the stain. If the fluid is CSF, it will form a yellowish ring around a central blood spot, creating a halo effect.

Choice B reason: Taping a sterile gauze pad under the nose and monitoring the amount of fluid is not the initial intervention that the nurse should perform, as it does not help to identify the type of fluid. It may also increase the risk of infection or pressure on the brain if the fluid is CSF.

Choice C reason: Documenting the presence of rhinorrhea is not the initial intervention that the nurse should perform, as it does not help to diagnose or treat the condition. Rhinorrhea is the medical term for a runny nose, which can have many causes, such as allergies, colds, or sinus infections. It is not a specific sign of a head injury or CSF leakage.

Choice D reason: Informing the physician of the assessment is an important intervention that the nurse should perform, but not the initial one. The nurse should first confirm if the fluid is CSF or not, as this can affect the management and prognosis of the patient. The nurse should then report the findings and the patient's vital signs, neurological status, and other relevant information to the physician.

Choice A reason: Risk for Falls is the priority nursing diagnosis for a patient with Parkinson disease, as the disease affects the patient's balance, coordination, and posture. The patient may have difficulty walking, turning, and standing, which increases the risk of falling and injuring themselves. The nurse should implement interventions to prevent falls, such as providing assistive devices, removing environmental hazards, and educating the patient and family about fall prevention.

Choice B reason: Ineffective Self-Care Ability related to cognitive deficit is a possible nursing diagnosis for a patient with Parkinson disease, as the disease may impair the patient's memory, judgment, and problem-solving skills. The patient may have difficulty performing activities of daily living, such as bathing, dressing, and grooming. The nurse should assess the patient's self-care abilities, provide assistance as needed, and encourage the patient to maintain their independence and dignity.

Choice C reason: Risk for Impaired Skin Integrity related to uncontrolled hand tremors is another possible nursing diagnosis for a patient with Parkinson disease, as the disease causes involuntary movements of the hands, arms, and legs. The patient may scratch, rub, or injure their skin due to the tremors. The nurse should monitor the patient's skin condition, provide skin care, and protect the patient from skin breakdown.

Choice D reason: Nutrition: Less Than Body Requirements related to frequent nausea during meals is a potential nursing diagnosis for a patient with Parkinson disease, as the disease may affect the patient's appetite, digestion, and swallowing. The patient may experience nausea, vomiting, constipation, or dysphagia, which can lead to malnutrition and dehydration. The nurse should assess the patient's nutritional status, provide dietary modifications, and ensure adequate fluid intake.