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?
Complete a halo test with the fluid.
Tape a sterile gauze pad under the nose and monitor the amount of fluid.
Document the presence of rhinorrhea
Inform the physician of the assessment.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is incorrect. Numbness of the fingers is not an early sign of a migraine with an aura, but rather a symptom of a sensory aura, which occurs after the visual aura and before the headache. A sensory aura is a tingling or numb sensation that affects one side of the body, usually the face, arm, or hand.
Choice B reason: This is correct. Visual disturbances are an early sign of a migraine with an aura, which precedes the headache by 10 to 60 minutes. A visual aura is a temporary change in vision, such as seeing flashes, zigzags, blind spots, or shimmering shapes.
Choice C reason: This is incorrect. Lethargy is not an early sign of a migraine with an aura, but rather a symptom of the postdrome phase, which occurs after the headache subsides. The postdrome phase is a period of recovery, where the patient may feel tired, weak, or confused.
Choice D reason: This is incorrect. Vertigo is not an early sign of a migraine with an aura, but rather a symptom of a vestibular migraine, which is a type of migraine that affects the balance and hearing. Vertigo is a sensation of spinning or dizziness that may occur with or without a headache.
Correct Answer is A
Explanation
Choice A reason: Eyes are deviated to the right is an assessment finding that indicates increased intracranial pressure and possible herniation of the brain. It is a sign of cranial nerve III palsy, which affects the movement of the eye and the size of the pupil. It is a medical emergency that requires immediate intervention.
Choice B reason: Amnesia to the cause of the trauma is an assessment finding that indicates memory loss and possible concussion. It is a sign of damage to the temporal lobe, which is involved in memory formation and retrieval. It is not a medical emergency, but it requires further evaluation and monitoring.
Choice C reason: Complaint of mild headache is an assessment finding that indicates pain and discomfort. It is a common symptom of traumatic brain injury, but it is not specific or severe. It can be managed with analgesics and rest.
Choice D reason: Pupils constrict from 5 mm to 2 mm with direct light stimulus is an assessment finding that indicates normal pupillary response. It is a sign of intact cranial nerve II and III function, which control the vision and the pupil size. It is not a cause for concern or notification.
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