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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Sudden unconsciousness, unresponsiveness, and apnea are not typical symptoms of a brain tumor. They are more likely to indicate a stroke, seizure, or cardiac arrest.

Choice B reason: Increased temperature, blood pressure, heart rate, and respirations are not specific symptoms of a brain tumor. They are more likely to indicate an infection, inflammation, or stress.

Choice C reason: Changes in vision and personality, and headache upon awakening are common symptoms of a brain tumor. They are caused by the pressure of the tumor on the brain tissue and the cranial nerves.

Choice D reason: Fever, increased white blood cell count, and decreased appetite are not typical symptoms of a brain tumor. They are more likely to indicate a systemic infection or malignancy.

A. macrocytic, normochromic B. microcytic, hypochromic C. normocytic, normochromic D. microcytic, normochromic

Correct Answer is A

Explanation

Choice A reason: This is correct. Folic acid deficiency causes macrocytic, normochromic anemia, which means that the red blood cells are larger than normal, but have normal color and hemoglobin content. Folic acid is a vitamin that is needed for the synthesis of DNA and the maturation of red blood cells.

Choice B reason: This is incorrect. Microcytic, hypochromic anemia means that the red blood cells are smaller than normal and have less color and hemoglobin content. This type of anemia is caused by iron deficiency, not folic acid deficiency.

Choice C reason: This is incorrect. Normocytic, normochromic anemia means that the red blood cells are normal in size, color, and hemoglobin content, but there are fewer of them. This type of anemia is caused by blood loss, hemolysis, or bone marrow failure, not folic acid deficiency.

Choice D reason: This is incorrect. Microcytic, normochromic anemia means that the red blood cells are smaller than normal, but have normal color and hemoglobin content. This type of anemia is rare and is caused by disorders of red blood cell production, such as thalassemia or sideroblastic anemia, not folic acid deficiency.

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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?

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Which early symptoms in a focused assessment by the nurse may indicate the presence of a brain tumor?

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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?