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 A
Explanation
Choice A reason: Decreased hematocrit and hemoglobin indicate anemia, which is a condition where the blood does not carry enough oxygen to the tissues. This can cause symptoms such as confusion, restlessness, fatigue, and weakness in older adults.
Choice B reason: Increased erythrocyte count, or polycythemia, is a condition where the blood has too many red blood cells. This can cause the blood to become thick and viscous, which can impair blood flow and oxygen delivery. However, this is not the best explanation for the patient's confusion and restlessness, as polycythemia usually causes symptoms such as headache, dizziness, itching, and flushing.
Choice C reason: Normochromic red blood cells are red blood cells that have a normal color and hemoglobin content. This is not a finding that would explain the patient's confusion and restlessness, as it indicates a normal red blood cell function.
Choice D reason: Decreased thrombocytes, or platelets, are blood cells that help with clotting. This is a finding that would increase the risk of bleeding, but not the risk of confusion and restlessness. Decreased thrombocytes can cause symptoms such as bruising, bleeding gums, nosebleeds, and petechiae.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: Lethargy is a sign of increased intracranial pressure (ICP), as it indicates a decreased level of alertness and responsiveness due to brain compression¹².
Choice B reason: Slowed responses to verbal cues are a sign of increased ICP, as they indicate a decreased level of cognitive function and communication ability due to brain compression¹².
Choice C reason: Negative Babinski sign is not a sign of increased ICP, as it indicates a normal reflex response of the toes to stimulation of the sole of the foot³. A positive Babinski sign, where the big toe extends upward and the other toes fan out, is a sign of neurological damage, but not necessarily increased ICP³.
Choice D reason: Altered speech is a sign of increased ICP, as it indicates a decreased level of language function and articulation due to brain compression¹².
Choice E reason: Decreased level of consciousness is a sign of increased ICP, as it indicates a decreased level of awareness and arousal due to brain compression¹².
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