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 D
Explanation
Choice A reason: This is incorrect. Arm and leg weakness, paresthesia, blurred vision, and facial frown are not specific to Parkinson disease, but may be seen in other neurological disorders, such as multiple sclerosis or stroke.
Choice B reason: This is incorrect. Uncontrollable rapid jerky movements in arms, trunk and facial muscles are characteristic of Huntington disease, not Parkinson disease. Huntington disease is a genetic disorder that causes progressive degeneration of the nerve cells in the brain.
Choice C reason: This is incorrect. Stumbling, backward tilt of the head, quick fluttering hand movements, and quick uncontrolled gait are signs of cerebellar ataxia, not Parkinson disease. Cerebellar ataxia is a disorder that affects the coordination and balance of the movements, caused by damage to the cerebellum.
Choice D reason: This is correct. Hand tremors, bradykinesia, skeletal muscle rigidity, and postural instability are the cardinal signs and symptoms of Parkinson disease. Parkinson disease is a chronic and progressive disorder that affects the dopamine-producing neurons in the brain, resulting in movement problems.
Correct Answer is A
Explanation
Choice A reason: Maintaining a flat lying position for 14 hours following the procedure is the highest priority teaching point for the patient who had a lumbar puncture. It helps to prevent cerebrospinal fluid leakage and post-lumbar puncture headache, which can be severe and debilitating.
Choice B reason: Muscular discomfort is expected after being in a curled position for a period of time, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, massage, or heat therapy.
Choice C reason: Resuming oral intake immediately after the procedure is not a priority teaching point for the patient who had a lumbar puncture. It is not contraindicated, but it is not essential either. The patient should drink plenty of fluids to replenish the cerebrospinal fluid and prevent dehydration.
Choice D reason: Mild pain is expected at the needle insertion site, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, ice packs, or dressing.
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