The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of leaking of cerebral spinal fluid (CSF)?
Swelling.
Change in the level of consciousness (LOC).
Signs of increased intracranial pressure (ICP).
Halo sign.
The Correct Answer is D
Halo sign. The presence of clear fluid with a yellowish ring around it (Halo sign) on the client's bed linens, tissues, or skin may indicate the presence of leaking of cerebral spinal fluid (CSF).
Swelling, choice A, change in the level of consciousness (LOC), choice B, and signs of increased intracranial pressure (ICP), choice C, may be indicative of a head injury, but do not specifically indicate the presence of leaking of CSF.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The assessment finding that is most important in determining which client has a higher risk for testicular cancer is cryptorchidism as an infant. Cryptorchidism, or undescended testicle(s), is a condition where one or both testicles fail to move from the abdomen into the scrotum before birth. Males with cryptorchidism are many times more likely to get testicular cancer than those with normally descended testicles. Cryptorchidism is the main risk factor for testicular cancer, while other factors such as previous STI, low sperm count, and family history of cancer are less clear or less common
Correct Answer is B
Explanation
In the Rinne test, the nurse first places a tuning fork on the mastoid process behind the ear, and when the client states that the sound is no longer heard, the tuning fork is placed beside the ear. This test is done to compare bone conduction with air conduction. When sound is no longer heard via bone conduction, the sound will still be heard via air conduction.
Choice A is incorrect because it describes the Weber test, not the Rinne test.
Choice C is incorrect because it is not a standard hearing test.
Choice D is incorrect because it describes the Whisper test, which is also used to test for hearing loss.
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