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.
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Related Questions
Correct Answer is ["A","B","C"]
Explanation
Polydipsia, Polyuria, and Polyphagia. These are the three P's of hyperglycemia, which are common symptoms of diabetes. Polydipsia refers to excessive thirst, polyuria refers to excessive urination, and polyphagia refers to excessive hunger. These symptoms are caused by high blood glucose levels in the body.
Polyhydramniosrefers to excessive amniotic fluid in the uterus during pregnancy, and it is not a sign or symptom of diabetes.
Correct Answer is {"dropdown-group-1":"B"}
Explanation
The term for severe itching is "pruritus," so the nurse should document the client's complaint as such. Pruritus can be caused by a variety of factors, including allergic reactions, skin conditions, and liver or kidney disease.
The nurse should assess the client's skin for any visible signs of irritation or rash and ask about any recent changes in medications or diet. Treatment for pruritus will depend on the underlying cause but may include topical or oral medications, cool compresses, or avoiding irritants.
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