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 ["A","C","D"]
Explanation
Meniere's disease is a disorder of the inner ear characterized by episodes of vertigo, hearing loss, tinnitus, and a feeling of fullness or pressure in the ear. Nystagmus is not a common symptom of Meniere's disease. Nystagmus is a rhythmic oscillation of the eyes and may be present in other conditions such as vestibular disorders, drug toxicity, or brainstem lesions.
Choice B, nystagmus, is incorrect because although nystagmus can occur in other vestibular disorders, it is not a common symptom of Meniere's disease.
Choice E, loss of vision, is incorrect because Meniere's disease affects the inner ear and does not typically cause vision loss.
Correct Answer is B
Explanation
Choice A is incorrect because stuporous is a state of reduced consciousness, and does not describe the posturing observed in the client.
Choice B is correct because decerebrate posturing is characterized by extension of the arms, wrists, and fingers, and extension and internal rotation of the legs, with plantar flexion of the feet.
Choice C is incorrect - Decorticate posturing is characterized by flexion of the arms, wrists, and fingers, extension, internal rotation, and adduction of the legs, with plantar flexion of the feet. This is caused by damage to the cerebral cortex and is indicative of a neurological problem.
Choice D is incorrect because flaccidity is a state of complete lack of muscle tone, and does not describe the posturing observed in the client.
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