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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Correct Answer is C
Explanation
Compression fractures. Osteoporosis is a condition characterized by decreased bone mass and density, which can lead to an increased risk of fractures. In severe cases of osteoporosis, the client may be at risk for compression fractures, especially in the spine. Compression fractures can lead to pain, loss of height, and a stooped posture.
Choice A, diabetes, is not the correct answer because it is a metabolic disorder that affects the way the body uses glucose.
Choice B, cardiac disease, is not the correct answer because it is a group of disorders that affect the heart and blood vessels.
Choice D, hypertension, is not the correct answer because it is a condition characterized by high blood pressure.
Correct Answer is B
Explanation
Glucose tolerance test in combination with a Growth hormone measurement. Acromegaly is a condition in which there is an excess of growth hormone (GH) production by the anterior pituitary gland, resulting in abnormal growth of bones and tissues in the body. The definitive diagnostic test for acromegaly involves a glucose tolerance test combined with a measurement of GH levels. During the test, the client will be given a dose of glucose, and the GH levels will be measured before and after the glucose is given. In acromegaly, the GH levels remain elevated even after glucose administration.
Choice A, bone radiographs, may show the enlarged bones associated with acromegaly, but it is not the definitive diagnostic test for the condition.
Choice C, growth hormone levels, is not specific enough for diagnosing acromegaly, as elevated GH levels can occur in other conditions as well.
Choice D, a serum glucose level, is not specific for acromegaly, as the glucose level may be normal in clients with the condition.
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