The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.
The nurse notices a yellow stain around fluid dripping from the patient's ear.
The nurse's priority intervention will be as follows:
Prevent the drainage by applying a pressure dressing.
Allow fluid to drain from the patient's ear onto gauze and notify the provider.
Hang intravenous (IV) fluids to replace fluids lost.
Administer antibiotics due to increased risk of infection.
The Correct Answer is B
Choice A rationale
Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.
Choice B rationale
Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.
Choice C rationale
Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.
Choice D rationale
Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Detached retina typically does not present with sharp, stabbing pain. Instead, patients experience painless symptoms like vision abnormalities due to separation of the retina from supporting tissue.
Choice B rationale
Total vision loss is rare with a detached retina unless extensive damage occurs. Partial visual disruption, such as curtain-like vision loss, is a hallmark symptom.
Choice C rationale
A curtain-like loss of vision arises from retinal detachment, disrupting visual fields as the retina separates from its vascular supply and neural connections.
Choice D rationale
Yellow sclera discoloration is associated with jaundice due to bilirubin accumulation, unrelated to retinal detachment pathology, which affects visual symptoms and not scleral appearance.
Correct Answer is B
Explanation
Choice A rationale
Administering recombinant tissue plasminogen activator (t-PA) may be necessary, but confirming ischemic stroke via CT scan precedes treatment to rule out hemorrhagic stroke, which contraindicates t-PA.
Choice B rationale
Performing a STAT non-contrast CT scan of the head is the priority to differentiate between ischemic and hemorrhagic stroke, enabling appropriate and timely intervention.
Choice C rationale
A STAT EKG and chest X-ray, though helpful in identifying concurrent cardiac or pulmonary issues, are not immediate priorities in acute stroke evaluation.
Choice D rationale
While assessing dysphagia is critical post-stroke, it is not a priority during initial stroke evaluation, which focuses on rapid imaging and differentiation of stroke type. .
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