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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale

Soft restraints are utilized for agitation but are not prioritized in epilepsy care. Emergency equipment like suction ensures airway safety during seizures.

Choice B rationale

Glasgow Coma Scale evaluates neurological function but is less relevant for epilepsy management compared to essential tools like suction equipment for airway protection.

Choice C rationale

Suction equipment and oxygen are vital in epilepsy management to clear secretions and maintain oxygenation during seizures. Patent IV access allows rapid administration of emergency medications.

Choice D rationale

Dextrose infusion is used to treat hypoglycemia rather than seizures. Epilepsy care prioritizes tools like suction and oxygen for immediate seizure-related complications. .

A. Scheduled voiding. B. External catheter. C. Indwelling urinary catheter. D. Intermittent catheterization.

Correct Answer is D

Explanation

Choice A rationale

Scheduled voiding relies on the patient’s ability to control bladder function, which is ineffective in cases of a flaccid bladder caused by spinal cord injuries.

Choice B rationale

External catheters, such as condom catheters, are suited for patients with partial bladder control but are not appropriate for flaccid or atonic bladder management.

Choice C rationale

Indwelling urinary catheters may be used short-term but pose higher risks of urinary tract infections and are not optimal for long-term management of flaccid bladder.

Choice D rationale

Intermittent catheterization is the preferred method for managing flaccid bladder, ensuring complete bladder emptying while minimizing infection risks compared to indwelling catheters.

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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:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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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: