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 ["D","E"]

Explanation

Choice A rationale

Weekly appointments to change the catheter are unnecessary unless specifically indicated. Most urinary catheters are changed monthly or as needed based on physician's discretion or complications.

Choice B rationale

Sexual intimacy is possible with an indwelling urinary catheter if handled properly. Providing education on safe practices promotes normalcy and quality of life for the patient.

Choice C rationale

Wearing underwear is recommended to protect the catheter and minimize risk of contamination or accidental dislodgement. This information supports proper hygiene and comfort.

Choice D rationale

Regular emptying of the leg bag every 4 hours or more frequently prevents overfilling, which could lead to backflow and increased risk of urinary tract infections.

Choice E rationale

Foul-smelling, cloudy urine can indicate infection such as a urinary tract infection. Prompt reporting ensures early treatment and prevention of complications.

A. Frequency of urination. B. Dysuria. C. Flank pain and fever. D. Pyuria and hematuria.

Correct Answer is C

Explanation

Choice A rationale

Monitoring frequency of urination indicates bladder involvement, often related to cystitis. However, it does not indicate ascending progression to the kidneys, which is more severe and requires additional symptoms.

Choice B rationale

Dysuria, or painful urination, typically signifies lower urinary tract infection rather than progression to upper urinary tract infection, such as pyelonephritis. It is not specific to kidney involvement.

Choice C rationale

Flank pain and fever are hallmark symptoms of pyelonephritis, indicating ascending progression of infection from the bladder to the kidneys. These symptoms signal systemic involvement and require immediate medical attention.

Choice D rationale

Pyuria and hematuria are signs of bladder infection but do not indicate progression to kidney infection. These are specific to inflammation or infection in the lower urinary tract.

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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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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: