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The nurse is caring for a trauma patient with suspected brain injury. The nurse notices a yellow stain around fluid dripping from the patient's ear. The nurse's priority intervention will be as follows:

Administer antibiotics due to increased risk of infection

Prevent the drainage by applying a pressure dressing

Hang intravenous (IV) fluids to replace fluids lost

Allow fluid to drain from the patient's ear onto gauze and notify provider

Answer and Explanation

The Correct Answer is D

A. Antibiotics may be necessary if infection is confirmed, but this is not the priority action.

B. Applying a pressure dressing could increase intracranial pressure or worsen the injury.

C. IV fluids can be helpful in managing shock but are not directly related to CSF leakage management.

D. Yellowish fluid from the ear, which creates a "halo" or yellow ring around it on gauze, may indicate cerebrospinal fluid (CSF) leakage. This is a sign of a potential skull fracture and requires prompt provider notification. Allowing the fluid to drain and collecting it can provide necessary information about the injury.

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Correct Answer is A

Explanation

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

A. display preinjury personality traits. B. actively participate in the rehabilitation process as appropriate. C. return to work as a corporate attorney. D. recall events from childhood.

Correct Answer is B

Explanation

A. Expecting a patient to display preinjury personality traits may not be feasible, as head injuries can lead to permanent personality changes.

B. Actively participating in rehabilitation is a realistic goal that focuses on the patient's engagement in the recovery process, which can improve functional outcomes.

C. Returning to a specific job, such as a corporate attorney, may not be a realistic goal initially and depends on the extent of cognitive recovery.

D. Recalling childhood events is not a priority goal in rehabilitation; functional and recovery-focused goals are more relevant.

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The nurse is caring for a trauma patient with suspected brain injury. 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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