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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While lung injury could occur in traumatic situations, it is not the primary reason for mechanical ventilation in the context of a spinal cord injury.
B. A history of smoking may affect lung health but does not directly justify the immediate need for mechanical ventilation following a spinal cord injury.
C. The nerves that control lung function may be injured in a cervical spinal cord injury, particularly at higher levels like C3-C5, leading to respiratory muscle paralysis and necessitating mechanical ventilation to support breathing.
D. While unconsciousness may complicate breathing, the primary concern is the loss of function in the spinal cord nerves controlling respiration.
Correct Answer is D
Explanation
A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.
B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.
C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.
D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.
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