The nurse is completing a head to toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?
Clear fluid leaking from the nose.
Sluggish pupillary response to light.
Periorbital ecchymosis of right eye.
Troubled with a severe headache.
The Correct Answer is A
Rationale:
A. Clear fluid leaking from the nose: Clear drainage from the nose following head trauma suggests a cerebrospinal fluid (CSF) leak, often from a basilar skull fracture. This finding requires immediate intervention because it increases the risk of meningitis and indicates a potential breach in the meningeal barrier protecting the brain.
B. Sluggish pupillary response to light: A delayed pupillary reaction may signal mild increased intracranial pressure or localized nerve injury. While important to monitor, it does not demand the same urgent response as a suspected CSF leak.
C. Periorbital ecchymosis of right eye: “Raccoon eyes” or bruising around the eyes may indicate a skull base fracture, but alone it is not an emergency unless accompanied by CSF leakage or neurological deterioration. It should be documented and reported for diagnostic evaluation.
D. Troubled with a severe headache: Headache is a common symptom following head trauma due to concussion or contusion. It requires monitoring and pain management but is not as critical as identifying a CSF leak, which signifies a more severe underlying injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Neurologically stable without indications of an increased ICP: A GCS score of 14 indicates that the client is alert and responding appropriately, with only minimal changes in neurological function. Stability of this score over several hours suggests that intracranial pressure is being adequately controlled and that cerebral perfusion is maintained.
B. Risk for irreversible cerebral damage related to increased ICP: A consistent GCS of 14 does not reflect worsening neurological status. Irreversible cerebral damage is associated with persistently low or deteriorating GCS scores, generally below 8, in severe brain injury.
C. Rehabilitative prognosis is an expected full recovery: While a GCS of 14 reflects a mild injury and positive neurological function, it does not guarantee complete recovery. Long-term prognosis depends on additional factors such as the type and location of the brain injury.
D. Insertion of an ICP monitoring device is necessary: ICP monitoring is typically indicated when a client’s GCS is ≤8 or there is evidence of worsening intracranial pressure. With a stable score of 14, invasive monitoring is not immediately required unless new neurological changes occur.
Correct Answer is C
Explanation
A. Mannitol is an osmotic diuretic that pulls fluid into the intravascular space and promotes diuresis, so sustained hypervolemia is not expected.
B. Mannitol does not significantly affect blood glucose levels; hyperglycemia is more commonly associated with corticosteroids or dextrose solutions.
C. Mannitol causes fluid shifts from intracellular to extracellular spaces, which can dilute serum sodium and lead to hyponatremia.
D. Mannitol increases urine output; decreased urine output would be an abnormal finding and may indicate renal impairment.
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