The nurse notes that a client with a head injury and periorbital ecchymosis has clear nasal drainage. Which nursing action is most appropriate upon this finding?

Perform a halo test

Instruct the client to blow his nose and check the nares for inflammation.

Obtain a specimen of the fluid for culture and sensitivity.

Check the nasal drainage for glucose.

Answer and Explanation

The Correct Answer is A

A. Perform a halo test: Clear nasal drainage in a client with periorbital ecchymosis may indicate cerebrospinal fluid (CSF) leakage. The halo or ring test helps differentiate CSF from normal nasal secretions, which is critical for detecting a basilar skull fracture. Early identification guides further neurologic assessment and prevents complications.

B. Instruct the client to blow his nose and check the nares for inflammation: Blowing the nose can increase intracranial pressure and worsen CSF leakage. Assessing for inflammation does not confirm CSF presence and may be harmful in suspected skull fractures.

C. Obtain a specimen of the fluid for culture and sensitivity: Culturing the fluid is unnecessary initially and may delay urgent assessment. Identifying CSF leakage takes priority to prevent infection and guide immediate care.

D. Check the nasal drainage for glucose: Glucose testing can suggest CSF, but the halo test provides a more rapid and reliable bedside assessment. Confirming CSF leakage quickly is essential for early intervention.

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Correct Answer is D

Explanation

A. bone marrow transplant: Bone marrow transplant does not reverse hyperacute rejection. This type of rejection occurs because of pre-existing antibodies, and once the process begins, the damage progresses too rapidly for immune-modulating procedures like marrow transplant to be effective.

B. immediate dialysis to prevent damage to the new kidney: Dialysis may be needed after the kidney is removed, but it does not stop the rejection process. Hyperacute rejection results in irreversible vascular injury to the graft, so dialysis cannot salvage the transplanted organ.

C. high-dose intravenous cyclosporin therapy: Cyclosporin is useful for preventing or managing acute rejection, not hyperacute rejection. In hyperacute rejection, the tissue damage occurs within minutes to hours, and immunosuppressive therapy cannot reverse the destruction once it has begun.

D. removal of the transplanted kidney: Hyperacute rejection is caused by preformed antibodies that immediately attack the graft, leading to rapid thrombosis and necrosis. The transplanted organ is nonviable, so prompt removal is necessary to prevent systemic complications such as sepsis or disseminated clotting.

A. hemorrhage from esophageal varices. B. liver abscess. C. hemorrhage from duodenal diverticulitis D. small bowel obstruction

Correct Answer is A

Explanation

A. hemorrhage from esophageal varices: Portal hypertension increases pressure in the portal venous system, leading to esophageal varices that can rupture. Massive bleeding from varices is life-threatening and requires immediate intervention, making this the most critical complication to monitor.

B. liver abscess: Liver abscesses can occur in clients with liver disease but are less immediately life-threatening than variceal bleeding. They develop over time and usually present with fever and localized pain rather than sudden hemorrhage.

C. hemorrhage from duodenal diverticulitis: Duodenal diverticulitis is rare and not a common complication of portal hypertension. While it can cause bleeding, it is not the primary life-threatening concern in this population.

D. small bowel obstruction: Small bowel obstruction is not directly associated with portal hypertension. Although it can cause significant complications, it is not an immediate risk in these clients.

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The nurse notes that a client with a head injury and periorbital ecchymosis has clear nasal drainage. Which nursing action is most appropriate upon this finding?

Nursing Test Bank

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