The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

prevent the drainage by applying a tight pressure dressing

administer antibiotics due to increased risk of infection

allow fluid to drain from the patient's car onto gauze and notify

hang intravenous (IV) fluids to replace fluids lost and prevent dehydration

Answer and Explanation

The Correct Answer is C

A) Prevent the drainage by applying a tight pressure dressing:
Applying a tight pressure dressing is not the appropriate intervention in this case. The presence of fluid draining from the ear, particularly a yellow stain, could indicate cerebrospinal fluid (CSF) leakage, which is a potential sign of a skull fracture or traumatic brain injury (TBI) involving the base of the skull. Applying a tight pressure dressing could potentially increase pressure or cause further injury.

B) Administer antibiotics due to increased risk of infection:
While there is an increased risk of infection with a CSF leak, antibiotics should not be administered immediately unless there is clear evidence of an infection. The priority action is to identify whether the fluid is CSF, as antibiotics alone will not address the underlying issue of a CSF leak. The nurse should allow the fluid to drain, collect a sample, and notify the healthcare provider for further assessment, which may include imaging or testing for the presence of CSF.

C) Allow fluid to drain from the patient's ear onto gauze and notify the healthcare provider:
The yellow stain around the fluid dripping from the patient's ear suggests the possibility of CSF leakage, a sign of a skull base fracture. CSF leakage may occur after a traumatic brain injury and should be handled carefully. The nurse's priority action is to allow the fluid to drain onto gauze to prevent the buildup of pressure and to prevent further leakage into the ear canal. The nurse should also immediately notify the healthcare provider for further evaluation and management.

D) Hang intravenous (IV) fluids to replace fluids lost and prevent dehydration:
While IV fluids may be necessary in some cases for patients with trauma, the priority in this situation is to identify the source and nature of the drainage. If the fluid is CSF, it may be important to manage the leak appropriately rather than focusing solely on replacing fluids. The nurse should first confirm whether the fluid is CSF and notify the healthcare provider for further assessment and management. Replacing fluids may be necessary, but it is not the immediate priority.

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Correct Answer is A

Explanation

A) Assess the patient's neurological status and repeat vital signs:
In patients with a spinal cord injury (SCI) at T1, autonomic dysreflexia or neurogenic shock can lead to unstable vital signs, including hypotension and bradycardia. The most immediate concern in this scenario is to determine if the patient is experiencing neurogenic shock, which can result from the loss of sympathetic nervous system function below the level of the injury. By assessing the patient’s neurological status (such as checking for changes in motor function, sensation, or level of consciousness) and repeating vital signs, the nurse can gather the necessary data to make informed decisions about further interventions.

B) Ask the patient care tech to check on the patient:
While the patient care tech can assist with tasks, this is not the priority action. The nurse must immediately assess the patient's condition, particularly given the vital sign changes and the potential for a life-threatening situation like neurogenic shock. The nurse's clinical judgment and expertise are required to evaluate the situation appropriately.

C) Place the client in reverse Trendelenburg position:
Placing the patient in reverse Trendelenburg may help with hypotension in certain situations, but it is not the priority intervention for someone with a spinal cord injury at T1. In cases of neurogenic shock or autonomic dysreflexia, positioning alone will not correct the underlying issue.

D) Administer intravenous (IV) fluids to increase cardiac output:
While IV fluids may be necessary to treat hypotension in some situations, the nurse must first assess the patient’s neurological status and repeat vital signs to determine the cause of the hypotension and bradycardia. Administering IV fluids without understanding the underlying cause could be inappropriate or even harmful, particularly if the low blood pressure is related to neurogenic shock, which requires careful management.

A. single color throughout B. diameter smaller than 2mm. C. has uneven or irregular borders. D. Is symmetrical in shape."

Correct Answer is C

Explanation

A) Single color throughout:
A mole that is a single, consistent color is typically not a concern for melanoma. However, one of the key warning signs of melanoma is a mole that has multiple colors or shades, such as tan, brown, black, or even red or blue. The presence of more than one color in a mole can indicate melanoma, and the client should be advised to seek medical attention if the mole has varied colors.

B) Diameter smaller than 2mm:
A mole that is smaller than 2mm in diameter is typically not a concern for melanoma. Melanomas are often larger than 6mm in diameter, about the size of a pencil eraser, though smaller melanomas can also occur. A mole smaller than 2mm is usually considered benign, but any change in size, shape, or color, regardless of the starting size, should be evaluated.

C) Has uneven or irregular borders:
One of the primary warning signs of melanoma is the presence of irregular or uneven borders on a mole. Normal moles typically have smooth, even borders, while moles with jagged, blurred, or irregular edges are more likely to be melanoma. The client should seek medical attention if they notice any moles with irregular borders, as this could be a sign of malignancy.

D) Is symmetrical in shape:
A mole that is symmetrical (both halves are the same size and shape) is generally not a concern for melanoma. In contrast, asymmetry (when one half of the mole does not match the other half) is a key warning sign for melanoma. A mole that lacks symmetry should be evaluated by a healthcare provider.

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The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

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Explanation

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