What sign/symptom of a patient would cause the nurse to suspect cerebral spinal fluid leakage?
Altered level of consciousness
Painful headache
Salty taste in their mouth, postnasal drip or clear fluid draining from the nose
All of the above
The Correct Answer is C
Choice A: Altered level of consciousness is not a sign/symptom of cerebral spinal fluid leakage, but rather a sign/symptom of increased intracranial pressure or brain injury.
Choice B: Painful headache is not a sign/symptom of cerebral spinal fluid leakage, but rather a sign/symptom of meningitis or sinusitis.
Choice C: Salty taste in their mouth, postnasal drip or clear fluid draining from the nose is a sign/symptom of cerebral spinal fluid leakage, as it indicates that the fluid is escaping from the brain or spinal cord through a tear or hole in the meninges or skull.
Choice D: All of the above is not correct, as only choice C is a sign/symptom of cerebral spinal fluid leakage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Incontinence is a cause of skin breakdown, as it can expose the skin to moisture, bacteria, and chemicals that can irritate and damage the skin.
Choice B: Altered level of consciousness is a cause of skin breakdown, as it can impair the patient's ability to sense and report pain, discomfort, or pressure on the skin.
Choice C: Immobility is a cause of skin breakdown, as it can reduce the blood flow and oxygen to the skin and increase the pressure on bony prominences.
Choice D: All of the above is correct, as all of these factors can contribute to skin breakdown.
Correct Answer is B
Explanation
Choice A: Unconsciousness, unarousable unresponsiveness is not a description of persistent vegetative state, but rather a description of coma, as it is a state of complete loss of consciousness and reflexes caused by severe brain injury.
Choice B: Devoid of cognitive function but has sleep-wake cycles is a description of persistent vegetative state, as it is a state of minimal awareness and responsiveness caused by widespread brain damage.
Choice C: Inability to move or respond except for eye movements due to a lesion affecting the pons is not a description of persistent vegetative state, but rather a description of locked-in syndrome, as it is a state of complete paralysis and preserved consciousness caused by damage to the brainstem.
Choice D: Unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes is not a description of persistent vegetative state, but rather a description of akinetic mutism, as it is a state of severe apathy and reduced motor activity caused by damage to the frontal lobes or basal ganglia.
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