Your patient in ED with a head injury develops rhinorrhea. You quickly grab a 4x4 gauze to test the drainage. When you observe the drainage on the gauze, which of the following would indicate a positive Halo sign?
Blood will cover the whole gauze
There will be a circle of blood in the center of gauze with a yellow ring around it
There will be a greenish color fluid present on the gauze
There will be multiple circles of blood noted on the gauze
The Correct Answer is B
A. Blood covering the whole gauze is incorrect because this suggests active bleeding only. It does not demonstrate separation of cerebrospinal fluid from blood and therefore does not indicate a cerebrospinal fluid leak.
B. There will be a circle of blood in the center of the gauze with a yellow ring around it is correct because this finding represents the positive Halo (or ring) sign. When cerebrospinal fluid is mixed with blood, the blood remains concentrated in the center while the clearer CSF migrates outward, forming a yellow or straw-colored ring. This indicates a possible CSF leak, commonly associated with a basilar skull fracture, and is a medical emergency due to the risk of meningitis.
C. There will be a greenish-colored fluid present on the gauze is incorrect because CSF is typically clear or straw-colored, not green. Green drainage is more suggestive of infection or purulent nasal discharge rather than a CSF leak.
D. There will be multiple circles of blood noted on the gauze is incorrect because multiple blood spots do not demonstrate the characteristic separation pattern seen with CSF. The halo sign specifically involves a central blood spot with a surrounding clear or yellow ring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Lean meats is incorrect because protein intake is important for patients on hemodialysisto replace protein lost during treatment. Lean meats are generally encouraged, though intake may be adjusted based on lab values such as BUN and albumin.
B. Fresh fruits is partially correct, but not all fruits need to be restricted. Fruits that are low in potassiumcan usually be eaten in moderation. The main concern is fruits high in potassium.
C. Whole grains is incorrect because whole grains provide fiber and other nutrients. They are generally not restricted unless there are specific concerns related to phosphorus content, which can sometimes require portion control.
D. Bananas and oranges is correct because these fruits are high in potassium, which can accumulate in patients with renal failure. Elevated potassium levels (hyperkalemia) are dangerous and can lead to cardiac arrhythmias or arrest. Patients on hemodialysis need to monitor and often limit high-potassium foods.
Correct Answer is B
Explanation
A. That the patient will be alert and oriented is incorrect because a GCS of 8 indicates severe impairment of consciousness, not alertness. Patients who are alert and oriented typically have a GCS of 13–15.
B. The patient will be comatose is correct because a GCS score of 8 or lessis generally considered coma or severe brain injury. This indicates significant neurological impairment, and the patient is likely unable to respond appropriately to verbal or painful stimuli. Immediate interventions often focus on airway protection, stabilization, and rapid neurological assessment.
C. The patient will likely have a UTI is incorrect because a urinary tract infection is not related to the GCS score. While a UTI can cause confusion in older adults, it does not directly correlate with a GCS of 8 in trauma or acute neurological events.
D. That the patient will be vomiting is incorrect because vomiting may occur in patients with elevated intracranial pressure or head trauma, but it is not a defining feature of a GCS of 8. The key concern is level of consciousnessand neurological status.
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