A 3-year-old patient who is admitted to the hospital for the treatment of a skull fracture has clear liquid draining from his nose. In consideration of the patient's injury, which action should the nurse take initially?
Give the patient a soft tissue to clean up the drainage.
Check the drainage for glucose content.
Obtain a specimen of the drainage for culture and sensitivity.
Ask the father if the patient had nasal drainage before his injury.
The Correct Answer is B
Choice A rationale:
Giving the patient a soft tissue is not the initial action to take when dealing with clear liquid drainage from the nose. Assessing the content of the drainage is more crucial for appropriate management.
Choice B rationale:
Checking the drainage for glucose content is essential because the presence of glucose indicates that the drainage is cerebrospinal fluid (CSF), which can occur with a skull fracture that involves the base of the skull.
Choice C rationale:
Obtaining a specimen of the drainage for culture and sensitivity is important, but it is not the initial action. Confirming the nature of the drainage takes precedence.
Choice D rationale:
Asking the father about nasal drainage before the injury is not as relevant as assessing the current drainage, which could be indicative of a CSF leak.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Polyarthritis is a manifestation of rheumatic fever, but it is not the primary manifestation. The main manifestation is carditis, involving inflammation of the heart's valves and structures.
Choice B rationale:
Carditis is a hallmark manifestation of rheumatic fever. It involves inflammation of the heart's valves and structures, leading to murmurs and potential long-term cardiac damage.
Choice C rationale:
Janeway lesions are not associated with rheumatic fever. They are painless, small erythematous or hemorrhagic macules on the palms and soles, typically seen in infective endocarditis.
Choice D rationale:
Subcutaneous nodules are not a primary manifestation of rheumatic fever. These nodules, which are firm and nontender, may develop over bony prominences in cases of severe rheumatic fever.
Choice E rationale:
Cervical lymphadenopathy is not a characteristic manifestation of rheumatic fever. This type of lymphadenopathy is more commonly seen in infections or lymphatic malignancies.
Correct Answer is B
Explanation
Weighing the patient's wet diapers prior to discarding them.
Choice A rationale:
Inserting an indwelling urinary catheter is invasive and not appropriate for a non-toilet-trained 2-year-old unless medically necessary.
Choice B rationale:
Weighing wet diapers is the most accurate way to measure urine output in a young child who isn't toilet trained. This method provides essential information for assessing hydration and kidney function.
Choice C rationale:
Sitting the patient on the bedpan every two hours is suitable for older children but may not be effective or tolerable for a 2-year-old.
Choice D rationale:
Applying a pediatric urine collection device is an option, but it might not be as accurate as weighing wet diapers and may cause discomfort for the child.
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