A nurse in an emergency department is assessing a client who has a basilar skull fracture and serosanguineous nasal discharge following a motor vehicle crash. Which of the following findings should the nurse identify as reliable for determining that the discharge is cerebrospinal fluid?

Papilledema.

Halo sign.

Racoon's eyes.

Elevated WBCs.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Papilledema refers to swelling of the optic disc in the eye, which can occur due to increased intracranial pressure. While it may be present in cases of basilar skull fracture, it is not a reliable finding for determining the discharge of cerebrospinal fluid (CSF).
Choice B rationale:
The halo sign is a reliable finding for determining that the nasal discharge is cerebrospinal fluid. The halo sign is characterized by a ring of blood surrounded by a clear or yellowish fluid (CSF) on a dressing or tissue. This occurs because blood from the fracture mixes with the clear CSF, creating a distinct appearance.
Choice C rationale:
Racoon's eyes, also known as periorbital ecchymosis, is a term used to describe bruising around the eyes. While it can be seen in basilar skull fractures, it is not specific to cerebrospinal fluid leakage and, therefore, not reliable for identifying the nasal discharge as CSF.
Choice D rationale:
Elevated white blood cells (WBCs) in the nasal discharge can indicate infection, inflammation, or an immune response. However, it does not provide direct evidence that the discharge is cerebrospinal fluid, so this is not a reliable finding for determining the nature of the nasal discharge in this context.

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Correct Answer is C

Explanation

Choice A rationale:

A three-prong plug attached to the electrical cord of the client's bed is not a safety hazard. It is a standard plug type used in many electrical devices and poses no immediate danger if properly installed.

Choice B rationale:

Inserting a protective cover into an unused outlet is actually a safety measure to prevent electrical accidents. It is not a hazard but a recommended practice.

Choice C rationale:

Plugging an IV pump into an outlet near a sink is a safety hazard. Water and electricity are a dangerous combination, and any spill or leakage around the outlet could lead to electrical shock or damage to the equipment.

Choice D rationale:

Coiling and securing an electrical cord to the floor can be a potential tripping hazard, but it is not as hazardous as having an electrical device near a sink. Tripping hazards can cause falls, while the combination of water and electricity is more likely to cause serious injuries.

A. A defined area of cool, boggy skin. B. A shallow crater involving the epidermis. C. Reddened area that does not blanch. D. Undermining or tunneling of the skin.

Correct Answer is B

Explanation

Choice A rationale:

A defined area of cool, boggy skin is not indicative of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, usually appearing as a shallow open ulcer with a red-pink wound bed, without slough or bruising.

Choice B rationale:

A shallow crater involving the epidermis is characteristic of a stage 2 pressure injury. It presents as a partial-thickness skin loss with the loss of the epidermis, and the wound may be superficial and appear as an abrasion, blister, or shallow ulcer.

Choice C rationale:

The reddened area that does not blanch is more indicative of an early-stage pressure injury (Stage 1). In Stage 1, the skin remains intact, but there is non-blanch-able erythema indicating damage to the skin and underlying tissue.

Choice D rationale:

Undermining or tunneling of the skin is not specific to stage 2 pressure injuries. These features may be observed in more advanced stages of pressure injuries, such as stages 3 and 4, where there is full-thickness skin loss with damage to the subcutaneous tissue and underlying structures.

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A nurse in an emergency department is assessing a client who has a basilar skull fracture and serosanguineous nasal discharge following a motor vehicle crash. Which of the following findings should the nurse identify as reliable for determining that the discharge is cerebrospinal fluid?

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