A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
Test the drainage for the halo sign.
Ask the client to blow his nose.
Notify the physician.
Suction the nostril.
The Correct Answer is A
Choice A reason:Testing the drainage for the halo sign is the first action the nurse should take, as clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal fluid (CSF) leak, which contains glucose.
Choice B reason:Asking the client to blow his nose could potentially increase the risk of infection or worsen a CSF leak and is not recommended as a first action.
Choice C reason:While notifying the physician is important, it should be done after confirming whether the drainage is CSF, which would require immediate medical intervention.
Choice D reason:Suctioning the nostril is not the first action to take, as it could potentially disrupt the site of the leak and is not diagnostic of a CSF leak.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Disequilibrium syndrome is characterized by headache, nausea, and agitation, which can occur during or after hemodialysis, especially in the first few sessions as the body adjusts to the treatment².
Choice B reason: Septicemia would typically present with fever, chills, and hypotension, not specifically headache and agitation².
Choice C reason: Air embolism is a rare complication that would present with sudden respiratory distress, chest pain, and possibly hypotension, not just headache and agitation².
Choice D reason: Peritonitis is associated with abdominal pain and tenderness, fever, and possibly altered bowel movements, not the symptoms described².
Correct Answer is B
Explanation
Choice A reason:Placing a cool cloth on the forehead may provide comfort but does not address intracranial pressure, which could be causing the headache[^10^].
Choice B reason:Elevating the head of the bed 30 degrees helps to decrease intracranial pressure and can alleviate headache symptoms associated with a closed head injury[^10^].
Choice C reason:Administering morphine for pain relief should be done with caution, as it can depress respiration and mask changes in the level of consciousness, which are important indicators of neurological status[^10^].
Choice D reason:A lumbar puncture is contraindicated in the presence of increased intracranial pressure due to the risk of brain herniation[^10^].
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