A nurse is caring for a client who had abdominal surgery. The client tells the nurse that "something gave way.”. The nurse removes the dressing and sees the wound has eviscerated. Identify the correct sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.).

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.

Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.