In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding?
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The Correct Answer is "{\"xRanges\":[389.5,439.5],\"yRanges\":[222,272]}"
Site- the nose
Rationale
Rhinorrhea refers specifically to cerebrospinal fluid (CSF) rhinorrhea. This occurs when there is a leakage of CSF from the nose due to a fracture or injury to the skull base or surrounding structures, such as the cribriform plate.
CSF is a clear fluid that surrounds and cushions the brain and spinal cord. When there is a fracture or disruption in the skull base, CSF can leak out through the nasal passages. This condition is concerning because it can increase the risk of infection, such as meningitis, due to the direct communication between the central nervous system and the external environment through the nasal cavity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.75"]
Explanation
Calculate the volume of the reconstituted solution that contains the prescribed dose of 0.1875 mg. Since the reconstituted solution has a concentration of 0.25 mg per 1 mL, we can set up a proportion to find the answer: (0.1875 mg / X mL) = (0.25 mg / 1 mL).
Solving for X gives us X = (0.1875 mg * 1 mL) / 0.25 mg, which equals 0.75 mL.
Therefore, the nurse should administer 0.75 mL of the reconstituted solution.
Correct Answer is ["B","E","F"]
Explanation
A. Since the client is already on a fraction of inspired oxygen (FIO2) of 35% and has successfully weaned off the ventilator, increasing the FIO2 may not be necessary unless the client's oxygenation status deteriorates post-extubation.
B. As the client has successfully weaned off pressure support and is now at 0 cm H2O, the healthcare provider may consider transitioning to a different ventilator mode such as T-piece or CPAP (Continuous Positive Airway Pressure) to further assess the client's ability to breathe spontaneously without ventilator support.
C. Ice chips are typically offered to conscious patients to alleviate thirst or dry mouth. The client was previously intubated and may not be fully conscious or able to swallow safely immediately post- extubation.
D. Since the client has been weaned off pressure support successfully, there is no indication to set the ventilator to provide mandatory breaths. The focus is on assessing the client's ability to breathe spontaneously.
E. Even though the client has been weaned off the ventilator, it's important to ensure adequate oxygenation. Setting up supplemental oxygen delivery, such as via nasal cannula or face mask, can support the client's oxygen needs during the transition phase post-extubation.
F. Since the client has been successfully weaned to 0 cm H2O pressure support and the healthcare provider is evaluating the client, gathering supplies for potential extubation is appropriate. This includes ensuring all necessary equipment and supplies for a safe extubation procedure are readily available at the bedside.
G. Unless specifically indicated for other medical reasons not mentioned, there is no immediate need to place a nasogastric tube based on the information provided about the client's current condition post- weaning.
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