The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of leaking of cerebral spinal fluid (CSF)?

Giving non-prescription laxatives to a client with cirrhosis can cause severe dehydration and electrolyte imbalances, which can be life-threatening. The nurse should report this intervention immediately to the physician.

Choice B is incorrect because measuring abdominal girth is a standard nursing intervention for clients with cirrhosis to assess for ascites.

Choice C is incorrect because asking the client about food intake is a standard nursing intervention for assessing nutritional status.

Choice D is incorrect because checking for signs of hepatic encephalopathy is a standard nursing intervention for clients with cirrhosis.

Explanation: When dealing with a client who has been physically aggressive and is in distress, the best approach for the nurse is to use brief statements and questions to obtain essential information. This approach helps to keep the communication clear, focused, and non-threatening. The nurse should maintain a calm and assertive demeanor while avoiding lengthy discussions that may escalate the client's agitation.

Options not appropriate in this situation:

B. Providing close contact to increase the client's sense of safety may not be safe for the nurse or the client, especially when dealing with someone who has been physically aggressive. It is essential to maintain a safe distance and ensure the safety of everyone involved.

C. Having a sense of humor to show a lack of fear can be misinterpreted by the client and may not be appropriate or therapeutic in this context. The focus should be on establishing a professional and respectful rapport with the client, prioritizing their needs and safety.

Option D may not be the best approach because open-ended questions could lead to lengthy responses, which may not be suitable for a client who is in distress and potentially aggressive. The nurse should aim for concise and clear communication to ensure safety and facilitate a psychiatric assessment efficiently.