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)?
Swelling.
Change in the level of consciousness (LOC).
Signs of increased intracranial pressure (ICP).
Halo sign.
The Correct Answer is D
Halo sign. The presence of clear fluid with a yellowish ring around it (Halo sign) on the client's bed linens, tissues, or skin may indicate the presence of leaking of cerebral spinal fluid (CSF).
Swelling, choice A, change in the level of consciousness (LOC), choice B, and signs of increased intracranial pressure (ICP), choice C, may be indicative of a head injury, but do not specifically indicate the presence of leaking of CSF.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Exposing the affected area to air. To maintain skin integrity, the nurse should advise the client to expose the affected area to air.
Barrier garments, such as liners and protective pants, can trap moisture and irritate the skin, which can lead to skin breakdown. Exposing the affected area to air can help keep the skin dry and prevent skin breakdown.
B is not the correct answer because the application of moisture sealant can help protect the skin and prevent skin breakdown.
C is not the correct answer because using an electric room deodorizer is not related to maintaining skin integrity.
Correct Answer is A
Explanation
"I am at lower risk for developing cervical warts." This is an incorrect statement because the Gardasil vaccine does not protect against genital warts caused by HPV types other than types 6 and 11. The vaccine protects against HPV types 16 and 18, which cause most cases of cervical cancer.
B: This option is incomplete and does not provide any information for the nurse to determine if further teaching is needed.
C: This statement is correct and indicates that the client understands the purpose of the Gardasil vaccine.
D: This statement is incorrect because the Gardasil vaccine does not prevent HPV infection from occurring.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.