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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

sigmoid. A double-barrel colostomy involves surgically creating two separate stomas from the colon, with the proximal stoma discharging stool and the distal stoma discharging mucus. This type of colostomy is typically performed in the sigmoid colon, which is the S-shaped segment of the large intestine located just before the rectum.

Choice A, ascending, is not the correct answer because an ascending colostomy is created in the ascending colon, which is located on the right side of the abdomen.

Choice B, descending, is not the correct answer because a descending colostomy is created in the descending colon, which is located on the left side of the abdomen.

Choice C, transverse, is not the correct answer because a transverse colostomy is created in the transverse colon, which is located across the upper abdomen.

A. Eustachian tube. B. The malleus. C. The pinna. D. The meatus.

Correct Answer is A

Explanation

Eustachian tube. The Eustachian tube is a narrow tube that connects the middle ear to the back of the nose and equalizes air pressure in the middle ear.

B. The malleus is a bone in the middle ear that transmits sound vibrations.

C. The pinna is the visible part of the ear that collects and directs sound waves.

D. The meatus is a passage or opening leading to the ear or nose.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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