The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.
The nurse notices a yellow stain around fluid dripping from the patient's ear.
The nurse's priority intervention will be as follows:

Prevent the drainage by applying a pressure dressing.

Allow fluid to drain from the patient's ear onto gauze and notify the provider.

Hang intravenous (IV) fluids to replace fluids lost.

Administer antibiotics due to increased risk of infection.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.

Choice B rationale

Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.

Choice C rationale

Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.

Choice D rationale

Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.

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Correct Answer is D

Explanation

Choice A rationale

Absence of short-term memory loss may be desirable but depends on the injury's severity and therapy progression. Memory recovery is inconsistent and often impractical as a definitive short-term outcome goal.

Choice B rationale

Resuming construction work is unrealistic within three weeks considering potential cognitive and physical impairments. This task exceeds achievable rehabilitation milestones, emphasizing safety over rapid return to demanding roles.

Choice C rationale

Pre-injury personality traits may not fully return, as emotional and personality changes often result from cerebral insults. Emotional stability is feasible but pre-injury personality restoration is speculative.

Choice D rationale

Medication adherence reflects successful cognitive rehabilitation, supporting long-term health stability by preventing further complications. This outcome is realistic and appropriate for patients recovering from intracranial injuries. .

A. Restlessness and altered mental status. B. Widening pulse pressure. C. Fixed and dilated pupils. D. Tachycardia and hypotension.

Correct Answer is A

Explanation

Choice A rationale

Restlessness and altered mental status are early signs of increasing intracranial pressure, resulting from cerebral edema compressing neural tissue and reducing oxygen supply to critical brain regions.

Choice B rationale

Widening pulse pressure is a later sign of increased intracranial pressure, indicating significant disruption of autonomic regulation and brainstem function. Early symptoms like restlessness occur first.

Choice C rationale

Fixed and dilated pupils signify severe and advanced intracranial pressure, often indicating brain herniation, which is a critical stage beyond initial compensatory mechanisms.

Choice D rationale

Tachycardia and hypotension are not hallmark signs of raised intracranial pressure. Bradycardia and hypertension align more closely with Cushing's triad, associated with late-stage intracranial hypertension. .

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The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.The nurse notices a yellow stain around fluid dripping from the patient's ear.The nurse's priority intervention will be as follows:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.
The nurse notices a yellow stain around fluid dripping from the patient's ear.
The nurse's priority intervention will be as follows: