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

Administer antibiotics due to increased risk of infection

Prevent the drainage by applying a pressure dressing

Hang intravenous (IV) fluids to replace fluids lost

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

Answer and Explanation

The Correct Answer is D

A. Antibiotics may be necessary if infection is confirmed, but this is not the priority action.

B. Applying a pressure dressing could increase intracranial pressure or worsen the injury.

C. IV fluids can be helpful in managing shock but are not directly related to CSF leakage management.

D. Yellowish fluid from the ear, which creates a "halo" or yellow ring around it on gauze, may indicate cerebrospinal fluid (CSF) leakage. This is a sign of a potential skull fracture and requires prompt provider notification. Allowing the fluid to drain and collecting it can provide necessary information about the injury.

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Correct Answer is C

Explanation

A. Soft restraints are not recommended during a seizure and can cause harm to the patient.

B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.

C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.

D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.

A. high sodium and high sugar." B. moderate protein and low fat." C. high carbohydrates and high protein." D. high fats and low carbohydrates."

Correct Answer is D

Explanation

A. A ketogenic diet does not focus on high sodium or high sugar, as high sugar intake would increase carbohydrate levels.

B. A ketogenic diet is high in fat rather than low in fat.

C. High carbohydrates are avoided in a ketogenic diet, as the goal is to limit carbohydrates to promote ketone production.

D. The ketogenic diet consists of high fat and low carbohydrates, which helps to manage seizure activity by altering the brain's energy source to ketones rather than glucose.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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