What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

Compress the nares.

Administer decongestant for postnasal drip.

Tilt the head back.

Collect the drainage.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.

Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.

Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.

Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.

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Correct Answer is C

Explanation

Choice A Reason: Encouraging deep-breathing exercises is not the most appropriate nursing intervention, as it may not reduce fatigue and may increase respiratory effort.

Choice B Reason: Providing a relaxing warm bath is not the most appropriate nursing intervention, as it may worsen fatigue and increase the risk of heat intolerance and dehydration.

Choice C Reason: Scheduling periods of rest in between activities is the most appropriate nursing intervention, as it helps to conserve energy, prevent exhaustion, and promote recovery.

Choice D Reason: Administering multivitamins is not the most appropriate nursing intervention, as it may not improve fatigue and may cause adverse effects or interactions with other medications.

A. Sharing personal hygiene items like razors B. Unprotected sexual activity C. Eating uncooked foods D. Getting a tattoo

Correct Answer is C

Explanation

Choice A Reason: Sharing personal hygiene items like razors is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, which are blood-borne infections.

Choice B Reason: Unprotected sexual activity is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, or other sexually transmitted infections.

Choice C Reason: Eating uncooked foods is a common way of spreading hepatitis A, as the virus can contaminate food or water that has been exposed to fecal matter from an infected person.

Choice D Reason: Getting a tattoo is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, or other blood-borne infections, if the equipment is not properly sterilized.

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What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

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