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 D

Explanation

Choice A Reason: High glucose level is not a finding that confirms bacterial meningitis, but it may indicate other conditions such as diabetes mellitus or hyperglycemia.

Choice B Reason: Low protein concentration is not a finding that confirms bacterial meningitis, but it may indicate other conditions such as malnutrition or liver disease.

Choice C Reason: Decreased CSF pressure is not a finding that confirms bacterial meningitis, but it may indicate other conditions such as dehydration or spinal cord injury.

Choice D Reason: Cloudy CSF is a finding that confirms bacterial meningitis, as it indicates that there is an infection and inflammation in the meninges that surround the brain and spinal cord.

A. Hypertension B. Fluid retention C. Elevated blood glucose D. Increased urine output

Correct Answer is D

Explanation

Choice A Reason: Hypertension is not a common finding in diabetes insipidus, but it may indicate increased intracranial pressure or other complications.

Choice B Reason: Fluid retention is not a common finding in diabetes insipidus, but it may indicate syndrome of inappropriate antidiuretic hormone secretion (SIADH) or heart failure.

Choice C Reason: Elevated blood glucose is not a common finding in diabetes insipidus, but it may indicate diabetes mellitus or hyperglycemia.

Choice D Reason: Increased urine output is a common finding in diabetes insipidus, as the lack of antidiuretic hormone (ADH) causes the kidneys to excrete large amounts of diluted urine.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A lumbar puncture is performed on a client with suspected bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse determines that the diagnosis is confirmed if which findings are noted?

Correct Answer is D

Explanation

A nurse is monitoring a client for findings related to diabetes insipidus following a craniotomy. Which of the following findings should indicate a manifestation of this condition to the nurse?

Correct Answer is D

Explanation

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