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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Loss of erythropoietin will not result in diminished immunologic function, but it may affect the production of some white blood cells and antibodies.
Choice B Reason: Loss of erythropoietin will not result in hypertension, but it may cause hypotension due to reduced blood volume and viscosity.
Choice C Reason: Loss of erythropoietin will not result in elevated lipid levels in the bloodstream, but it may be associated with dyslipidemia due to other factors such as malnutrition, inflammation, or medication use.
Choice D Reason: Loss of erythropoietin will result in anemia, as erythropoietin is a hormone that stimulates the bone marrow to produce red blood cells.
Correct Answer is D
Explanation
Choice A Reason: Hypertension is not a common finding in a client with low calcium level, but it may indicate other conditions such as renal disease or pheochromocytoma.
Choice B Reason: Diaphoresis is not a common finding in a client with low calcium level, but it may indicate other conditions such as fever, anxiety, or hyperthyroidism.
Choice C Reason: Increased thirst is not a common finding in a client with low calcium level, but it may indicate other conditions such as diabetes mellitus, dehydration, or psychogenic polydipsia.
Choice D Reason: Muscle tetany is a common finding in a client with low calcium level, as it indicates that the nerves and muscles are overexcited and contract involuntarily. It may manifest as spasms, cramps, twitching, or tingling sensations.
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