Nokea
The nurse is caring for a patient with a head injury who has clear nasal drainage. Which of the following actions should the nurse take?
- A. Have the patient blow the nose.
- B. Check the nasal drainage for glucose.
- C. Assure the patient that rhinorrhea is normal after a head injury.
- D. Obtain a specimen of the fluid to send for culture and sensitivity.
Correct Answer: B
Rationale: Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
You may also like to solve these questions
The nurse is assessing a patient with bacterial meningitis and obtains the following data. Which of the following findings should be reported immediately to the health care provider?
- A. The patient has a positive Kernig's sign.
- B. The patient complains of having a stiff neck.
- C. The patient's temperature is 38.3°C (100.9°F).
- D. The patient's blood pressure is 86/42 mm Hg.
Correct Answer: D
Rationale: Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life-threatening as the hypotension.
The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which of the following nursing actions is most important?
- A. Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
- B. Emphasize the importance of handwashing to prevent spread of infection.
- C. Immunize adolescents and postsecondary students against Neisseria meningitidis.
- D. Encourage adolescents and young adults to avoid crowded areas in the winter.
Correct Answer: C
Rationale: The Neisseria meningitidis vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and postsecondary students. Handwashing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.
Which of the following statements by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?
- A. I will return if I feel dizzy or nauseated.
- B. I am going to drive home and go to bed.
- C. I do not even remember being in an accident.
- D. I can take acetaminophen for my headache.
Correct Answer: B
Rationale: Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.
The nurse is caring for a patient who has a head injury and is diagnosed with a concussion. Which of the following actions should the nurse plan to take?
- A. Coordinate the transfer of the patient to the operating room.
- B. Provide discharge instructions about monitoring neurological status.
- C. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.
- D. Arrange to admit the patient to the neurological unit for observation for 24 hours.
Correct Answer: B
Rationale: A patient with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates. MRI, hospital admission, or surgery is not indicated in a patient with a concussion.
The nurse is admitting a patient to the emergency department (ED) who is unconscious following a head injury. The patient's partner and children are at the patient's side with many questions for the nurse regarding care. Which of the following actions is best for the nurse to take?
- A. Ask the family to stay in the waiting room until the initial assessment is completed.
- B. Allow the family to stay with the patient and briefly explain all procedures to them.
- C. Call the family's pastor or spiritual advisor to support them while initial care is given.
- D. Refer the family members to the hospital counselling service to deal with their anxiety.
Correct Answer: B
Rationale: The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counselling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.