After facial trauma, a client has a nasal fracture and is reporting constant nasal drainage, a headache, and difficulty with vision. What is the nurse's first action?
a. Collect the nasal drainage on a piece of filter paper.
b. Send the client for a facial x-ray.
c. Perform a vision test.
d. Palpate all facial areas for crepitus.
A
The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebral spinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the client's risk for infection.
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