The ED nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from her nose. What should the ED nurse suspect?
A) Fracture of the cribriform plate
B) Rupture of an ethmoid sinus
C) Abrasion of the soft tissue
D) Fracture of the nasal septum
Ans: A
Feedback:
Clear fluid from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid. The symptoms are not indicative of an abrasion of the soft tissue or rupture of a sinus. Clear fluid leakage from the nose would not be indicative of a fracture of the nasal septum.
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The nurse is reviewing safety concerns throughout the lifespan. List the following in order of appropriate age, from youngest to oldest: Standard Text: Click and drag the options below to move them up or down. Choice
1. Encourage counseling for issues with addiction coping. Choice 2. Teach about stranger danger. Choice 3. Reinforce the importance of safety restraints in the vehicle. Choice 4. Make certain walkways and stairways are well lighted and uncluttered. Choice 5. Teach safety rules for recreational and sports activities.
The nurse is reading a pregnant patient's history and physical. What information does the nurse recognize might indicate the need for a cesarean delivery? (Select all that apply.)
a. History of childhood rickets b. Immobile coccyx c. Prepregnant weight of 100 pounds d. Avid horse rider e. Pelvic fracture 3 years ago
When working with a client with anorexia nervosa, which of the following nursing diagnoses is most difficult to resolve successfully?
A) Imbalanced nutrition: less than body requirements B) Disturbed body image C) Deficient knowledge (nutritious eating patterns) D) Social isolation
Which of the following is the best example of a nurse's use of reflection?
1. The nurse places a client experiencing respiratory difficulties in a high-Fowler's position. 2. The nurse calls the provider when a client reports feeling "chilled and achy" while having an oral temperature of 100.2° F. 3. While caring for a client with a history of asthma, the nurse assesses the client's pulse oximetry reading when he "doesn't sound right." 4. A nurse tells a client; "When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time."