A 42-year-old patient is admitted to the emergency department (ED) following being mugged. The patient received blunt trauma to the face and has clear fluid draining from the right nostril. What does the ED nurse know to assess this fluid for?
A) Sodium
B) Protein
C) Calcium
D) Glucose
Ans: D
Feedback: Clear fluid draining from either nostril suggests a fracture of the cribifrom plate with leakage of cerebrospinal fluid. Because cerebrospinal fluid contains glucose, it can readily be differentiated from nasal mucus by means of a dipstick (Dextrostix). Sodium, protein, and calcium cannot be assessed by detrostix.
You might also like to view...
A surgical patient has been diagnosed with type 2 diabetes during his current admission to the hospital
The nurses and other members of the care team have attempted to engage the patient in education about his new diagnosis, the effects it will have on his lifestyle and the medications that will be necessary to treat it. However, the patient is unwilling to discuss these matters, usually citing fatigue or the desire to watch TV or make phone calls. What potential nursing diagnosis should the nurse prioritize? A) Ineffective coping B) Knowledge deficit C) Acute confusion D) Anxiety
Prescribers have been shown to override a medication alert about a patient's allergies when:
1. The history showed that the patient had tolerated the medication in the past 2. The benefit outweighed the risk 3. The medication was therapeutically appropriate and needed 4. All of the above
The nurse is aware that the tonic neck reflex has several postural clues, which are: (Select all that apply.)
a. Head turned to one side b. Arm and leg extended on one side and flexed on the other c. Prancing movements of the legs when held upright d. Extending the flexion of extremities when startled e. Turning the head in the direction of anything that touches the cheek
The nurse suspects that the patient's communication is being negatively influenced by personal attitude when he is heard stating:
a. "They think I'm mentally ill but I'm not; I just get a little depressed at times." b. "I can't concentrate on anything besides getting out of here and back to my kids." c. "Obviously my therapist can't understand where I'm coming from because our lives are so different." d. "There isn't anyone here in this hospital I can trust enough to talk to about why I abuse alcohol and drugs."