The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities
The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action? a. Insert bilateral ear plugs.
b. Monitor airway patency.
c. Maintain neutral head position.
d. Apply a small nasal drip pad.
D
Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care.
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The nurse is teaching a couple about X-linked disorders. They are concerned that they might pass on hemophilia to their children. Which of the following responses indicates the need for further teaching?
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The state orders a person newly diagnosed with tuberculosis to be quarantined. On what basis can the state do this?
1. Constitutional law 2. Legislation and regulation 3. Judicial and common law 4. Police power