A patient is admitted with a fracture to the base of the skull. What might the nurse assess in this patient?
1. Depressed respiratory rate
2. Ecchymoses of the neck
3. Increased intracranial pressure
4. Cerebral spinal fluid leak from the nose
4
Rationale 1: There is no evidence to suggest that the patient will have a depressed respiratory rate with this fracture.
Rationale 2: Ecchymoses of the neck is not associated with a basilar skull fracture.
Rationale 3: There is no evidence to suggest that the patient will have increased intracranial pressure with this fracture.
Rationale 4: Basilar fractures occur at the base of the skull. Patients may develop a dural tear and have cerebral spinal fluid draining from their nose and/or ears.
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