Following a motorcycle accident a 17-year-old male is brought to the emergency department. He has sustained multiple traumas including a head injury
What physical assessment findings related to the ear should be reported by the nurse immediately?
A) The malleus can be visualized during otoscopic examination.
B) The tympanic membrane is pearly gray.
C) Tenderness is reported by the client when the mastoid area is palpated.
D) Clear, watery fluid is draining from the ear.
Ans: D
Feedback: In the client experiencing acute head trauma, the presence of clear, watery drainage from the ear should be reported at once. The fluid is likely to be cerebrospinal fluid associated with skull fracture. The ability to visualize the malleus is a normal physical assessment finding. The tympanic membrane is normally pearly gray in color. Tenderness of the mastoid area usually indicates inflammation. This should be reported but is not a finding indicating urgent intervention.
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