The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/or leaking of cerebral spinal fluid?
A) Change in the level of consciousness (LOC)
B) Signs of increased intracranial pressure (IICP)
C) Halo sign
D) Swelling
C
Feedback:
To detect any CSF drainage, the nurse looks for a halo sign. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice. Change in the LOC and signs of IICP are part of the neurologic assessment and do not assist in detecting any CSF drainage. The presence of swelling does not assist in detecting CSF drainage.
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