The nurse observes drainage from a client's ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. Which of the following descriptions would best support this finding?
1. Yellow without sediment
2. Blood-tinged without sediment
3. Clear, colorless
4. Pink without sediment
3
Rationale 1: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Yellow drainage is not consistent with cerebral spinal fluid.
Rationale 2: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Blood-tinged fluid is not consistent with cerebral spinal fluid.
Rationale 3: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea.
Rationale 4: It is important to recognize CSF as clear and colorless. Pink drainage without sediment is not consistent with cerebral spinal fluid.
You might also like to view...
The nurse is conducting a primary prevention intervention. An example of this type of intervention would be:
a. blood glucose screening. b. dietary education to reduce high cholesterol. c. parenting education. d. providing immunizations.
A patient with a desire to stop smoking asks a nurse about nicotine chewing gum [Nicorette]. The patient currently smokes 30 cigarettes per day. Which statement by the nurse is correct?
a. "Stop using the gum 6 months after you stop using cigarettes." b. "Use the 4-mg strength gum and chew one piece every 2 to 3 hours." c. "Use the gum whenever you feel a craving for a cigarette." d. "You should start with 30 pieces of the 2-mg strength gum per day."
To test for HIV the majority of laboratory tests test for:
1. the HIV virus. 2. HIV antibodies. 3. CD4 counts. 4. CD8 counts.
A patient is admitted to the unit. The nurse notes that the medical record for this patient lists a fall risk of 75% per the Morris Fall Risk scale. What would be an appropriate nursing intervention?
A) Assess for orthotics B) Use environmental cues C) Use an accessory high seat on the toilet D) Encourage the patient to use canes bilaterally