A client has an open head injury resulting from a fall and loses consciousness during transport to the hospital. The nurse observes clear fluid in the outer ear, which may indicate:
a. infection in the injured area c. injury to facial bones
b. cerebrospinal fluid leakage d. cerebral laceration
B
Nursing care of clients with head injury focuses on monitoring neurological status, including level of consciousness, motor function, eye movement, pupillary reaction, vital signs, and other manifestations such as headache, bleeding, nausea or drainage of clear fluid in the outer ear or nose, which can indicate cerebrospinal fluid leakage.
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