Identify the nursing action that is most appropriate when the nurse assesses a small amount of clear, watery fluid oozing from the nose of a client who received a blow to the head in a barroom fight.
A)Encourage the client to blow his nose to clear the sinuses.
B)Use a dipstick to test the drainage for glucose.
C)Keep the client's head flat.
D)Ask the client about what type of object he was struck with.

Question

Quizplus · Accepted Answer

Testing the drainage for glucose can help determine if the fluid is cerebrospinal fluid (CSF), which can leak from the nose or ears after a skull fracture. This is a critical step in assessing for a potential basilar skull fracture. Encouraging the client to blow his nose, keeping the head flat, or asking about the object used in the assault does not directly address the potential severity of a CSF leak.

Identify the Nursing Action That Is Most Appropriate When the Nurse