The nurse is admitting a patient with a basal skull fracture. The ...

[jerry coleman]

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question?
 
  a. Keep the head of bed elevated.
  b. Insert nasogastric tube to low suction.
  c. Turn patient side to side every 2 hours
  d. Apply cold packs intermittently to face.

Question 2

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?
 
  a. Have the patient gently blow the nose.
  b. Check the drainage for glucose content.
  c. Teach the patient that rhinorrhea is ex-pected after a head injury.
  d. Obtain a specimen of the fluid to send for culture and sensitivity.

[ju]

Answer to Question 1

ANS: B
Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage. Insertion of a naso-gastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

Answer to Question 2

ANS: B
Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

[jerry coleman]

Thank you

[ju]

Happy to help you