The nurse observes drainage from a client's ears after a head ...

[wrbasek0]

The nurse observes drainage from a client's ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. Which description of the fluid supports the nurse's suspicion?
 
  1. Yellow without sediment.
  2. Blood-tinged without sediment.
  3. Clear, colorless.
  4. Pink without sediment.

Question 2

The nurse is performing a neurological assessment and needs to assess for vibration, as well as sharp and dull sensation. Which objects will the nurse use to complete this assessment? Select all that apply.
 
  1. Tuning fork.
  2. Paper clip.
  3. Safety pin.
  4. Cotton ball.
  5. Tongue blade.

[kristenb95]

Answer to Question 1

Correct Answer: 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. Yellow drainage, blood-tinged fluid, and pink drainage without sediment are not consistent with cerebral spinal fluid.

Answer to Question 2

Correct Answer: 1, 3
To test for sharp and dull sensation, areas of the client's skin are touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the client's body. The paper clip may be used to assess for the ability to determine the identity of an object unseen. A cotton ball may be used to assess sensation when evaluating the facial nerve. A tongue blade would be used to assess the gag reflex and the movements of the tongue.