A nurse assesses a client who has facial trauma. Which assessment ...

[rlane42]

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)
 
  a. Stridor
  b. Nasal stuffiness
  c. Edema of the cheek
  d. Ecchymosis behind the ear
  e. Eye pain
  f.
  Swollen chin

Question 2

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)
 
  a. Observe for clear drainage.
  b. Assess for signs of bleeding.
  c. Watch the client for frequent swallowing.
  d. Ask the client to open his or her mouth.
  e. Administer a nasal steroid to decrease edema. f.
  Change the nasal packing.

[6ana001]

Answer to Question 1

ANS: A, D
Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called battle sign and indicates basilar skull fracture.
Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention.

Answer to Question 2

ANS: A, B, C, D
The nurse should observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse should assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse should also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which should be changed by the surgeon the first time.