A nurse assesses a client who has a nasal fracture. The client ...

[rlane42]

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?
 
  a. Collect the nasal drainage on a piece of filter paper.
  b. Encourage the client to blow his or her nose.
  c. Perform a test focused on a neurologic examination.
  d. Palpate the nose, face, and neck.

Question 2

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first?
 
  a. Contact the provider for a prescription for sleep medication.
  b. Tell the client not to drink beverages with caffeine before bed.
  c. Educate the client to sleep upright in a reclining chair.
  d. Ask the client if he or she has ever been evaluated for sleep apnea.

[memslove]

Answer to Question 1

ANS: A
The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the client's risk for infection.

Answer to Question 2

ANS: D
Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

[rlane42]

TYSM

[shailee]

Gracias!