Question

The nurse monitors a client with suspected nasal bone fractures for cerebrospinal fluid leakage by:

a) Assessing for clear nasal drainage
b) Checking for increased heart rate
c) Observing for dilated pupils
d) Palpating for bony crepitus

Answer 1

A nurse looks for clear nasal drainage to monitor for CSF leakage in a patient with suspected nasal bone fractures, as this can indicate a CSF leak.

Step-by-step explanation:

The nurse monitors a client with suspected nasal bone fractures for cerebrospinal fluid (CSF) leakage by assessing for clear nasal drainage. Clear nasal drainage can be suggestive of a CSF leak, particularly after a trauma that may have caused a fracture. The presence of beta-2 transferrin, which is a protein found exclusively in CSF, would confirm the leakage. To ensure an accurate diagnosis, a sample of the clear drainage could be tested for the presence of beta-2 transferrin, as well as for its glucose content, which tends to be higher in CSF compared to other fluids.