Question

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 expected after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.

Answer 1

The nurse should check the nasal drainage for glucose content to determine if it is cerebrospinal fluid (CSF), which can help identify a potential skull fracture following a head injury.

Step-by-step explanation:

The nurse should check the drainage for glucose content. Clear nasal drainage following a head injury may be a sign of cerebrospinal fluid (CSF) leak, which could indicate a skull fracture. Testing the fluid for the presence of glucose can help differentiate between CSF and regular nasal secretions, as CSF typically has a higher glucose content. Options such as having the patient blow the nose could potentially worsen the situation if it's indeed a CSF leak. Educating the patient that rhinorrhea is expected may be misleading, and obtaining a specimen for culture is not immediately necessary unless infection is suspected. The priority is to correctly identify the nature of the nasal drainage.