Question

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?

A) A scalp laceration oozing blood.
B) Serosanguineous nasal drainage.
C) Headache rated 10 on a 0-10 scale.
D) Dizziness, nausea and transient confusion.

Answer 1

The most critical finding to assess further in a patient with a traumatic brain injury is Serosanguineous nasal drainage, as it may indicate a basilar skull fracture and risk of arterial damage leading to a life-threatening condition.

Step-by-step explanation:

Assessment of Traumatic Brain Injury

For a client who has suffered a traumatic brain injury, the most critical finding that requires further assessment is B) Serosanguineous nasal drainage. This symptom could indicate the presence of a basilar skull fracture, which is associated with the risk of damaging major arteries such as the ones that pass through the carotid canal, leading to a potentially life-threatening condition. Bleeding inside the skull or the formation of a hematoma can put dangerous pressure on the brain, leading to severe complications or even death.

While a scalp laceration, severe headache, dizziness, nausea, and confusion are also important symptoms commonly associated with head injuries, serosanguineous nasal drainage could be a sign of cerebrospinal fluid leak, which is a grave concern that requires immediate medical attention. In the context of head injuries, it is crucial that healthcare professionals prioritize assessments that may reveal intracranial bleeding or fractures that could lead to rapid deterioration.