A nurse is caring for a client who sustained a basal skull fracture. When

performing morning hygiene care, the nurse notices a thin stream of clear

drainage coming from out of the client's right nostril. Which of the following

actions should the nurse take first?

(Ans- *Test the drainage for glucose.

Rationale: The greatest risk to a client who has a basal skull fracture is

injury from cerebral spinal fluid (CSF) leak; therefore, the nurse should first

test the drainage for glucose.

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse

should recognize that the client is at risk for autonomic dysreflexia. Which

of the following interventions should the nurse take to prevent autonomic

dysreflexia?

(Ans- *Prevent bladder distention.

Rationale: Autonomic dysreflexia can occur in clients who have a spinal

cord injury at or above the T-6 level. Autonomic dysreflexia can occur as a

result of an irritation, or stimulus to the nervous system below the level of

injury. Triggers of autonomic dysreflexia include bladder distention,

insertion of rectal suppository, enemas, or a sudden change in position

A nurse is caring for a client who is being evaluated for endometrial cancer.

Which of the following findings should the nurse expect the client to report?

(Ans- *Abnormal vaginal bleeding

Rationale: The nurse should expect the client to experience abnormal

vaginal bleeding, including postmenopausal bleeding and bleeding

between normal periods. Abnormal vaginal bleeding is the most common

finding in endometrial cancer in premenopausal women.