Jeff Dickson is a 17-year-old admitted to the Emergency Department via ambulance following a motor vehicle accident (MVA). He is accompanied by his parents and two of the three friends who were in the vehicle with him. Another friend, who was driving the vehicle, was transported to a different hospital by LifeCare Helicopter. A basilar skull fracture is a linear skull fracture that extends over the base of the frontal and temporal lobes. The nurse knows that this particular type of fracture can cause damage to the nerve pathways, cranial nerves, or vital centers. Jeff's vital signs and neurologic status will be monitored frequently.
1. Which assessment technique allows the nurse to assess for Battle's sign?
B) Observe the area behind Jeff's ears.
Other manifestations of a basilar skull fracture include tinnitus, facial paralysis, hearing difficulty, epistaxis, and CSF (cerebral spinal fluid) leakage from the nose or ears. The nurse is concerned about the rhinorrhea that Jeff is experiencing.
2. What methods can the nurse use to determine if the drainage is CSF?
C) Observe for a "halo" around a spot of drainage.
Nursing Plans and Interventions: The nurse applies a sterile nasal drip pad and initiates interventions to prevent increased intracranial pressure (ICP).
3. Which nursing intervention should be initiated to prevent increased ICP?
B) Administer a prescribed stool softener as needed (PRN).
4. Which medication is best for the nurse to administer to Jeff for his complaint of headache?
D) Acetaminophen (Tylenol).
Glasgow Coma Scale (GCS): Jeff is medicated and reports that his headache is relieved. The nurse continues to monitor Jeff's vital signs, and his neurologic status is assessed using the Glasgow Coma Scale (GCS). About an hour later, Jeff's Glasgow Coma Scale rating changes from 13 to 10.
5. What does this indicate to the nurse?
B) Diminished neurologic status.
Do any of these ring a bell?
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