Free NCLEX-PN Practice Questions Practice Question
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage, indicating a rupture of the meninges, which poses a risk of meningitis or other complications in a head injury. This must be reported immediately. Eyelid edema (A) and minor bleeding (C) are less urgent, and withdrawal to pain (D) is consistent with the initial assessment.
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