ATI NCLEX-RN Practice Questions Practice Question
The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:
Correct Answer: C
Rationale: The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. Cerebrospinal fluid is positive for sugar; mucus is not. Turning her to her side will have no effect on her 'runny nose.' It is necessary to gather further assessment data.
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