HESI RN Exit VI Proctored Exam
In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)
Explanation & Rationale
In the assessment of a client with a head injury, the nurse should be vigilant for signs of rhinorrhea, which could indicate a leakage of cerebrospinal fluid (CSF). The nurse should observe for a clear, watery discharge from the nose, which is a characteristic sign of CSF rhinorrhea.
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