The nurse is completing a head to toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

Rationale: A. Clear fluid leaking from the nose: Clear drainage from the nose following head trauma suggests a cerebrospinal fluid (CSF) leak, often from a basilar skull fracture. This finding requires immediate intervention because it increases the risk of meningitis and indicates a potential breach in the meningeal barrier protecting the brain. B. Sluggish pupillary response to light: A delayed pupillary reaction may signal mild increased intracranial pressure or localized nerve injury. While important to monitor, it does not demand the same urgent response as a suspected CSF leak. C. Periorbital ecchymosis of right eye: “Raccoon eyes” or bruising around the eyes may indicate a skull base fracture, but alone it is not an emergency unless accompanied by CSF leakage or neurological deterioration. It should be documented and reported for diagnostic evaluation. D. Troubled with a severe headache: Headache is a common symptom following head trauma due to concussion or contusion. It requires monitoring and pain management but is not as critical as identifying a CSF leak, which signifies a more severe underlying injury.