A client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:

Correct Answer: D

Rationale: The correct answer is D because cerebrospinal fluid (CSF) typically separates into concentric rings when placed on a white pad due to its high protein content. This phenomenon is known as the "halo sign." Additionally, CSF should test positive for glucose as it is a clear, colorless fluid that contains glucose. Choices A, B, and C are incorrect because CSF is clear and tests positive for glucose, not negative. It is not typically bloody in appearance with a pH of 6, clumping together with a pH of 7, or showing any other characteristics mentioned in the incorrect choices.

Correct Answer: C

Rationale: The correct technique for assessing the carotid arteries is to auscultate for bruits before palpating. This is important because listening for bruits can indicate the presence of any abnormal sounds or blockages in the arteries, which can affect the palpation results. Palpating before auscultating may disrupt any potential bruits that should be detected. Auscultating both arteries simultaneously (Choice A) is not recommended as it may lead to missing subtle differences between the two sides. Palpating both arteries simultaneously (Choice B) is not ideal as it may not allow for accurate assessment of each artery individually. Palpating the arteries firmly to assess for strength (Choice D) is not recommended as excessive pressure can lead to inaccurate results and potential harm.

Correct Answer: B

Rationale: The correct answer is B because the Weber test is performed by striking a tuning fork and placing it on the patient's forehead. This causes vibrations that are conducted through the skull to both cochleas. In a normal hearing individual, the sound will be heard equally in both ears. If there is unilateral conductive hearing loss, the sound will be louder in the affected ear, and if there is unilateral sensorineural hearing loss, the sound will be louder in the unaffected ear. Choice A is incorrect because the Weber test does not involve whispering words for the patient to repeat. Choice C is incorrect because it describes the Rinne test, not the Weber test. Choice D is incorrect because it does not involve identifying different tones, but rather assessing for lateralization of sound.

Correct Answer: A

Rationale: Accommodation is the correct answer because it refers to the ability of the eye to adjust its focus when moving between objects at different distances. When the pupils constrict while focusing on a near object, it indicates the eye is accommodating to improve clarity for close-up vision. Convergence (B) is the coordinated movement of both eyes towards a near object, not pupil constriction. Refraction (C) is the bending of light as it passes through the eye, not the pupil's response. Visual acuity (D) is the sharpness of vision, not related to pupil constriction during accommodation.

Correct Answer: D

Rationale: The correct answer is D: Pupil size. The Glasgow Coma Scale (GCS) assesses a patient's level of consciousness based on eye opening, motor response, and verbal response. Pupil size is not included in the GCS as it focuses on assessing the patient's neurological status and responsiveness to stimuli. Pupil size is typically assessed separately as part of a neurologic examination but is not a component of the GCS. Therefore, D is the correct answer. A, B, and C are incorrect because they are the three components (eye opening, motor response, verbal response) included in the Glasgow Coma Scale.