A patient with a closed head injury is admitted to the hospital. The nurse observes a yellow ring around a clear moist area on the patient’s pillow. The nurse is correct by thinking that this finding is:

An indication of cerebrospinal fluid drainage that should be monitored and reported.

Explanation

• Cerebrospinal fluid (CSF) can leak through the nose or ears in closed head injuries (halo sign). Monitoring is indicated, and the physician should be informed promptly, but this is not an emergency

• CSF has high glucose content. Using test tape or Dextro-stix can confirm the presence of glucose. Cleaning of the ears or suctioning of the nose can increase the leakage of CSF and should be avoided

• Incorrect: Vomitus would not have a yellow circle with a clear center

Visit our website for other NCLEX topics now!