Difficulty: Medium
Average Score: 64%
Simulated
A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?
Correct answer
D
Rationale
Clear fluid in the ear may indicate a cerebrospinal fluid leak, a serious complication of head injury requiring immediate attention. Bruising, disorientation, and tachycardia, while concerning, are less urgent.