一位有頭部外傷病史的病人，若出現下列哪項狀況，護理師應立即回報醫師？
Which of the following findings in a client with a history of head injury should the nurse report to the provider immediately?
- AClear fluid drainage from the nose✓ 正解鼻腔流出清澈液體
- BA small bruise on the forehead額頭有小塊瘀青
- CMild headache輕微頭痛
- DDifficulty sleeping睡眠困難
核心概念：頭部外傷（Head Injury）後的潛在併發症辨識。 為何正確答案對： A. 從鼻腔流出清澈液體（Clear fluid drainage from the nose）需高度懷疑是腦脊髓液（Cerebrospinal Fluid, CSF）鼻漏（Rhinorrhea）。這表示顱底（Skull base）可能發生骨折，導致腦膜（Meninges）破損，CSF 滲漏。CSF 漏是腦膜炎（Meningitis）的嚴重風險因子，可能引發致命感染，因此必須立即回報醫師進行評估與處置。 為何其他選項錯： B. 輕微頭痛（Mild headache）是頭部外傷後常見的症狀，不一定代表嚴重併發症。 B. 額頭上的小瘀傷（A small bruise on the forehead）是局部創傷的正常表現。 D. 睡眠困難（Difficulty sleeping）可能是頭部外傷後的心理或生理影響，但不如 CSF 漏來得緊急與直接關聯到致命感染風險。
Core concept: recognition of potential complications after head injury. Why the correct answer is right: A. Clear fluid drainage from the nose should raise strong suspicion of cerebrospinal fluid (CSF) rhinorrhea. This suggests a possible basilar skull fracture leading to disruption of the meninges and CSF leakage. CSF leak is a serious risk factor for meningitis and may cause a fatal infection, so it must be reported to the provider immediately for evaluation and management. Why the other options are wrong: B. Mild headache is a common symptom after head injury and does not necessarily indicate a serious complication. C. A small bruise on the forehead is a normal manifestation of local trauma. D. Difficulty sleeping may be a psychological or physiological sequela of head injury but is not as urgent as a CSF leak and is not directly linked to a fatal infection risk.