頭部受傷病人鼻部流出清澈液體，護理師的優先處置為何？
A client with a head injury exhibits clear fluid draining from the nose. What is the nurse's priority action?
- ATest the fluid for glucose✓ 正解測試液體中的葡萄糖
- BSuction the nasal cavity抽吸鼻腔
- CInsert nasal packing插入鼻腔填塞物
- DApply an ice pack to the nose在鼻子上敷冰袋
頭部外傷後的鼻腔或耳道滲出液，必須高度警覺腦脊髓液（Cerebrospinal Fluid, CSF）外漏的可能性，這代表硬腦膜（Dura mater）受損，有引發腦膜炎（Meningitis）的極高風險。護理師的優先處置是確認該液體是否為 CSF。CSF 含有葡萄糖，而鼻涕或痰液則不含或僅有極少量。測試液體中的葡萄糖濃度（利用試紙測試）是臨床最快速的鑑別方式。絕對禁止進行侵入性操作，以防止細菌直接進入腦部。
After head trauma, fluid draining from the nose or ear must raise high suspicion for cerebrospinal fluid (CSF) leakage, which indicates damage to the dura mater and a high risk of meningitis. The nurse's priority is to determine whether the fluid is CSF. CSF contains glucose, while nasal mucus or sputum contains little to no glucose. Testing the fluid's glucose concentration (with a reagent strip) is the fastest clinical method of differentiation. Invasive procedures are absolutely contraindicated to prevent direct introduction of bacteria into the brain.