An older adult client visits the community health clinic, reporting the onset of pain, redness, and swelling in the right eye.
What is the most important for the clinic nurse to ask the client?

Answer and explanation The correct answer is B. Choice A rationale

Applying oxygen via a nasal cannula might help alleviate the client’s shortness of breath, but it does not address the potential cause of the client’s symptoms.

Choice B rationale

Given the client’s symptoms and potential exposure to an unknown substance, it is crucial to monitor his vital signs and cardiorespiratory status. This will help healthcare providers detect any changes in the client’s condition and respond appropriately.

Choice C rationale

Infusing IV fluid boluses might be necessary if the client is dehydrated, but there is no indication of this in the scenario.

Choice D rationale

Administering antiviral medication would be appropriate if the client were confirmed to have a viral infection. However, the client’s symptoms and history suggest a potential exposure to an unknown substance, which requires further evaluation.

Answer and explanation

The correct answer is Choice A.

Choice A rationale

If an older adult client reports pain, redness, and swelling in the eye, asking about discharge from the eye is crucial. These symptoms could indicate a number of conditions, including conjunctivitis or uveitis. Discharge, especially if it is pus-like or sticky, could suggest an infection.

Choice B rationale

While keeping immunizations up-to-date is generally important for health, it is not the most relevant question in this context. Not all eye conditions are preventable through immunization.

Choice C rationale

Asking about new medications is relevant as certain medications can cause side effects or allergic reactions that affect the eyes. However, the symptoms described are more commonly associated with conditions like conjunctivitis or uveitis, which are not typically caused by medications.

Choice D rationale

Regular hand washing is important for general health and can prevent the spread of many diseases. However, it is not the most relevant question when a client presents with pain, redness, and swelling in the eye.