The emergency department nurse has several clients present to triage with eye complaints. Which client will the nurse assess first?

The client who suddenly has periocular pain and loss of central vision in the left eye for an hour

The client who has noticed decreased peripheral vision in both eyes during the past year

The client who has reduced vision bilaterally after spending two hours skiing on a sunny day

The client who has reduced vision on one side when coming out of a dark place into sunlight

Answer and Explanation

The Correct Answer is A

A. Sudden onset of periocular pain and loss of central vision may indicate acute angle-closure glaucoma, retinal detachment, or central retinal artery occlusion, all of which are ophthalmic emergencies that can result in permanent vision loss if not treated immediately. This client requires priority assessment.

B. Gradual peripheral vision loss over a year suggests chronic conditions such as glaucoma, which require assessment but are not immediately vision-threatening.

C. Temporary reduced vision after sun exposure is likely photokeratitis and is usually self-limiting; urgent assessment is not required.

D. Transient reduced vision when moving from dark to bright light is a normal physiologic response (adaptation to light) and is not an emergency.

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Correct Answer is C

Explanation

A. Macular degeneration is progressive and irreversible, so promoting hope for recovery may be unrealistic and could lead to frustration or false expectations.

B. While encouraging the use of other senses may help with adaptation, this does not directly address the client’s psychosocial needs.

C. Assessing and supporting the client’s coping skills is essential in helping them adjust to permanent vision loss, maintain independence, and prevent depression or anxiety. Psychosocial interventions are critical in chronic, irreversible conditions.

D. Blindness will change the client’s lifestyle, so emphasizing that nothing will change is misleading and could hinder realistic adjustment.

A. The client has acute pain with movement B. The client is not taking deep breaths C. Bile-colored fluid in the Jackson Pratt drain. D. Rigidity of the abdomen

Correct Answer is D

Explanation

A. Pain is an expected finding after surgery, especially with movement. Pain should be managed, but it does not require immediate provider notification unless unrelieved or worsening significantly.

B. Shallow breathing is often due to pain after abdominal surgery. While this increases the risk of atelectasis or pneumonia, it is not the most urgent concern. The nurse should encourage deep breathing and incentive spirometry.

C. Bile-colored fluid in the drain may occur following gallbladder surgery and should be monitored. While excessive drainage or sudden increases may need to be reported, a small amount of bile-stained drainage is not unexpected.

D. Abdominal rigidity is a sign of peritonitis or intra-abdominal bleeding, both of which are life-threatening complications requiring immediate intervention. This assessment finding is a surgical emergency.

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Heart Rate	105 beats/minute.
Blood Pressure	130/85 mmHg
Pain	6 on a 0-10 scale
Temperature	101.3 F (38.5 C)
White Blood Cell (WBC)	12,000 mm3 (Ref: 4,000-10,000 mm3)
Platelet Count	150,000 mcl (Ret: 150,000-400,000 mcl)

The emergency department nurse has several clients present to triage with eye complaints. Which client will the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is legally blind as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action is most appropriate?

Correct Answer is C

Explanation

The nurse is caring for a client who has just returned to the post-surgical unit following cholecystectomy for gallbladder disease. What assessment finding should the nurse immediately report to the health care provider?

Correct Answer is D

Explanation

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