The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?

Instill anesthetic eye drops in both eyes

Perform a visual acuity exam

Determine the pH of the chemical splash

Irrigate both eyes with normal saline

Answer and Explanation

The Correct Answer is D

A. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.

B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.

C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.

D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.

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Correct Answer is C

Explanation

A. Chronic head injury patients often struggle with processing multiple pieces of information simultaneously due to cognitive limitations.

B. Activities requiring complex strategy, like chess, are typically challenging shortly after admission and not a realistic expectation.

C. Difficulty with planning and organizing thoughts and behaviors is a common cognitive deficit in patients with chronic head injury due to impaired executive function, often resulting from damage to the frontal lobe.

D. While non-compliance can occur, it is less predictable and may not be directly linked to chronic head injury itself.

A. Clarify misinformation and reorient when confused B. Turn patient every 2 hours C. Ensure bed alarm is on when leaving the patient's room D. Vary schedule to prevent memorization and boredom

Correct Answer is C

Explanation

A. Reorienting confused patients is important but is not directly related to cerebellar injury.

B. While turning every 2 hours is important to prevent pressure injuries, it does not address the specific fall risk associated with cerebellar damage.

C. The cerebellum is responsible for balance and coordination, so injuries in this area increase the risk of falls. Ensuring the bed alarm is on provides immediate alerts if the patient attempts to get out of bed, helping to prevent falls.

D. Varying the schedule to prevent boredom is not a priority in the care of patients with cerebellar injury.

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The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which behavior(s) by the patient diagnosed with a chronic head injury would the nurse expect to find?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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