The nurse is caring for a patient who has sustained eye trauma as a result of a motor vehicle crash (MVC). Which intervention should the nurse provide regarding a foreign body?
Remove all foreign objects
Stabilize object and lightly protect with covering
Provide a light meal with clear liquids
Instruct the patient vigorously blow their nose if necessary
The Correct Answer is B
A. Removing objects is contraindicated, as it can worsen the injury.
B. Stabilizing the object and covering it prevents further injury until medical evaluation, which is critical in cases of eye trauma. Moving or removing a foreign body could lead to additional damage.
C. Providing a light meal is not directly related to managing eye trauma and does not address the immediate concern.
D. Blowing the nose could increase intraocular pressure, potentially worsening the injury.
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Related Questions
Correct Answer is C
Explanation
A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.
B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.
C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.
D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.
Correct Answer is D
Explanation
A. Establishing IV access may be necessary if hypotension persists but is not the initial priority.
B. Bladder distension assessment is essential for managing autonomic dysreflexia in SCI patients; however, symptoms here suggest orthostatic hypotension rather than autonomic dysreflexia.
C. Rescheduling therapy may be considered if dizziness persists, but it does not address the immediate concern.
D. Lowering the head of the bed and obtaining vital signs can help stabilize blood pressure and monitor for orthostatic hypotension, which is common in patients with SCI due to autonomic dysfunction. This intervention helps to prevent syncope.
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