A client diagnosed with cholecystitis reports right upper quadrant pain that radiates to the right shoulder. Which of the following interventions is the priority for the nurse to implement?

Choice A Reason: This is incorrect because nystagmus is not a response to stimuli, but a condition that causes involuntary eye movements. Nystagmus can be caused by various factors, such as inner ear disorders, brain lesions, or drug toxicity, but not necessarily by cervical spine injury.

Choice B Reason: This is incorrect because decorticate positioning is a response to stimuli that indicates damage to the cerebral cortex or the corticospinal tract. Decorticate positioning is characterized by flexion of the arms and extension of the legs. It does not indicate cervical spine injury, which affects the spinal cord below the brainstem.

Choice C Reason: This is incorrect because lack of any response to stimuli can indicate various levels of brain damage or coma, but not specifically cervical spine injury. Lack of any response can also be influenced by other factors, such as sedation, hypothermia, or shock.

Choice D Reason: This is correct because decerebrate positioning is a response to stimuli that indicates damage to the brainstem or the upper cervical spine. Decerebrate positioning is characterized by extension and outward rotation of the arms and legs. It indicates a severe and life-threatening injury that can impair vital functions, such as breathing and blood pressure.

Choice A reason: This is incorrect because it is necessary to remove contact lenses before administering medications. Contact lenses can absorb or interfere with the absorption of eye drops and cause irritation or infection. The nurse should instruct the client to remove contact lenses before applying eye drops and wait at least 15 minutes before reinserting them.
Choice B reason: This is incorrect because administering the medications by touching the tip of the dropper to the sclera of the eye can cause contamination or injury. The sclera is the white part of the eye that covers most of the eyeball. The nurse should instruct the client to avoid touching the tip of the dropper to any part of the eye or eyelid and hold it about 1 cm above the lower eyelid.
Choice C reason: This is correct because administering the medications 5 min apart can prevent dilution or washout of one medication by another. Timolol and pilocarpine are two different types of eye drops that are used to treat open-angle glaucoma, which is a condition that causes increased pressure inside the eye and damage to the optic nerve. Timolol is a beta-blocker that reduces the production of fluid in the eye, and pilocarpine is a cholinergic agent that increases the drainage of fluid from the eye. The nurse should instruct the client to apply one drop of each medication in the affected eye(s) and wait at least 5 minutes between each medication.
Choice D reason: This is incorrect because holding pressure on the conjunctival sac for 2 min following the application of eye drops can reduce systemic absorption and side effects of eye drops. The conjunctival sac is the space between the lower eyelid and the eyeball. The nurse should instruct the client to gently close their eyes after applying eye drops and press their index finger against the inner corner of their eye for 2 minutes. This can block the tear duct that drains fluid from the eye to the nose and prevent it from entering the bloodstream.