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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

A. Frequent passive range of motion B. Coughing and deep breathing exercises once per shift C. Turn patient every 4 hours D. Ambulate patient twice per shift

Correct Answer is A

Explanation

A. Frequent passive range of motion exercises are crucial for preventing complications of immobility, such as contractures and pressure ulcers, and to promote circulation in patients with spinal cord injuries.

B. While coughing and deep breathing exercises are important for respiratory health, they should be performed more frequently than once per shift in patients with reduced mobility to prevent respiratory complications.

C. Turning the patient every 4 hours may not be adequate to prevent pressure ulcers; typically, patients should be turned at least every 2 hours.

D. Patients with a complete spinal cord injury at C7 typically lack the ability to ambulate, making this intervention inappropriate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Correct Answer is A

Explanation

The nurse is caring for a patient with a complete spinal cord injury at the level of C7. Which intervention would the nurse implement in order to prevent complications related to immobility?

Correct Answer is A

Explanation

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