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 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. Fifth intercostal space, left midclavicular line B. Fourth intercostal space, right sternal boarder C. Third intercostal space, left midclavicular line D. Second intercostal space, right sternal boarder

Correct Answer is A

Explanation

A. The fifth intercostal space at the left midclavicular line is the location of the mitral valve, where murmurs associated with mitral valve disease are best auscultated.

B. The fourth intercostal space at the right sternal border is the location for assessing the tricuspid valve, not the mitral valve.

C. The third intercostal space at the left midclavicular line is not associated with loudest auscultation of the mitral valve murmur.

D. The second intercostal space at the right sternal border is where the aortic valve sounds are best heard.

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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

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