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. Conjunctivitis (pink eye) is not a typical complication of Bell's Palsy.

B. Retinal detachment is unrelated to the incomplete eye closure seen in Bell’s Palsy.

C. Bell's Palsy often results in incomplete eye closure, which can lead to drying and irritation of the cornea, increasing the risk for corneal abrasions. An eye patch protects the cornea by helping the eye stay moist and protected from injury.

D. A chalazion is a small eyelid bump caused by blocked oil glands, not associated with Bell’s Palsy.

A. Suction the patient to minimize secretions B. Continue with the assessment and document the finding C. Notify the physician and raise HOB to 35-45 degrees D. Lower the head of the bed and pad the side rails

Correct Answer is C

Explanation

A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.

B. Documenting without intervention could lead to worsening of the patient's condition.

C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.

D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.

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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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