Page 1969 - Saunders Comprehensive Review For NCLEX-RN

is produced when a force is sufficient to break the integrity of the blood vessels in
the eye and can be caused by direct injury, such as a penetrating injury from a BB or
pellet, or indirectly, such as from striking the forehead on a steering wheel during an
accident. The client is treated by bed rest in a semi-Fowler’s position to assist gravity
in keeping the hyphema away from the optical center of the cornea.
Test-Taking Strategy: Focus on the subject, care of the client who has sustained a
hyphema. Remember that placing the client flat will produce an increase in pressure
at the injured site. Also, note that the correct option is the one that identifies a
position different from the other options.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Eye: Inflammation/Infections/Injuries
Priority Concepts: Safety; Tissue Integrity
Reference: Jarvis (2016), p. 321.

683. Answer: 1

Rationale: Treatment for a contusion begins at the time of injury. Ice is applied
immediately. The client then should be seen by a PHCP and receive a thorough eye
examination to rule out the presence of other eye injuries.
Test-Taking Strategy: Focus on the strategic word, immediately. Recalling the
principles related to initial treatment of injuries and noting the type of injury
sustained will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Eye: Inflammation/Infections/Injuries
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), p. 981.

684. Answer: 2

Rationale: If the eye injury is the result of a penetrating object, the object may be
noted protruding from the eye. This object must never be removed except by the
ophthalmologist, because it may be holding ocular structures in place. Application of
an eye patch or irrigation of the eye may disrupt the foreign body and cause further
tearing of the cornea.
Test-Taking Strategy: Note the strategic word, initial, and note the word
penetrating. This should indicate that a laceration has occurred and that interventions
are directed at preventing further disruption of the integrity of the eye. The only
option that will prevent further disruption is to assess visual acuity.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation

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