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
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 B
Explanation
A. A hearing test does not address the infection symptoms and would not be the priority.
B. Obtaining a culture of the drainage is necessary to identify any infection and guide appropriate antibiotic treatment.
C. Removing a foreign body may not be relevant and could worsen infection symptoms if not necessary.
D. A CT scan may be needed if further complications are suspected, but it is not the priority for infection symptoms.
Correct Answer is ["A","C","E"]
Explanation
A. Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations.
B. Bladder function is impacted by spinal cord injuries; however, it is not the initial priority in an emergency setting when life-threatening complications must be managed first.
C. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia.
D. Reflexes are often assessed in cases of spinal injury, but they are not the immediate priority when stabilizing the patient upon arrival.
E. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.