Asked by Caitlin Moore on May 21, 2024
Verified
An adolescent gets hit in the eye during a fight. The school nurse, using a flashlight, notes the presence of gross hyphema (hemorrhage into anterior chamber) . What is the priority nursing action?
A) Apply a Fox shield
B) Instruct the adolescent to apply ice for 24 hours
C) Have the adolescent rest with eye closed and ice applied
D) Notify parents that the adolescent needs to see an ophthalmologist
Gross Hyphema
A severe condition where a large amount of blood collects in the front chamber of the eye, often as a result of trauma, significantly obstructing vision.
Anterior Chamber
The fluid-filled space inside the eye between the cornea and the iris, contributing to eye pressure.
- Understand key nursing actions for immediate care in cases of eye injuries and infections.
Verified Answer
KA
Kevin AhearnMay 23, 2024
Final Answer :
D
Explanation :
The parents should be notified that the adolescent needs to see an ophthalmologist as soon as possible. Applying a Fox shield, instructing the adolescent to apply ice for 24 hours, and having the adolescent rest with eye closed and ice applied may cause further damage. Referral to an ophthalmologist is indicated.
Learning Objectives
- Understand key nursing actions for immediate care in cases of eye injuries and infections.
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