A nurse is caring for a client who sustained a blunt trauma to the right eye resulting in a contusion. Which a…

Question

A nurse is caring for a client who sustained a blunt trauma to the right eye resulting in a contusion. Which assessment finding would be the priority concern requiring immediate intervention?

Accepted Answer

보기 2: Sudden onset of severe eye pain with nausea and vomiting

Sudden severe eye pain with nausea/vomiting indicates increased intraocular pressure, a vision-threatening emergency. Other findings are less urgent.

Answer

보기 1: Mild periorbital edema and ecchymosis around the affected eye

Answer

보기 3: Subconjunctival hemorrhage with blood visible in the sclera

Answer

보기 4: Photophobia and excessive tearing from the injured eye

Assessment Finding	Clinical Significance & Rationale
1. Mild periorbital edema and ecchymosis	This is an expected finding following blunt trauma and contusion. While it requires monitoring, it does not independently indicate a compartment syndrome. Periorbital ecchymosis and hematoma are common and typically self-limiting ^[2].
2. Sudden onset of severe eye pain with nausea and vomiting	Priority concern. This is the hallmark presentation of acute OCS. The severe pain results from rapid stretching of pain fibers due to elevated pressure, and the oculocardiac reflex triggers nausea and vomiting. This requires immediate intervention, such as an emergency lateral canthotomy and cantholysis, to decompress the orbit and restore perfusion to the optic nerve ^[1]^[4].
3. Subconjunctival hemorrhage with blood visible in the sclera	While visually alarming, a subconjunctival hemorrhage in the context of blunt trauma is generally a benign finding that resolves spontaneously. It does not cause an increase in orbital pressure unless it is associated with a deeper, expanding retrobulbar hematoma ^[3].
4. Photophobia and excessive tearing	These findings are consistent with traumatic iritis or a corneal abrasion, which are painful but not immediately sight-threatening in the same rapid timeframe as OCS. They do not reflect the compressive ischemic process of a compartment syndrome.

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A nurse is caring for a client who sustained a blunt trauma to the right eye resulting in a contusion. Which assessment finding would be the priority concern requiring immediate intervention?

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