# A nurse is caring for a client who sustained a hyphema following blunt trauma to the eye. Which nursing intervention is the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541594  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a client who sustained a hyphema following blunt trauma to the eye. Which nursing intervention is the priority?

## 보기

1. Elevate the head of the bed to 30-45 degrees and maintain bed rest **✔ 정답**
2. Apply ice packs to the affected eye every 2 hours
3. Administer prescribed analgesics for pain management
4. Encourage frequent eye movements to prevent adhesions

**정답: 1**

## 해설

Elevating the head of the bed and maintaining bed rest helps prevent rebleeding and allows blood to settle, reducing intraocular pressure. Other options are supportive but not the priority.

## 심화 해설

Understanding Traumatic Hyphema

A hyphema is the accumulation of blood in the anterior chamber of the eye, the space between the cornea and the iris, typically following blunt or penetrating trauma [1,2]. While the annual incidence is relatively low, timely recognition is critical because hyphema can lead to serious complications that threaten vision, including elevated intraocular pressure (IOP), corneal blood staining, anterior and posterior synechiae, and optic nerve atrophy [1,2]. A particularly dangerous sequela is rebleeding, which is associated with increased rates and severity of these complications .

Priority Nursing Intervention: Bed Rest and Head Elevation

The priority intervention is to elevate the head of the bed to 30-45 degrees and maintain strict bed rest. This position serves two immediate, evidence-based purposes grounded in the pathophysiology of hyphema management.

First, elevating the head of the bed promotes the settling of red blood cells in the dependent portion of the anterior chamber through gravity. This action clears the visual axis and helps to prevent the formation of synechiae, which are adhesions between the iris and the cornea or lens that can permanently impair aqueous humor outflow and pupil function . Second, bed rest minimizes the risk of a secondary hemorrhage, or rebleed. Rebleeding is a significant concern because it is often more severe than the initial bleed and dramatically increases the risk of elevated IOP and permanent vision loss from optic atrophy or corneal staining [1,2]. By limiting physical activity, including sudden movements, bending, and straining, the nurse reduces fluctuations in IOP that could dislodge a clot from the injured vessel, thereby directly preventing this major complication.

Analysis of Other Options

- Option 2: Apply ice packs to the affected eye every 2 hours. While cold compresses may provide mild comfort and vasoconstriction, this is a comfort measure, not a priority action. Applying any direct pressure to an injured globe is contraindicated as it can further increase IOP and worsen damage. The primary goal is to prevent rebleeding and control IOP, which is best achieved through positioning and rest.

- Option 3: Administer prescribed analgesics for pain management. Pain management is an important component of care, but it is not the initial priority. Importantly, the choice of analgesic is critical; non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin are contraindicated because their antiplatelet effects can significantly increase the risk of rebleeding [1,3]. This intervention requires careful assessment and medication verification, making it secondary to the immediate, universally safe action of positioning.

- Option 4: Encourage frequent eye movements to prevent adhesions. This action is contraindicated in the acute phase of hyphema. Frequent eye movement places stress on the injured blood vessels in the iris and ciliary body, increasing the likelihood of dislodging the clot and causing a rebleed. Bed rest with minimal eye movement is the standard of care to allow clot stabilization. Mydriatic or cycloplegic agents, not eye exercises, are used pharmacologically to paralyze the iris and ciliary body, thereby preventing movement and synechiae formation [3,4].

Clinical Reasoning and NCLEX Focus

For the NCLEX-RN, this question tests your ability to prioritize interventions using the ABCs (Airway, Breathing, Circulation) and safety framework, applied to a sensory organ. While the eye is not a life-threatening airway or breathing concern, the "C" in this context translates to preserving circulation to the optic nerve and preventing a secondary hemorrhage that can cause permanent disability (vision loss). The global standard of care, as confirmed by surveys of ophthalmological institutions, consistently includes bed rest and head elevation as a foundational, non-pharmacological intervention for layered hyphema . The rationale is to use gravity to clear the visual axis and immobilization to stabilize the clot, directly mitigating the two most immediate threats: elevated IOP and rebleeding [1,2,3].

## 임상 시나리오

Traumatic Hyphema ManagementPriority nursing actions to prevent vision loss
The priority intervention is to elevate the head of the bed to 30-45 degrees and enforce strict bed rest. This uses gravity to settle red blood cells in the dependent portion of the anterior chamber, clearing the visual axis and preventing synechiae formation.

Bed rest is critical to minimize the risk of rebleeding, a secondary hemorrhage that is often more severe and dramatically increases the risk of elevated intraocular pressure (IOP) and permanent vision damage.

CautionDo not encourage eye movements; the eye must be rested. Activities that increase IOP, such as bending, straining, or rapid eye movement, are contraindicated. Always protect the eye with a rigid shield, not a pressure patch.

## 핵심 개념

- **Hyphema** — Accumulation of blood in the anterior chamber of the eye, usually caused by blunt trauma.
- **Rebleeding** — A secondary hemorrhage in the eye that is often more severe than the initial bleed and increases the risk of permanent vision loss.
- **Synechiae** — Adhesions between the iris and the cornea or lens that can block fluid outflow and impair pupil function.
- **Intraocular Pressure (IOP)** — The fluid pressure inside the eye; elevated IOP is a serious complication of hyphema that can damage the optic nerve.
- **Anterior Chamber** — The fluid-filled space inside the eye between the cornea and the iris.

## 같은 주제 문제

- [A nurse is assessing a patient who sustained blunt trauma to the eye. Which finding would …](https://mymerci.kr/pages/nclex_q.php?qn_id=541591)
- [A nurse is assessing a patient with suspected hyphema following blunt trauma to the eye. W…](https://mymerci.kr/pages/nclex_q.php?qn_id=541592)
- [A nurse is caring for a client with hyphema following blunt trauma to the eye. Which nursi…](https://mymerci.kr/pages/nclex_q.php?qn_id=541593)
- [A nurse is caring for a client who sustained blunt trauma to the eye and has been diagnose…](https://mymerci.kr/pages/nclex_q.php?qn_id=541595)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._