# A nurse is caring for a client who sustained a blunt eye injury. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541602 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client who sustained a blunt eye injury. Which nursing intervention should be the priority? A 25-year-old male presents to the emergency department after being struck in the right eye by a baseball during a game. ## 보기 1. Apply warm compresses to reduce swelling 2. Instill antibiotic eye drops immediately 3. Encourage the client to rub the eye gently to assess pain level 4. Apply a protective eye shield without applying pressure **✔ 정답** **정답: 4** ## 해설 The priority is to apply a protective eye shield without pressure to prevent further injury to eye structures. Other interventions like warm compresses, antibiotic drops, or rubbing could worsen the condition. ## 심화 해설 Understanding the Priority in Blunt Eye Injury The scenario describes a blunt eye injury from a baseball, which carries a risk of serious complications, including open-globe injury (OGI)—a full-thickness violation of the eye wall—and orbital compartment syndrome (OCS). In the initial emergency setting, the immediate priority is to protect the eye from further harm while avoiding any intervention that could worsen an undiagnosed rupture or increase intraocular pressure. [1][4] Analysis of the Options 1. Apply warm compresses to reduce swelling: This is contraindicated. In the context of trauma, applying warmth can promote vasodilation and increase bleeding. More critically, any direct manipulation or pressure on the globe could cause extrusion of intraocular contents if an occult open-globe injury is present. [1][4] 2. Instill antibiotic eye drops immediately: While infection prophylaxis is a key component of ocular trauma management, it is not the first priority. Instilling any substance into an eye with a potential rupture is dangerous and should only be done after a thorough examination has ruled out an open-globe injury. [2][4] 3. Encourage the client to rub the eye gently to assess pain level: This is absolutely contraindicated. Rubbing the eye applies direct pressure to the globe, which can significantly worsen a corneal laceration, prolapse intraocular contents through a scleral rupture, or exacerbate a retrobulbar hemorrhage, potentially precipitating OCS. [1][4] 4. Apply a protective eye shield without applying pressure: This is the correct priority intervention. A rigid shield protects the injured eye from accidental contact, rubbing, or further blunt force while avoiding any pressure on the globe itself. Pressure could extrude intraocular contents through an undetected rupture. This action follows the core principle of stabilizing the injury and preventing iatrogenic harm before a definitive ophthalmologic evaluation. [1][2][4] The Underlying Pathophysiology and Risks A blunt injury from a baseball creates a sudden, dramatic increase in intraocular pressure, which can lead to a ruptured globe at the weakest points of the sclera. Simultaneously, trauma can cause a retrobulbar hemorrhage, where bleeding accumulates in the confined space behind the eye. This is a primary cause of orbital compartment syndrome (OCS), a vision-threatening emergency where rising pressure within the orbit compromises the optic nerve and retinal blood flow. OCS requires rapid identification and immediate treatment, such as a lateral canthotomy and inferior cantholysis, to preserve vision. [1] The initial nursing priority is to prevent any action that could tip a contained injury into a catastrophic one, which is why a non-pressure shield is the only safe and immediate intervention before a specialist examination. [1][2][4]References (research sources) - [1]Orbital compartment syndrome: Pearls and pitfalls for the emergency physician.Research articleMurali S, Davis C, McCrea MJ, Plewa MC. (2021) · DOI: 10.1002/emp2.12372 - [2]Explosive Weapons Trauma Care Collective (EXTRACCT) Blast Injury Clinical Practice Guideline: Ocular Trauma.GuidelineButterfield E, Bolt A, Clare G, Mattia J, Tin-U AM, Ndyabawe I, Schwab L, Wagner SK, EXTRACCT Clinical Practice Guidelines Collaboration. (2026) · DOI: 10.1002/wjs.70204 - [4]Pediatric open-globe injury: Current perspectives, surgical principles, and literature review.Research articleWong JCY, Yonekawa Y. (2025) · DOI: 10.4103/tjo.tjo-d-24-00061 ## 임상 시나리오 Blunt Eye Injury: Initial Nursing PriorityProtect the globe without applying pressure The immediate priority for a suspected blunt eye injury is to place a rigid protective eye shield over the affected eye. This must be done without applying any pressure to the globe to prevent extrusion of intraocular contents if an occult open-globe injury (OGI) exists. Do not instill any drops, apply compresses, or allow the patient to rub the eye before a thorough examination rules out a rupture. Any manipulation can increase intraocular pressure (IOP) and worsen the injury. CautionNever apply direct pressure, patch the eye tightly, or use a dependent eye cup. If a shield is unavailable, a paper cup can be taped loosely in place as a temporary measure. Keep the patient NPO in case surgical repair is needed. ## 핵심 개념 - **Open-Globe Injury (OGI)** — A full-thickness wound of the eye wall (cornea or sclera), often caused by blunt or penetrating trauma, requiring immediate protection to prevent extrusion of contents. - **Orbital Compartment Syndrome (OCS)** — An emergency condition where increased pressure within the bony orbit compromises optic nerve function, which can be exacerbated by pressure on the eye. - **Protective Eye Shield** — A rigid device placed over the injured eye without applying any pressure to the globe, used to prevent further trauma during transport and assessment. - **Intraocular Pressure (IOP)** — The fluid pressure inside the eye; any manipulation, rubbing, or pressure on the globe can dangerously elevate IOP in the setting of trauma. ## 같은 주제 문제 - [A nurse is assessing a 25-year-old male who sustained an eye contusion from a baseball inj…](https://mymerci.kr/pages/nclex_q.php?qn_id=541596) - [A nurse is assessing a patient who sustained a blunt trauma to the left eye 2 hours ago. 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