# A nurse is caring for a client who sustained a blunt eye contusion. Which assessment finding would be the most important for the nurse to monitor immediately? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541603 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client who sustained a blunt eye contusion. Which assessment finding would be the most important for the nurse to monitor immediately? A 30-year-old female presents to the emergency department after being struck in the left eye by a tennis ball during a match. The client reports severe eye pain and blurred vision. ## 보기 1. Presence of conjunctival redness 2. Changes in intraocular pressure **✔ 정답** 3. Degree of eyelid swelling 4. Amount of tearing from the eye **정답: 2** ## 해설 Changes in intraocular pressure are critical as increased pressure can lead to permanent vision loss. Other findings like conjunctival redness, eyelid swelling, or tearing are less urgent. ## 심화 해설 Understanding the Priority: Why Intraocular Pressure Matters Most When a client presents with blunt eye trauma, such as being struck by a tennis ball, the immediate nursing priority is to identify and monitor for the most vision-threatening complication. While all the listed assessment findings are common after an eye injury, changes in intraocular pressure (IOP) provide the most critical data regarding the internal health of the eye and the risk of permanent vision loss. The mechanism of injury—a blunt, closed-globe contusion—can trigger a cascade of events that dangerously elevate IOP, a condition known as traumatic glaucoma [2]. The Pathophysiology of the Danger Blunt trauma causes a sudden compression of the globe, which can damage the delicate structures responsible for draining the aqueous humor, the fluid that maintains the eye's normal pressure. Specifically, the trabecular meshwork can be torn or scarred, and blood (a hyphema) or inflammatory cells can physically clog the drainage channels [2]. As the drainage system fails, fluid continues to be produced, causing the IOP to rise sharply. This elevated pressure directly compromises the optic nerve and its blood supply. Without prompt detection and intervention, this can lead to irreversible glaucomatous damage and permanent visual function loss [2]. This makes IOP assessment a direct measure of a potentially catastrophic process happening inside the eye. Why Other Findings Are Lower Priority The other options represent expected or less immediately dangerous consequences of blunt trauma. Conjunctival redness (often from subconjunctival hemorrhage) and eyelid swelling are common anterior segment findings that, while dramatic in appearance, are typically self-limiting and do not directly threaten vision . Similarly, tearing is a normal reactive response to pain and surface irritation. The most deceptive danger is that significant posterior segment pathology, like a retinal tear or a rise in IOP, can coexist with these mild anterior findings and be easily overlooked . The client’s report of severe pain and blurred vision is a red flag that points beyond surface damage. Blurred vision can be a symptom of a retinal injury like commotio retinae or a submacular hemorrhage , but it is also a classic symptom of acute IOP elevation. Monitoring IOP is the direct action that screens for the most time-sensitive, treatable cause of permanent vision loss.References (research sources) - [2]Traumatic GlaucomaResearch articleNg JK, Kaur K. (2026) ## 임상 시나리오 Blunt Eye Trauma: IOP MonitoringPrioritizing the Assessment to Prevent Vision Loss After a blunt contusion, the highest priority is monitoring for changes in intraocular pressure. A sudden rise signals traumatic glaucoma, which can cause permanent optic nerve damage within hours. The mechanism involves damage to the trabecular meshwork or obstruction from a hyphema. A normal IOP ranges from 10 to 21 mmHg. Any elevation must be reported immediately. CautionDo not be distracted by superficial findings like conjunctival redness or lid swelling. These are expected but do not reflect the internal, vision-threatening process. Avoid any eye manipulation or patching that could increase pressure. ## 핵심 개념 - **Traumatic Glaucoma** — Elevated intraocular pressure caused by blunt eye injury damaging the drainage structures or clogging them with blood/inflammatory cells. - **Hyphema** — Blood in the anterior chamber of the eye, a common complication of blunt trauma that can obstruct fluid outflow and raise IOP. - **Trabecular Meshwork** — The spongy tissue located around the base of the cornea responsible for draining aqueous humor from the eye. - **Intraocular Pressure (IOP)** — The fluid pressure inside the eye; elevated levels can compress the optic nerve and cause permanent vision loss. ## 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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