# A nurse is assessing a patient who presents to the emergency department with a suspected foreign body in the right eye. Which assessment finding would be most concerning and require immediate intervention?

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> subject: Adult Health

## 문제

A nurse is assessing a patient who presents to the emergency department with a suspected foreign body in the right eye. Which assessment finding would be most concerning and require immediate intervention?

A 28-year-old construction worker arrives at the emergency department after getting a metal fragment in his right eye while grinding without protective eyewear.

## 보기

1. Mild tearing and blinking of the affected eye
2. Patient reports feeling like "something is in my eye"
3. Visible penetrating object protruding from the cornea **✔ 정답**
4. Conjunctival redness and mild photophobia

**정답: 3**

## 해설

A visible penetrating object protruding from the cornea is a serious ocular emergency requiring immediate intervention to prevent vision loss. Other findings like tearing or redness are less concerning.

## 심화 해설

Understanding the Priority: Penetrating Ocular Trauma

When assessing a patient with a suspected foreign body in the eye, the nurse must rapidly differentiate between a superficial irritation and a true ophthalmic emergency. The scenario describes a mechanism of injury—a metal fragment from grinding without eye protection—that carries a high risk for a high-velocity, penetrating injury. In the context of NCLEX-RN prioritization, a visible penetrating object protruding from the cornea is the most critical finding because it signifies a ruptured globe, which demands immediate, life- and sight-saving interventions to prevent permanent vision loss.

Analysis of the Correct Answer (Option 3)

A visible object penetrating the cornea is a direct sign of an open-globe injury. The cornea and sclera form the rigid outer layer of the eye, and a full-thickness break in this layer constitutes a rupture. The primary danger is not just the foreign body itself, but the loss of intraocular pressure and the potential for extrusion of the eye's internal contents, such as the vitreous humor. As described in a case of penetrating trauma, a full-thickness scleral perforation can lead to vitreous prolapse and dense hemorrhage, which are associated with a poor visual prognosis, including complete loss of visual acuity to no light perception [2]. Furthermore, an open globe creates a direct pathway for microorganisms to enter the eye, dramatically increasing the risk of devastating infections like endophthalmitis or rapidly progressive corneal ulcers that can lead to corneal melting and perforation if not treated with emergency surgery [3]. The immediate nursing intervention is to protect the eye from any pressure, stabilize the object, and prepare the patient for emergency surgical repair, often a penetrating keratoplasty [3]. The critical nature of a penetrating injury is further underscored when the object extends beyond the globe, as even a transorbital penetration can involve major intracranial vessels, requiring a staged, multidisciplinary surgical approach under endovascular standby [4].

Analysis of the Incorrect Answers

Option 1: Mild tearing and blinking of the affected eye. This is an expected physiological response to a corneal foreign body or abrasion. Tearing is a protective reflex to flush out the irritant, and blepharospasm (involuntary blinking) is a response to pain and photophobia. While distressing, these symptoms alone do not indicate a ruptured globe and are not the highest priority.

Option 2: Patient reports feeling like "something is in my eye." This is the classic foreign body sensation, a hallmark symptom of a corneal abrasion or a retained superficial foreign body. While it requires assessment and intervention, the subjective report itself does not confirm a penetrating injury. The nurse must perform a thorough examination to rule out a deeper wound, but this symptom is an expected finding, not the most concerning one.

Option 4: Conjunctival redness and mild photophobia. These are common signs of conjunctival and corneal irritation, often seen with conjunctivitis, keratitis, or a superficial foreign body. Photophobia results from ciliary muscle spasm and irritation of the richly innervated cornea. While these findings warrant a full assessment and pain management, they are not immediately vision-threatening and do not take priority over a visible penetrating object, which signals a structural breach of the globe.References (research sources)

- [2]Hunting Firearm Induced Optic Nerve Transection.Research articleCalabresi V, Cuccu A, Corda C, Giannaccare G. (2026) · DOI: 10.2147/imcrj.s592326

- [3]Anterior Segment OCT in Fulminant <i>Pseudomonas aeruginosa</i> Corneal Ulcer with Stromal Melting Requiring Emergency Penetrating Keratoplasty.Research articleLuboń W, Sarnat-Kucharczyk M, Dorecka M. (2026) · DOI: 10.3390/diagnostics16081189

- [4]Transorbital penetrating brainstem injury by a chopstick with major vessel proximity: staged extraction under endovascular standby and serial vascular follow-up.Research articleAsano H, Kakino Y, Kano S, Wakayama Y, Takada E, Kimura K, Kuroda A, Miura T, Mizuno Y, Fukuta T, Takei H, Suzuki K, Miyake T, Enomoto Y, Yoshida S, Izumo T, Okada H. (2026) · DOI: 10.1186/s12245-026-01160-x

## 임상 시나리오

Open-Globe Injury: Emergency ManagementPrioritize sight-saving interventions for penetrating eye trauma
A visible penetrating object protruding from the cornea or sclera is a direct sign of a ruptured globe. This is a true ophthalmic emergency requiring immediate action to prevent permanent vision loss.

The primary danger is the loss of intraocular pressure and potential extrusion of internal contents like the vitreous humor. Any increase in pressure can worsen the injury.

CautionNever attempt to remove the penetrating object. Do not apply pressure or a patch to the eye. Protect the eye with a rigid shield (e.g., metal or plastic cup) and prepare the patient for emergency surgery. Elevate the head of the bed to 30 degrees.

## 핵심 개념

- **Open-Globe Injury** — A full-thickness wound of the eyewall (cornea or sclera), often caused by blunt or penetrating trauma, leading to loss of intraocular pressure.
- **Ruptured Globe** — A severe type of open-globe injury where the eyewall integrity is compromised, risking extrusion of intraocular contents and permanent vision loss.
- **Vitreous Humor** — The clear gel filling the space between the lens and the retina; its prolapse through a wound indicates a severe open-globe injury.
- **Corneal Abrasion** — A superficial scratch on the corneal epithelium, causing pain and foreign body sensation but not a full-thickness penetration.
- **Intraocular Pressure (IOP)** — The fluid pressure inside the eye; a sudden drop is a critical sign of globe rupture and requires emergency management.

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