# A nurse is caring for a client who presents to the emergency department with a metal fragment embedded in the right eye following a workplace accident. What is the most important initial nursing assessment for this client? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541612 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client who presents to the emergency department with a metal fragment embedded in the right eye following a workplace accident. What is the most important initial nursing assessment for this client? ## 보기 1. Assess the client's visual acuity in both eyes using a Snellen chart 2. Examine the depth and location of the penetrating object using direct visualization 3. Assess for signs of increased intraocular pressure and globe rupture **✔ 정답** 4. Evaluate the client's ability to move the affected eye in all directions **정답: 3** ## 해설 The priority assessment is to evaluate for signs of increased intraocular pressure and globe rupture, which are sight-threatening emergencies. Other assessments like visual acuity or object examination are secondary and may worsen injury. ## 심화 해설 Clinical Context and Priority Setting When a client presents with a metal fragment embedded in the eye, this constitutes an open globe injury until proven otherwise. The NCLEX-RN examination consistently tests the principle that in penetrating ocular trauma, preserving the structural integrity of the eye and preventing further damage takes absolute precedence over other assessments. Ocular trauma is a leading cause of acquired monocular blindness worldwide, and initial emergency department management directly influences long-term visual outcomes [1]. Why Option 3 is the Priority Assessing for signs of increased intraocular pressure (IOP) and globe rupture is the most important initial nursing assessment. A penetrating metal fragment creates a full-thickness defect in the cornea or sclera, allowing aqueous humor or vitreous to escape. This immediately threatens the structural integrity of the globe. Signs of rupture include a teardrop-shaped pupil (pointing toward the wound), shallowing of the anterior chamber, subconjunctival hemorrhage involving the entire visible sclera, and visible uveal tissue. Any manipulation of the eye before recognizing a ruptured globe—such as checking extraocular movements or applying pressure during visual acuity testing—can cause extrusion of intraocular contents, converting a salvageable injury into permanent vision loss. The clinical practice guideline for ocular trauma emphasizes that the initial assessment must focus on identifying open globe injuries before any other examination maneuvers are attempted [2]. Analysis of Incorrect Options Option 1 (Visual acuity assessment): While visual acuity is a critical component of the complete ocular examination, performing a Snellen chart test requires the client to open and move both eyes. In the presence of an embedded metal fragment, this movement risks dislodging the object or extending the laceration. Additionally, the pressure of an eye patch or occluder over the unaffected eye can trigger consensual eye movement. Visual acuity should be documented, but only after ruling out globe rupture and stabilizing the eye. Option 2 (Direct visualization of depth and location): Directly examining the depth of a penetrating object with a penlight or ophthalmoscope is contraindicated. Applying any pressure to the globe or manipulating the eyelid against the embedded object can worsen the injury. If a ruptured globe is suspected, the eye should be protected with a rigid eye shield (not a pressure patch), and further examination should be deferred to the ophthalmologist. The emergency department management of such injuries prioritizes shielding the eye and obtaining emergent ophthalmology consultation . Option 4 (Extraocular movement assessment): Evaluating extraocular movements requires the client to move the affected eye in multiple directions. In the setting of a penetrating injury with an embedded foreign body, this movement can cause the metal fragment to lacerate intraocular structures, increase vitreous loss through the wound, or drive the fragment deeper. Extraocular muscle entrapment is a relevant concern in orbital floor fractures, but in penetrating trauma with a retained foreign body, the immediate priority is immobilization, not mobility testing. Pathophysiology and Clinical Reasoning The mechanism of injury here involves a high-velocity metal fragment, which carries kinetic energy sufficient to penetrate the corneoscleral coat. Once the globe is opened, the normal intraocular pressure (typically 10–21 mmHg) is lost, and the risk of expulsive choroidal hemorrhage or retinal detachment increases. The nurse's role is to recognize the clinical signs of an open globe—shallow anterior chamber, peaked pupil, hypotony (soft eye on very gentle palpation over closed lids only if absolutely necessary), and visible intraocular tissue—and to protect the eye from any further trauma. This aligns with the systematic review finding that prompt and accurate initial assessment is essential for favorable prognosis in ocular trauma [1]. The long-term consequences of mismanaged ocular trauma extend beyond vision loss to include significant psychosocial burden and reduced quality of life, underscoring the importance of correct initial nursing actions . Key NCLEX Safety Principle In penetrating eye injuries, the nursing priority follows a "do no further harm" approach: shield the eye, avoid any manipulation or pressure, keep the client NPO for possible surgical repair, and assess for associated injuries. The assessment for globe rupture is the foundational step that determines the safety of all subsequent interventions.References (research sources) - [1]Artificial intelligence in the diagnosis and prognosis of ocular trauma: a systematic review.Meta-analysis/systematic reviewDolatabadi ZA, Foodani MN, Farkhad MF, Golvardi-Yazdi F. (2026) · DOI: 10.1186/s12886-026-04688-x - [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 ## 임상 시나리오 Penetrating Eye Injury: Initial AssessmentRuling Out Open Globe Before Any Manipulation A metal fragment in the eye is an open globe injury until proven otherwise. The priority is to assess for globe rupture and increased intraocular pressure without applying pressure to the eye. Key signs of rupture include a teardrop pupil, shallow anterior chamber, extensive subconjunctival hemorrhage, or visible uveal tissue. Any manipulation before recognizing a rupture can cause extrusion of contents and permanent vision loss. CautionDo **not** check visual acuity, examine the object's depth, or test extraocular movements initially. These actions increase intraocular pressure and risk worsening the injury. ## 핵심 개념 - **Open Globe Injury** — A full-thickness wound of the eye wall (cornea or sclera) caused by blunt or penetrating trauma, requiring immediate protection and surgical repair. - **Globe Rupture** — A severe form of open globe injury where the integrity of the eyeball is compromised, often indicated by a teardrop pupil or flat anterior chamber. - **Intraocular Pressure (IOP)** — The fluid pressure inside the eye; in penetrating trauma, sudden decompression from a wound can lead to dangerously low pressure or secondary hemorrhage. - **Teardrop Pupil** — A classic sign of globe rupture where the pupil appears pear-shaped or points toward the wound site due to iris prolapse. ## 같은 주제 문제 - [A 28-year-old construction worker presents to the emergency department with a penetrating …](https://mymerci.kr/pages/nclex_q.php?qn_id=541611) - [A nurse is caring for a client who sustained a penetrating eye injury from a metal fragmen…](https://mymerci.kr/pages/nclex_q.php?qn_id=541613) - [A nurse is caring for a client who presents to the emergency department with a metal fragm…](https://mymerci.kr/pages/nclex_q.php?qn_id=541614) - [A nurse is caring for a client who presents to the emergency department with a metal fragm…](https://mymerci.kr/pages/nclex_q.php?qn_id=541615) - [A nurse is caring for a client who presents to the emergency department with a metal fragm…](https://mymerci.kr/pages/nclex_q.php?qn_id=541616) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._