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1. Question
The client arrives in the emergency department following an automobile accident. The client’s forehead hit the steering wheel and a hyphema is diagnosed. The nurse places the client in which position?
Correct
Answer & Rationale:
Option 2 is Correct
Rationale: A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bedrest in a semi-Fowler’s position to assist gravity in keeping the hyphema away from the optical center of the cornea.
Incorrect
Answer & Rationale:
Option 2 is Correct
Rationale: A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bedrest in a semi-Fowler’s position to assist gravity in keeping the hyphema away from the optical center of the cornea.
Hyphema
Description
Presence of blood in the anterior chamber that occurs as a result of an injury
The condition usually resolves in 5 to 7 days.
Interventions
Encourage rest with the client in a semi-Fowler’s position.
Avoid sudden eye movements for 3 to 5 days to decrease the likelihood of bleeding.
Administer cycloplegic eye drops as prescribed to relax the eye muscles and place the eye at rest.
Instruct the client in the use of eye shields or eye patches as prescribed.
Instruct the client to restrict reading and limit watching television.