Neurological Question #42

Question

The nurse caring for an unconscious client enters the room and observes the client has one eye closed while the other eye is partially open. Which action will the nurse perform to prevent complications of the eye while the client is unconscious?

Answers

  1. Cleanse the eye every shift of debris and matter.
    • Rationale:
  2. Taping the eye closed.
    • Rationale:
  3. Do nothing as the client may be waking from coma.
    • Rationale:
  4. Apply artificial tears every each shift.
    • Rationale:

Overview

Explanation

Taping one or both eyes is appropriate since the blinking reflex may be absent in an unconscious client. If absent, and if the eye cannot close, risk of corneal abrasion occurs because of dryness. Taping will help avoid this injury. While cleansing the eyes is good, it still does not protect from corneal injury. Instilling artificial tears once per shift may not be enough. Having one or both eyes open does not imply that the client is waking from unconsciousness.

Learning Outcomes

Test Taking Tip

Video Rationale