Question

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, 'Last week I crashed my car because my vision suddenly became blurry.' Which of the following actions is the nurse's priority?

a. Assess the client's wrist for swelling and deformity.

b. Request a social services consult for driving assessment.

c. Assess the client's visual acuity and perform an ophthalmoscopic exam.

d. Inquire about the use of corrective lenses.

Answer 1

The nurse's priority should be to assess the client's visual acuity and perform an ophthalmoscopic exam. This is due to the potential of a serious neurological event, such as a stroke, which could have led to the fall and wrist fracture. Subsequent inquiries about corrective lenses and a driving assessment are important but secondary.

Step-by-step explanation:

The nurse's priority should be to assess the client's visual acuity and perform an ophthalmoscopic exam. Considering the client's report of sudden blurry vision and a recent car accident, this assessment is critical to identify any neurological deficits that could indicate a serious condition such as a stroke, which may have contributed to the fall and subsequent wrist fracture.

Neurological assessments in an emergency setting are essential because they can guide the immediate management of the patient and prioritize interventions. A rapid assessment of neurological function can help determine the location and extent of a potential neurological injury, which is vital in an emergency situation such as the one described, where the patient's symptoms may suggest the possibility of an acute neurological event.

In addition to the immediate visual and neurological assessment, it would also be appropriate to inquire about the use of corrective lenses and consult social services for a driving assessment, but these actions are secondary to the priority of assessing potential neurological impairment.