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Certified Emergency Nurse (CEN)

Certified Emergency Nurse (CEN) Examination

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The Anatomy of a Question


Question

A 26-year-old patient presents with eye pain and blurred vision after being hit in the eye. Layering of blood is noted across the iris. Which of the following is the most likely diagnosis?


Answer choice options
  • A. Hyphema
  • B. Ruptured globe
  • C. Subconjunctival hemorrhage
  • D. Traumatic iritis

The incorrect options (distractors) are not totally wrong. These options can be diagramed as follows:

Most Correct
Least Correct
  • A.
    Hyphema Blood in the anterior chamber is classic for hyphema, especially in the setting of trauma.
  • B.
    Ruptured globe Associated with hyphema, but no evidence of reduced intraocular pressure in vignette.
  • C.
    Subconjunctival hemorrhage Usually benign and associated with blood in the conjunctiva, not the anterior chamber.
  • D.
    Traumatic iritis Presents with eye pain, blurry vision, and decreased visual acuity. Blood in the anterior chamber is not characteristic.

The Anatomy of an Explanation

Traumatic hyphema occurs after blunt trauma to the eye. A hyphema can be graded as I (< 33% of anterior chamber), II (33–50%), III (> 50%), and IV (100%). Patients may also present with nausea, vomiting, headache, and photophobia. It presents with visible blood in the anterior chamber of the eye that layers across the iris and can cause vision loss. Patients should have a slit lamp exam performed, and visual acuity should be documented. A fluorescein stain should be performed to rule out abrasions, and intraocular pressure should be checked if there is no concern for a globe rupture. Management involves elevating the head of the bed, placing an eye shield, analgesia, and an ophthalmology consultation.

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