Nokea
A client with chronic open-angle glaucoma is now presenting with eye pain and intraocular pressure of 50 mm Hg. An immediate iridotomy is scheduled. Which explanation by the nurse describes the desired effects of this procedure?
- A. Reverse optic nerve damage
- B. Restore vision
- C. Improve outflow drainage
- D. To relieve pain
Correct Answer: C
Rationale: Laser iridotomy or standard iridotomy is a surgical procedure that provides additional outlet drainage of aqueous humor. This is done to lower the IOP as quickly as possible since permanent vision loss can occur in 1 to 2 days. Once optic nerve damage occurs, it cannot be reversed, and vision is not restored. Pain that occurs with rising IOP will be controlled once pressure is lowered through improved outflow drainage.
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Which technique would be most beneficial for ambulation of a client who is visually impaired?
- A. Speak before touching the client.
- B. Provide a detailed description of the room and walkway.
- C. Allow client to follow the nurse's lead.
- D. Provide the client with a guide dog.
Correct Answer: C
Rationale: A blind person feels more secure and safe when assisted by someone who is sighted. The nurse should walk slightly ahead while allowing the client to hold onto the nurse's upper arm or elbow. Speaking before touching is an important care action in dealing with clients who have impaired vision but does not assist in ambulation. Providing a detailed description of the room may allow the client an image of the surroundings but is not as helpful in initial ambulation. Finding a perfect fit between guide dog and client is a lengthy process and should be pursued upon request of client.
A middle-aged client reports increasing difficulty reading newspaper print. Which of the following nursing explanations best describes this type of refractive error?
- A. Client is nearsighted.
- B. Lens has become cloudy and thick.
- C. Loss of elasticity of the lens.
- D. Floaters in the eye increase with age.
Correct Answer: C
Rationale: Presbyopia is a result of poor accommodation due to a loss of elasticity of the ciliary muscles and lens. Nearsighted refers to myopia. Cloudiness of lens is also associated with the aging process and does interfere with vision as a result of cataract formation. Floaters in the eyes are more apparent with aging but appear as dark spots.
A nurse is assessing a client for a fracture to the bony orbit. What would the nurse document if the assessment for fracture was positive?
- A. There is excessive tearing.
- B. The client's vision is blurred.
- C. A rust ring is seen around the pupil.
- D. The client has diplopia.
Correct Answer: D
Rationale: If the bony orbit is fractured, the eyes may appear asymmetric, and the client has diplopia or double vision. Excessive tearing, presence of rust rings, or blurry vision do not indicate a fractured bony orbit.
Following cataract removal, the client receives discharge instructions from the nurse. Which of the following instructions is most important?
- A. Apply a protective patch to the affected eye at bedtime.
- B. For the first 48 hours, avoid any activity that could cause particles to lodge in the eye.
- C. Avoid washing face and eyes for the first 24 hours.
- D. Avoid heavy lifting for 1 week.
Correct Answer: D
Rationale: For at least 1 week, the client should avoid strenuous activity and heavy lifting; bending, stooping, or other exercises that potentially increase intraocular pressure; immersing the eyes in water (clients may use a clean damp cloth to remove any eye discharge); and any activity that could cause dust or other particles to lodge in the eye. Clients may sleep on the back or unaffected side. The client should wear a protective eye shield for 24 hours after the procedure and then at night and during naps for about a week. Therefore, it is insufficient for the nurse to instruct the client to wear a protective shield at bedtime.
A nurse is caring for a client who has exhibited repeated return of hordeolum (sty). Which assessment finding is most important in determining care for this client?
- A. Dabbing the eyes multiple times with a washcloth
- B. Presence of low blood sugar
- C. Use of disposable wash cloths
- D. Use of antibacterial facial wash
Correct Answer: A
Rationale: Hordeolum is an infection usually caused by Staphylococcus aureus. To avoid transferring microorganisms, the client should not dab the eyes multiple times with a washcloth but should instead clean the unaffected eye first and change the washcloth, towel, and water after contact with the affected eye. The nurse should also instruct the client to use separate fresh tissues, cotton balls, or gauze for each wiping stroke when cleaning exudate from the eye. Clients with high blood sugar are more likely to develop hordeolum. Use of disposable wash cloths, antibacterial cleansers, and good hygiene practices are preventable techniques.