Nokea
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.
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An eighth-grade client visits the school nurse and reports having been to an eye doctor who identified an astigmatism and described it as a condition in which the eyeball is not shaped correctly. The client asks the nurse why both eyes look alike in the mirror if this is the case. What is the nurse's best response?
- A. Astigmatism means that the very front part of the eye is shaped differently than the very front part in most eyes.
- B. Astigmatism means that the overall shape of the eye resembles an olive more than most eyes.
- C. Astigmatism means that the inside of the eye is shaped differently than the inside of most eyes.
- D. Astigmatism means that the overall shape of your eye is shorter than most eyes.
Correct Answer: A
Rationale: Astigmatism is visual distortion caused by an irregularly shaped cornea. When the overall shape of the eye is like an olive, or more oblong, it results in myopia, not astigmatism, although both conditions may be present at once. The inside of the eye is not shaped differently in the client with an astigmatism. The overall shape of the eye being shorter results in hyperopia, not astigmatism.
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.
While cleaning gutters, a client reports getting debris in the eyes. On inspection, the nurse notes no obvious foreign object. Which diagnostic evaluation technique would be most beneficial for this client?
- A. Administer fluorescein dye.
- B. Obtain an x-ray for orbital fractures.
- C. Assess intraocular movements.
- D. Assess with tonometer.
Correct Answer: A
Rationale: Fluorescein dye stains the eye and helps to identify minute foreign body or abrasions in the cornea. X-ray of the eye orbit would be done if a blow to the area preceded the visit. Assessment of intraocular movements (cranial nerves III, IV, and VI) would not be indicated. Tonometry is done for assessment of intraocular pressure and would not be indicated.
A nurse is caring for a client who has just been diagnosed with glaucoma. What teaching should the nurse include with this client?
- A. How long it will be necessary to wear dark glasses
- B. The importance of regular bowel habits
- C. What vegetables to eat
- D. When it will be possible to read again
Correct Answer: B
Rationale: Instructions for the client with glaucoma include the following: Obtain assistance from a family member, relative, or friend if having trouble instilling eye drops. Avoid all drugs that contain atropine. Check with physician or pharmacist before using any nonprescription drug. preparations for cold or allergy symptoms may contain an atropine-like drug. Maintain regular bowel habits; straining at stool can raise intraocular pressure (IOP). Avoid heavy lifting and emotional upsets (especially crying) because they increase IOP. Patients do not have to wear dark glasses. Vegetable consumption is not restricted. Reading does not increase IOP.
A nurse is caring for a client scheduled for general anesthesia. Which assessment finding would contraindicate the use of atropine in this client?
- A. Detached retina
- B. Cerebrovascular accident
- C. Cataracts
- D. Glaucoma
Correct Answer: D
Rationale: Cholinergic blockers (such as atropine) are often used preoperatively to dry up secretions. Use of these drugs results in dilation of pupils, which increases intraocular pressure (IOP). Clients with glaucoma should avoid use of atropine in an effort to maintain normal range of IOP. Detached retina, CVA, and cataracts are insignificant in the use of cholinergic blockers.