Nokea
A nurse is caring for a client immediately following cataract removal. Which symptom would be most alarming to the nurse?
- A. Irritation in the operative eye
- B. Dilation of the pupil
- C. Dry, tickling cough
- D. Fever
Correct Answer: C
Rationale: Coughing can rise the intraocular pressure and should be avoided. A cough suppressant can be prescribed. The pupil was intentionally dilated during the surgical approach and will resolve. The client may complain of mild eye irritation in the immediate postoperative period. Fever can be a complication of cataract surgery but not expected in the immediate period postoperatively.
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The client with chronic open-angle glaucoma is receiving timolol eye drops. Which evaluation finding would indicate to the nurse the treatment is working?
- A. Intraocular pressure 15 mm Hg
- B. Reduced peripheral vision
- C. Halos around lights
- D. Decrease in nausea and vomiting
Correct Answer: A
Rationale: Timolol is a beta-blocker that is used topically to decrease the flow rate of aqueous humor in the eye. As flow rate decreases, the intraocular pressure decreases. IOP of 12 to 21 mm Hg is within normal range. Reduced peripheral vision, halos around lights, and blurred vision are all symptoms of open-angle glaucoma. Nausea and vomiting are more likely to occur with acute angle-closure glaucoma.
A client asks the nurse why miotic eye solutions were prescribed in the treatment of the client's glaucoma. Which is the best nursing rationale for the use of this medication?
- A. Constricts intraocular vessels
- B. Paralyzes ciliary muscles
- C. Constricts pupil
- D. Dilates the pupil
Correct Answer: C
Rationale: A miotic agent works by constricting the pupil and pulling the iris away from the drainage channels so that the aqueous fluid can escape. These medications increase outflow and decrease intraocular pressure. Cycloplegics paralyze the ciliary muscles of the eye. Mydriatics drugs are used to dilate the pupil and are contraindicated in glaucoma.
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.
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 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.