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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.
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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.
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.
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 doing preoperative and postoperative teaching with a client who is undergoing cataract surgery. What is an important teaching point the nurse should emphasize to the client?
- A. Prepare for possible feelings of depression.
- B. Expect increased urine output.
- C. Eat soft, easily chewed food until healing is complete.
- D. Anticipate development of a periorbital hematoma.
Correct Answer: C
Rationale: Advise clients who have had cataract surgery to eat soft, easily chewed foods until healing is complete to avoid tearing from excessive facial movements. Clients who undergo cataract surgery do not become depressed, have increased urine output, or develop a periorbital hematoma.
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.