Nokea
The client asks the nurse about symptoms associated with retinal detachment. Which symptoms should the nurse identify? Select all that apply.
- A. Seeing bright flashes of light
- B. Shooting, throbbing eye pain
- C. Severe frontal headache
- D. Diminished visual acuity
- E. Seeing floating dark spots in the vision field
Correct Answer: A,D,E
Rationale: As the choroid and retina partially separate, the client notices flashes of light, decreased vision, and floating dark spots. Pain is not associated with retinal detachment due to few pain fibers in the retina. Headache is not associated with retinal detachment.
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The nurse completes an assessment of the older adult client. Which disorder should the nurse associate with the finding illustrated?
- A. Glaucoma
- B. Arcus senilis
- C. Cataract
- D. Mydriasis
Correct Answer: C
Rationale: The illustration shows opacity of the lens of the eye. The nurse should associate this finding with a cataract. Glaucoma causes increased pressure within the eye and is not visible. Arcus senilis is a bluish-white ring within the outer edge of the cornea, which is not present in this illustration. Mydriasis is constriction of the pupil, which is not present in the illustration.
The client with macular degeneration is told the condition is progressing to an advanced stage. Which findings should the nurse expect when completing the assessment? Select all that apply.
- A. Curtain appearance over part of the visual field
- B. Loss of peripheral vision in the affected eye
- C. Difficulty seeing in dimly lit environments
- D. Visual distortions in the central vision
- E. Clouding of the lens in both eyes
Correct Answer: C,D
Rationale: Difficulty seeing in dimly lit environments is from the slow breakdown of the outer layer of the retina and the formation of drusen within the macula. The macula is the area of central vision, and with macular degeneration, there is the loss or distortion of central vision. Curtain appearance is associated with retinal detachment, peripheral vision loss with glaucoma, and clouding of the lens with cataracts.
The client is scheduled for right-eye cataract removal surgery in five (5) days. Which preoperative instruction should be discussed with the client?
- A. Administer dilating drops to both eyes for 72 hours prior to surgery.
- B. Prior to surgery do not lift or push any objects heavier than 15 pounds.
- C. Make arrangements for being in the hospital for at least three (3) days.
- D. Avoid taking any type of medication which may cause bleeding, such as aspirin.
Correct Answer: D
Rationale: Avoiding bleeding-risk medications like aspirin prevents intraoperative hemorrhage. Dilating drops are not used for 72 hours, lifting restrictions are postoperative, and cataract surgery is typically outpatient.
The nurse is teaching the client with open-angle glaucoma. Which instruction should the nurse include?
- A. Limit oral fluid intake to 1000 mL daily.
- B. Eat foods that are high in omega-3 fatty acids.
- C. Have annual eye exams with an eye specialist.
- D. Use timolol maleate eye drops when feeling eye pressure.
Correct Answer: C
Rationale: Glaucoma is a chronic progressive disease; annual eye examinations should be completed by an eye specialist physician. Fluid restriction and omega-3 fatty acids do not affect intraocular pressure. Elevated intraocular pressure cannot be felt, and timolol maleate should be used as prescribed.
A 10-year-old boy comes to the school clinic holding his broken pair of glasses. He says that he got hit in the face playing ball and his eye hurts and feels like there's something in it. What should the nurse do before taking him to the emergency room?
- A. Thoroughly examine his eyes
- B. Put a pressure dressing on his right eye.
- C. Cover both eyes lightly with gauze
- D. Flush his right eye with water for 20 minutes
Correct Answer: C
Rationale: Covering both eyes lightly with gauze prevents tracking and further injury, suitable for a suspected foreign body until emergency evaluation.