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The nurse is teaching a parent how to instill drops in a 12-year-old child's eyes. Which action would the nurse instruct the parent to perform first?
- A. Close the eye gently.
- B. Tilt the head slightly backward.
- C. Instill the prescribed number of drops into the conjunctival pocket.
- D. Do not allow the tip of the container to touch the eye.
Correct Answer: B
Rationale: To instill eye drops, tilt the head slightly backward and toward the eye in which the medication is to be instilled. Do not allow the tip of the container to touch the eye. Instill the prescribed number of drops into the conjunctival pocket or apply a thin ribbon of ointment directly into the conjunctival pocket, beginning at the inner comer and moving outward. Close the eye gently.
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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.
A client is diagnosed with blepharitis. What symptoms should a nurse monitor in this client?
- A. Patchy flakes clinging to the eyelashes
- B. A red pustule in the internal tissue of the eyelid
- C. Redness surrounding the conjunctival sac
- D. A halo around the pupil
Correct Answer: A
Rationale: Blepharitis is an inflammation of the lid margins. The nurse monitors visible patchy flakes clinging to the eyelashes and about the lids. The condition does not cause redness or a halo around the pupil. In case of a sty, the nurse would observe a red pustule in the internal tissue of the eyelid.
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 caring for an older adult client with macular degeneration who has received injections of angiogenesis inhibitors. Which assessment finding would indicate the condition is worsening?
- A. Blurred vision
- B. Burning sensation of the eyes
- C. Loss of peripheral field vision
- D. Central vision impairment
Correct Answer: D
Rationale: When the macula becomes irreparably damaged, central vision is lost and the client can only see images via peripheral field. Blurred vision is the initial symptom of the disease and does not signify worsening. Burning sensation is a common adverse reaction to the treatment injection.
Following an ophthalmologic exam, an anxious client asks the nurse, 'How serious is a refraction error?' Which is the best response from the nurse?
- A. It is nothing serious.
- B. It means corrective lenses are required.
- C. Simple surgery can fix this problem.
- D. This is normal for anyone your age.
Correct Answer: B
Rationale: Refractive errors can be corrected with glasses or contact lenses. Telling a client that 'nothing is serious' does not provide the necessary information to help alleviate fears. The word surgery can increase fears. If the refractive error is associated with aging, this is a normal finding but does not provide information about the condition.