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The nurses assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patients visual acuity?
- A. Assess the patients vision using a Snellen chart.
- B. Determine whether the patient is able to see the nurses hand motion.
- C. Perform a detailed examination of the patients external eye structures.
- D. Palpate the patients periocular regions.
Correct Answer: B
Rationale: If the patient cannot count fingers, testing hand motion detection is the next step to assess visual acuity. Snellen charts require better vision, and external exams or palpation do not measure acuity.
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The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision?
- A. Im planning to avoid exposure to direct sunlight on my next vacation.
- B. Ive never exercised regularly, but Im going to start working out at the gym daily.
- C. Im planning to talk with my pharmacist to review my current medications.
- D. Im certainly going to keep a close eye on my blood pressure from now on.
Correct Answer: D
Rationale: Hypertension is a major risk factor for vision loss, such as in hypertensive retinopathy. Sunlight, exercise, and medications are less directly threatening to vision.
During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?
- A. Ask the social worker to investigate alternative housing arrangements.
- B. Ask the social worker to investigate community support agencies.
- C. Encourage the patient to explore surgical corrections for the vision problem.
- D. Arrange for referral to a rehabilitation facility for vision training.
Correct Answer: B
Rationale: Community support agencies provide low-vision aids and training for medication management. Housing changes or rehabilitation facilities are excessive, and surgical options may not be applicable.
The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye?
- A. 30 seconds
- B. 1 minute
- C. 3 minutes
- D. 5 minutes
Correct Answer: D
Rationale: A 5-minute wait ensures adequate absorption of the first eye drop before administering the second, preventing dilution or reduced efficacy.
A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education?
- A. Risk factors for postoperative cytomegalovirus (CMV)
- B. Compensating for vision loss for the next several weeks
- C. Non-pharmacologic pain management strategies
- D. Signs and symptoms of increased intraocular pressure
Correct Answer: D
Rationale: Educating about signs of increased intraocular pressure and infection is critical post-vitreoretinal surgery to prevent complications. CMV, vision loss, and pain are less urgent concerns.
The nurse should recognize the greatest risk for the development of blindness in which of the following patients?
- A. A 58-year-old Caucasian woman with macular degeneration
- B. A 28-year-old Caucasian man with astigmatism
- C. A 58-year-old African American woman with hyperopia
- D. A 28-year-old African American man with myopia
Correct Answer: A
Rationale: Macular degeneration, prevalent in older adults, is a leading cause of blindness. Astigmatism, hyperopia, and myopia are refractive errors with lower blindness risk.