Nokea
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.
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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 undergone enucleation. What complication of enucleation should be addressed by the nurse?
- A. Hypotension
- B. Nausea and vomiting
- C. Hemorrhage
- D. Pneumonia
Correct Answer: C
Rationale: The nurse should take measures to prevent hemorrhage, a complication of enucleation, by applying a pressure dressing. Nausea and vomiting are common side effects of surgery. Enucleation does not increase risk of developing hypotension or pneumonia.
A client with chronic open-angle glaucoma is now presenting with eye pain and intraocular pressure of 50 mm Hg. An immediate iridotomy is scheduled. Which explanation by the nurse describes the desired effects of this procedure?
- A. Reverse optic nerve damage
- B. Restore vision
- C. Improve outflow drainage
- D. To relieve pain
Correct Answer: C
Rationale: Laser iridotomy or standard iridotomy is a surgical procedure that provides additional outlet drainage of aqueous humor. This is done to lower the IOP as quickly as possible since permanent vision loss can occur in 1 to 2 days. Once optic nerve damage occurs, it cannot be reversed, and vision is not restored. Pain that occurs with rising IOP will be controlled once pressure is lowered through improved outflow drainage.
Which technique would be most beneficial for ambulation of a client who is visually impaired?
- A. Speak before touching the client.
- B. Provide a detailed description of the room and walkway.
- C. Allow client to follow the nurse's lead.
- D. Provide the client with a guide dog.
Correct Answer: C
Rationale: A blind person feels more secure and safe when assisted by someone who is sighted. The nurse should walk slightly ahead while allowing the client to hold onto the nurse's upper arm or elbow. Speaking before touching is an important care action in dealing with clients who have impaired vision but does not assist in ambulation. Providing a detailed description of the room may allow the client an image of the surroundings but is not as helpful in initial ambulation. Finding a perfect fit between guide dog and client is a lengthy process and should be pursued upon request of client.
The nurse is caring for a client who underwent surgery for a retinal detachment. The surgery included the injection of an air bubble to promote contact between the retina and choroids. What position should the nurse keep the client in?
- A. With the face parallel to the floor
- B. With the client's head slightly elevated
- C. With the client lying in a high Fowler's position
- D. With the client in an upright position
Correct Answer: A
Rationale: If an air bubble is instilled to promote contact between the retina and sclera, the client is positioned with the face parallel to the floor so that the bubble floats to the posterior of the eye. The client is asked to be on complete bed rest for several days with the head immobilized and to avoid any physical movements.