ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 42 : Caring for Clients With Eye Disorders Questions
Question 1 of 5
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?
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.
Question 2 of 5
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?
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.
Question 3 of 5
The client with chronic open-angle glaucoma is receiving timolol eye drops. Which evaluation finding would indicate to the nurse the treatment is working?
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.
Question 4 of 5
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?
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.
Question 5 of 5
A nurse is caring for a client scheduled for general anesthesia. Which assessment finding would contraindicate the use of atropine in this client?
Correct Answer: D
Rationale: Cholinergic blockers (such as atropine) are often used preoperatively to dry up secretions. Use of these drugs results in dilation of pupils, which increases intraocular pressure (IOP). Clients with glaucoma should avoid use of atropine in an effort to maintain normal range of IOP. Detached retina, CVA, and cataracts are insignificant in the use of cholinergic blockers.