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
At morning report, the nurse learns the assigned client is blind. Which question should the nurse ask the client upon initial assessment?
Correct Answer: D
Rationale: Many people who are considered blind perceive light and motion. Establishing this fact can help in developing a plan of care for this client. Establishing cause and length of time for visual impairment is not required for initial care. Asking the client about dependence is important, but the new environment could provide safety issues (even if independent) if no perception of light is identified.
Question 2 of 5
Which technique would be most beneficial for ambulation of a client who is visually impaired?
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.
Question 3 of 5
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?
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.
Question 4 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 5 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.