Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders

The nurse is assessing a client using an Amsler Grid. The nurse is assessing for which of the following?

Macular problems Explanation: The Amsler grid is a test used to assess clients for macular problems. Visual acuity is tested using the Snellen chart. Intraocular pressure is measured using tonometry. Perimetry testing evaluates the field of vision.

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 of the following describes the desired effects of this procedure?

Improve outflow drainage Explanation: 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.

To avoid the side effects of corticosteroids, which medication classification is used as an alternative in treating inflammatory conditions of the eyes?

Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.

A patient visits a clinic for an eye examination. He describes his visual changes and mentions a specific diagnostic clinical sign of glaucoma. What is that clinical sign?

The presence of halos around lights Explanation: Colored halos around lights is a classic symptom of acute-closure glaucoma.

A client suffered trauma to the sclera and is being treated for a subsequent infection. During client education, the nurse indicates where the sclera is attached. Which structure would not be included?

eyelids Explanation: The sclera does not attach to the eyelids. The sclera protects structures in the eye, and connects directly to the cornea, anterior chamber, iris, and pupil.

The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find?

Marked blurring of vision Explanation: Glaucoma is often called the "silent thief of sight" because most patients are unaware that they have the disease until they have experienced visual changes and vision loss. The patient may not seek health care until he or she experiences blurred vision or "halos" around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.

Which of the following would be an inaccurate clinical manifestation of a retinal detachment?

Pain Explanation: Patient may report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters. Patients do no complain of pain.

Which term refers to swelling of the optic disc due to increased intracranial pressure?

Papilledema Explanation: Papilledema is swelling of the optic disc due to increased intracranial pressure. Chemosis is edema of the conjunctiva. Ptosis is a drooping eyelid. Photophobia is ocular pain on exposure to light.

A patient presents to an eye clinic with a number of symptoms related to his diminished vision. An initial history leads the nurse practitioner to suspect that the patient has acute angle-closure glaucoma. Which of the following symptoms would apply to this diagnosis? Select all that apply.

Severe eye pain Reddening of the eye Sudden onset of visual disturbance Nausea and vomiting Explanation: Gradual loss of peripheral vision, usually in both eyes, and tunnel vision in advanced stages are symptoms of primary open-angle glaucoma.

A nurse is performing an eye examination. Which question would not be included in the examination?

"Are you able to raise both eyebrows?" Explanation: Asking to raise both eyebrows is a test for cranial nerve VII, the facial nerve, and would not be included in an eye assessment.

An 8th grade boy comes to the school nurse and tells the nurse that he had an eye exam the day before. He says the eye doctor told him he had astigmatism and that meant his eyeball wasn't shaped right. The boy is concerned because he says he went home and looked in the mirror and both eyes looked just alike. What is the school nurse's best response?

"Astigmatism means that the cornea of the eye is shaped differently than the cornea in most eyes." Explanation: Astigmatism is visual distortion caused by an irregularly shaped cornea. Many people have both astigmatism and myopia or hyperopia. Options B, C, and D are incorrect because they are not the best answer.

Which client statement would lead the nurse to suspect that the client is experiencing bacterial conjunctivitis?

"My eyelids were stuck together this morning." Explanation: Burning, a sensation of a foreign body, and pain in bright light (photophobia) are signs and symptoms associated with any type of conjunctivitis. The drainage related to bacterial conjunctivitis is usually present in the morning, and the eyes may be difficult to open because of adhesions caused by the exudate.

A 52-year-old comes to the clinic for a follow-up examination after being diagnosed with glaucoma. The client states, "I'm hoping that I don't have to use these drops for very long." Which response by the nurse would be most appropriate?

"You'll need to use the drops for the rest of your life to control the glaucoma." Explanation: The client is demonstrating a lack of understanding about the condition and its treatment. The nurse needs to provide additional information to the client that the condition can be controlled but not cured. The statement about lifelong therapy would be most appropriate. Eye medications would most likely be needed for the long term, not just a few months. Surgery may be used in conjunction with medication therapy; however, neither method cures the condition. The goal of therapy is to reduce the intraocular pressure to prevent optic nerve damage. In some clients, medication may be all that is needed. In other cases, additional or combination treatment with surgery or laser procedures may be necessary.

When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of:

10 to 20 mm Hg. Explanation: Normally, pressure in the anterior chamber of the eye remains relatively constant at 10 to 20 mm Hg.

The ophthalmologist tells a patient that he has increased intraocular pressure (IOP). The nurse understands that increased pressure resulting from optic nerve damage is indicated by a reading of:

>21 mm Hg. Explanation: Normal intraocular pressure is 10 to 21 mm Hg. Readings of more than 21 are indicative of increased pressure and probably optic nerve damage.

Which type of glaucoma presents an ocular emergency?

Acute angle-closure glaucoma Explanation: Acute angle-closure glaucoma results in rapid progressive visual impairment. Normal tension glaucoma is treated with topical medication. Ocular hypertension is treated with topical medication. Chronic open-angle glaucoma is treated initially with topical medications, with oral medications added at a later time.

The nurse is demonstrating how to perform punctal occlusion. Which activities does the nurse perform?

Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye Explanation: Punctal occlusion is done by applying gentle pressure to the inner canthus of each eye for 1 to 2 minutes immediately after eye drops are instilled. The nurse does not apply pressure to the eyeball when administering medications. The lower eyelid is held down to expose the conjunctival sac. The other action described will not aid in the retention or absorption of medication.

A nurse is caring for a client scheduled to have angiography of the right eye in 1 hour. What is the highest priority nursing intervention?

Assess blood urea nitrogen (BUN) and creatinine levels. Explanation: The nurse should assess the BUN and creatinine levels to ensure the client has adequate renal function to excrete the contrast used. Inability to excrete the contrast could lead to complications. Instructing the client to hold his or her head still and educating about the feeling of warmth and metallic taste that might occur are appropriate interventions; assessing renal function remains the highest priority. Assessing for dark yellow to orange urine is appropriate in the postprocedural time frame, so it would not be the highest priority.

A nurse instructs a client to refrain from blinking after administering eye drops based on which rationale?

Blinking causes the eye drop to be expelled from the conjunctival sac. Explanation: Blinking expels an instilled eye drop from the conjunctival sac, which interferes with the efficacy of the medication. Blood-ocular barriers keep foreign substances from entering the eye. The size of the conjunctival sac does change with blinking. It can hold only 50 uL.

An ophthalmologist diagnoses a patient with myopia. The nurse explains that this type of impaired vision is a refractive error characterized by:

Blurred distance vision. Explanation: People who have myopia are said to be nearsighted. They have deeper eyeballs; thus, the distant visual image focuses in front of, or short of, the retina. Myopic people experience blurred distance vision.

The nurse is caring for geriatric clients who state that they are prescribed reading glasses. Some individuals state needing assistance with seeing writing far away, and others need assistance with closer vision. The nurse is correct to understand that the aging visual changes relate to which of the following?

Changes in accommodation Explanation: The changes that occur in vision during aging, which include difficulty reading and the need for reading glasses, include changes in accommodation. Accommodation occurs when the ciliary muscles contract or relax to focus an image on the retina.

Which medication classification increases aqueous fluid outflow in the client with glaucoma?

Cholinergics Explanation: Cholinergics increase aqueous fluid outflow by contracting the ciliary muscle, causing miosis and opening the trabecular meshwork. Beta-blockers decrease aqueous humor production. Alpha-adrenergic agonists decrease aqueous humor production. Carbonic anhydrase inhibitors decrease aqueous humor production.

Miotic eye solutions are often ordered in the treatment of glaucoma. Which is the best nursing rationale for the use of this medication?

Constricts pupil Explanation: A miotic agent works by constricting the pupil and pulling the iris away from the drainage channels so that the aqueous fluid can escape. These medications increase outflow and decrease intraocular pressure. Cycloplegics paralyze the ciliary muscles of the eye. Mydriatics drugs are used to dilate the pupil and are contraindicated in glaucoma.

Which of the following is the main refracting surface of the eye?

Cornea Explanation: The cornea is a transparent, avascular, domelike structure that covers the iris, pupil, and anterior chamber. It is the most anterior portion of the eyeball and is the main refracting surface of the eye. The iris is the colored part of the eye. The pupil is a space that dilates and constricts in response to light. Normal pupils are round and constrict symmetrically when a bright light shines on them. The conjunctiva provides a barrier to the external environment and nourishes the eye.

The nurse asks a client to follow the movement of a pencil up, down, right, left, and both ways diagonally. The nurse is assessing which of the following?

Extraocular muscle function Explanation: The nurse is testing the client's extraocular eye muscle function by having the client follow an object through the six cardinal directions of gaze (up, down, right, left, and both diagonals). Pupillary reaction is tested using a penlight. The nurse observes the position of the eyelids for drooping. The nurse asks a client to stare at an object and then each eye is covered and then uncovered quickly while the examiner looks for any shifts in the eye and oscillations in the eyeball

Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry-red in color?

Hemangioma Explanation: Hemangiomas are vascular capillary tumors that may be bright, superficial, strawberry-red lesions or bluish and purplish deeper lesions. Milia are small, white, slightly elevated cysts of the eyelid that may occur in multiples. Xanthelasma are yellowish, lipoid deposits on both lids near the inner angle of the eye; these commonly appear as a result of the aging of the skin or a lipid disorder. Nevi are freckles.

The upper eyelid normally covers the uppermost portion of the iris and is innervated by which cranial nerve?

III Explanation: The upper lid is innervated by the oculomotor nerve (CN III). Cranial nerve I is the olfactory nerve, cranial nerve II is the optic nerve, and cranial nerve IV is the trochlear nerve.

The nurse is obtaining a visual history from a client who has noted an increase in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis?

Identification of opacities on the lens Explanation: The client states an increased glare and changes in color perception, which indicates a cataract. Identification of opacities on the lens confirms that diagnosis. A white circle around the cornea and a yellowish aging spot are also symptoms of aging but with different symptoms. Redness of the sclera indicates irritation.

Which action should the nurse recommend to a client with blepharitis?

Keep lid margins clean Explanation: Instructions on lid hygiene (to keep the lid margins clean and free of exudates) are given to the client. Treatment of a stye includes warm soaks of the area and incision and drainage. The client is not required to sleep with the face parallel to the floor.

A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing:

Loss of accommodative power in the lens. Explanation: Presbyopia is a refractive change that occurs with age. The lens of the eye loses accommodative power. Opacity in the lens indicates a cataract.

Which of the following occurs when there is deviation from perfect ocular alignment?

Strabismus Explanation: Strabismus is a condition in which there is deviation from perfect ocular alignment. Ptosis is a drooping eyelids. Chemosis is edema of the conjunctiva. Nystagmus is an involuntary oscillation of the eyeball.

To straighten the ear canal in an adult for examination, the nurse practitioner would grasp the auricle and pull it:

Up and backward. Explanation: The tympanic membrane is inspected with an otoscope, which should be held in the examiner's right hand. Using the opposite hand, the auricle is grasped and gently pulled upward and back to straighten the canal in an adult.

Which of the following types of conjunctivitis is preceded by symptoms of an upper respiratory infection?

Viral Explanation: Viral conjunctivitis is usually preceded by symptoms of an upper respiratory infection. The other types of conjunctivitis are not usually preceded by symptoms of a respiratory infection.

A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition?

hyperopia Explanation: Hyperopia is farsightedness. People who are hyperopic see objects that are far away better than objects that are close.

A client with multiple sclerosis is being seen by a neuro-ophthalmologist for a routine eye exam. The nurse explains to the client that during the examination, the client will be asked to maintain a fixed gaze on a stationary point while an object is moved from a point on the side, where it can't be seen, toward the center. The client will indicate when the object becomes visible The nurse further explains that the test being performed is called a:

perimetry test Explanation: A visual field test or perimetry test measures peripheral vision and detects gaps in the visual field.

A nurse notices that a client's left upper eyelid is drooping. The nurse has observed:

ptosis Explanation: Ptosis is drooping or falling of the upper or lower eyelid. Ptolemy is not a medical condition. Proptosis is the extended or protruded upper eyelid that delays closing or remains partially open. Nystagmus is uncontrolled oscillating movement of the eyeball.

After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms?

retinal detachment Explanation: A detached retina is associated with a hole or tear in the retina caused by stretching or degenerative changes. Retinal detachment may follow a sudden blow, penetrating injury, or eye surgery.

The nurse is giving a visual field examination to a 55-year-old male client. The client asks what this test is for. What would be the nurse's best answer?

"This test measures peripheral vision and detects gaps in the visual field." Explanation: A visual field examination or perimetry test measures peripheral vision and detects gaps in the visual field.

A client who wears soft contact lenses opts for laser correction surgery. The nurse would instruct the client to discontinue using the contact lenses for which time period before surgery?

2 to 3 weeks Explanation: The client is required to discontinue using soft contact lenses for 2 to 3 weeks before the laser correction surgery.

It is determined that a patient is legally blind and will be unable to drive any longer. Legal blindness refers to a best-corrected visual acuity (BCVA) that does not exceed what reading in the better eye?

20/200 Explanation: Legal blindness is a condition of impaired vision in which a person has best corrected visual acuity that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less (Prevent Blindness America, 2012).

Retinoblastoma is the most common eye tumor of childhood. It is hereditary in which percentage of cases?

30 to 40 Explanation: Retinoblastoma can be hereditary or nonhereditary. It is hereditary in 30% to 40% of cases. All bilateral cases are hereditary.

The nurse admits a client to the emergency department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately?

Acute angle-closure glaucoma Explanation: Acute angle-closure glaucoma is an emergency where the nurse should refer the client for medical treatment immediately because vision may be permanently lost in 1 to 2 days. Treatment of a chalazion is not necessary if the cyst is small and does not interfere with vision. Occurrence of a hordeolum or blepharitis is not an emergency and may be treated with warm soaks or frequent washing of the eye.

The nurse is administering an ophthalmic ointment to a patient with conjunctivitis. What disadvantage of the application of an ointment does the nurse explain to the patient?

Blurred vision results after application. Explanation: Ophthalmic ointments have extended retention time in the conjunctival sac and provide a higher concentration than eye drops. The major disadvantage of ointments is the blurred vision that results after application. In general, eyelids and eyelid margins are best treated with ointments.

What type of medication would the nurse use in combination with mydriatics to dilate the patient's pupil?

Cycloplegics Explanation: Mydriasis, or pupil dilation, is the main objective of the administration of mydriatics and cycloplegics (Table 63-3). These two types of medications function differently and are used in combination to achieve the maximal dilation that is needed during surgery and fundus examinations to give the ophthalmologist a better view of the internal eye structures.

Which of the following is the role of the nurse toward a patient who is to undergo eye examinations and tests?

Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss Explanation: Although nurses may not be directly involved in caring for patients who are undergoing eye examinations and tests, it is essential that they ensure that patients receive eye care to preserve their eye function and/or prevent further visual loss. The nurse is not involved in conducting the various tests to determine the status of the eyes and in determining if further action is warranted. Patients who are to undergo eye examinations and tests are not required to modify their diet and exercise regimen.

The nurse is providing care to a client who has been admitted to the hospital for treatment of an infection. The client is visually impaired. Which of the following would be most appropriate for the nurse to do when interacting with the client?

Face the client when speaking directly to him. Explanation: When interacting with a client with a visual impairment, the nurse should face the client and speak directly to the client using a normal tone of voice. It is not necessary to raise the voice unless the client asks the nurse to do so and it is not necessary to avoid the terms, "see" or "look" when interacting with the client. The nurse should identify himself or herself when approaching the client and before making any physical contact.

The nurse should monitor for which manifestation in a client who has undergone LASIK?

Halos and glare Explanation: Symptoms of central islands and decentered ablations can occur after LASIK surgery; these include monocular diplopia or ghost images, halos, glare, and decreased visual acuity. These procedures do not cause excessive tearing or result in cataract or stye formation.

A client presents to the ED reporting a chemical burn to both eyes. Which is the priority nursing intervention?

Irrigate both eyes. Explanation: The eyes should immediately be irrigated to remove the chemical and preserve the eye. If the chemical is allowed to remain on the eye surface, it may cause ulcerations and permanent damage to the eye. It is appropriate to obtain the MSDS and assess the pH of the corneal surface after irrigation has begun. Irrigation should continue until the pH normalizes. Visual acuity can be assessed once the emergent phase is over.

The nurse is preparing to administer medication to a client who has been diagnosed with glaucoma. Which information should the nurse include related to client teaching for each of the identified medications?

Pilocarpine can cause poor vision in dimly lit areas; therefore, the nurse should include appropriate instructions to the client to maintain safety. Timolol can cause hypotension and is contraindicated in clients who have asthma, chronic obstructive pulmonary disease (COPD), and/or heart failure/heart block. The client should have their serum electrolytes monitored because acetazolamide can lead to metabolic disturbances. Pilocarpine does not have to be refrigerated and can remain at room temperature for up to 8 weeks and then discarded. Pilocarpine causes vasodilation, not vasoconstriction. Timolol does not lead to dry mouth or an increase in heart rate. It can lead to bradycardia. Acetazolamide can lead to weight loss, not weight gain, and is not associated with the development of heart failure.

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision:

Sees an object from 20 feet away that a person with normal vision sees from 200 feet away. Explanation: The fraction 20/20 is considered the standard of normal vision. Most people, positioned 20 feet from the eye chart, can see the letters designated as 20/20 from a distance of 20 feet.

A young client is being seen by a pediatric ophthalmologist due to a recent skateboarding accident that resulted in trauma to the right cornea, and is now at risk of developing an infection. Which nursing intervention would be contraindicated for a client at risk for infection?

To ensure correct application of antibiotic ointment, gently drag tip of tube along lower lid while squeezing ointment on to lid. Explanation: Avoid contaminating the medication dropper or tube by holding the tip above the eye and adjacent tissue. Using a separate container of ophthalmic medication for each client prevents cross-contamination. Maintaining asepsis prevents the introduction and transmission of infection. Handwashing prevents infection.

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first aid treatment?

To prevent vision loss Explanation: Prolonged eye irrigation after a chemical burn is the most effective way to prevent formation of permanent scar tissue and thus help prevent vision loss. After a potentially serious eye injury, the victim should always seek medical care. Eye irrigation isn't considered a stopgap measure.

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

demonstrate eyedrop instillation. Explanation: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma.

Which features should a nurse observe during an ophthalmic assessment? Select all that apply

external eye appearance pupil responses Explanation: During an ophthalmic assessment, the nurse should examine the external appearance of the eye and the pupil responses. Intraocular pressure and visual acuity involve a more complex examination and would be performed by a vision specialist.

A patient with low-tension glaucoma and an IOP of 22 mm Hg will be started on a medication regimen. The initial target score for a lowered IOP reading would be:

15. Explanation: The initial goal is to lower the IOP by 30%. Therefore, for a patient with an IOP of 22, the goal would be a mean daily reading of 15 (30% × 22 = 6.6 - 22 = 15.4). Levels do change throughout the day.

After surgery for removal of cataract, a client is being discharged, and the nurse has completed discharge instruction. Which client statement indicates that the outcome of the teaching plan has been met?

"I should avoid pulling or pushing any object that weighs more than 15 lbs." Explanation: After cataract surgery, the client needs to avoid lifting, pulling, or pushing any object that weighs more than 15 pounds to prevent putting excessive pressure on the surgical site. Sunglasses should be worn when outdoors during the day because the eye is sensitive to light. Dots, flashing lights, a decrease in vision, pain, and increased redness need to be reported to the physician immediately. The eye patch is worn for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1 to 4 weeks.

A client is diagnosed with a corneal abrasion and the nurse has administered proparacaine hydrochloride per orders to assess visual acuity. The client requests a prescription for this medication because it completely took away the pain. What is the best response by the nurse?

"Prescriptions of this medication are generally not given because it can cause corneal problems." Explanation: Proparacaine hydrochloride can cause corneal softening and other complications if overused. Clients with corneal abrasions or other painful eye disorders have a tendency to overuse the medication, thus leading to the complications. It would not be appropriate to give the bottle with written instructions, and it is not a standard prescription for eye disorders because of the complications from overuse. Telling the client that you will let the doctor know does not provide the education needed about this medication.

On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as:

Acute angle-closure. Explanation: Acute angle-closure glaucoma is characterized by the symptoms listed, as well as by being rapidly progressive and accompanied by pain.

A major role for nursing in the management of glaucoma is health education. Which of the following is the most important teaching point that the nurse should advise the patient of?

Adhere to the medication regimen. Explanation: All of the teaching points are important but the most important is emphasizing the strict adherence to the medication regimen because glaucoma cannot be cured but its progression can be slowed.

A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?

Amsler grid Explanation: Clients with macular problems are tested with an Amsler grid. It is made up of a geometric grid of identical squares with a central fixation point. The examiner instructs the client to stare at the central fixation spot on the grid and report if they see any distortion of the squares. Clients with macular problems may say some of the squares are faded or wavy. An Ishihara polychromatic plate, visual field, or slit lamp test will not diagnose macular degeneration.

A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography?

BUN and creatinine Explanation: Angiography is done using fluorescein or indocyanine green as contrast agents. Fluorescein angiography is used to evaluate clinically significant macular edema, document macular capillary nonperfusion, and identify retinal and choroidal neovascularization (growth of abnormal new blood vessels) in age-related macular degeneration. It is an invasive procedure in which fluorescein dye is injected, usually into an antecubital vein. Prior to the angiography, the patient's blood urea nitrogen (BUN) and creatinine should be checked to ensure that the kidneys will excrete the contrast agent (Fischbach & Dunning, 2011).

Which of the following medications needs to be withheld for 5 to 7 days prior to cataract surgery?

Coumadin Explanation: It has been common practice to withhold any anticoagulant therapy such as Coumadin to reduce the risk for retrobulbar hemorrhage (after retrobulbar injection) for 5 to 7 days before surgery.

A colleague has been splashed in the eye with cleaning solution. Which of the following would be the priority?

Irrigating the eye immediately with tap water Explanation: With any ocular burn, the priority is to irrigate the eye with tap water immediately. While or after this is done, information about the substance can be obtained. A local anesthetic is instilled, particulate matter is removed, and irrigation continues until the pH normalizes. Then antibiotics are instilled and the eye is patched.

Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella?

Laser-assisted in situ keratomileusis (LASIK) Explanation: LASIK involves flattening the anterior curvature of the cornea by removing a stromal lamella or layer. PRK is used to treat myopia and hyperopia with or without astigmatism. Keratoconus is a cone-shaped deformity of the cornea. Keratoplasty involves replacing abnormal host tissue with healthy donor (cadaver) corneal tissue.

A nurse is teaching a client about medications for glaucoma. What is the main marker of glaucoma control with medication?

Lowering intraocular pressure to target pressure Explanation: The main marker of the efficacy of the medication in glaucoma control is lowering of the intraocular pressure to the target pressure. Opacity of the lenses relates to cataract formation. The appearance of the optic nerve head and the visual field are not goals with glaucoma medication.

A nurse practitioner is performing direct ophthalmoscopy and observes the fundus. Which area of the fundus would the nurse examine last?

Macula Explanation: When performing direct ophthalmoscopy, the last area of the fundus to be examined is the macula, because this area is the most sensitive to light. When the fundus is examined, the vasculature (veins and arteries) comes into focus first. Next the physiologic cup is examined, followed by the periphery of the retina.

An older adult patient has noticed a significant amount of vision loss in the last few years. What does the nurse recognize as the most common cause of visual loss in older adults?

Macular degeneration Explanation: Age-related macular degeneration is the most common cause of visual loss in people older than 65 years in the United States (Prevent Blindness America, 2011b).

During an initial assessment, the nurse notes a symptom of a mild case of bacterial conjunctivitis and documents in the electronic medical record that the client is displaying which of the following ?

Mucopurulent ocular discharge Explanation: Bacterial conjunctivitis manifests with an acute onset of redness, burning, and discharge. Purulent discharge occurs in severe acute bacterial infections, whereas mucopurulent discharge appears in mild cases.

Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following?

Myopia Explanation: Myopia, or nearsightedness, refers to the condition in which the client can see near objects but has blurred distant vision. Astigmatism is an irregularity in the curve of the cornea, which affects both near and distant vision. Hyperopia, or farsightedness, refers to the client's ability to see distant objects clearly but near objects as blurry. Emmetropia refers to normal eyesight in which the image focuses precisely on the retina.

During a routine eye examination, a patient complains that she is unable to read road signs at a distance when driving her car. What should the patient be assessed for?

Myopia Explanation: Some people have deeper eyeballs, in which case the distant visual image focuses in front of, or short of, the retina; those with myopia Impaired Vision are said to be nearsighted and have blurred distance vision.

A nurse is reviewing the medical records of several patients who have had their intraocular pressure (IOP) measured: Patient A: IOP 12 mm Hg Patient B: IOP 15 mm Hg Patient C: IOP 21 mm Hg Patient D: IOP 24 mm Hg Which patient would the nurse identify as having increased IOP suggesting glaucoma?

Patient D Explanation: When IOP is in balance, the pressure ranges from 10 to 21 mm Hg. Increased IOP greater than 21 mm Hg suggests glaucoma.

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate?

Presbyopia Explanation: Refractive changes, such as presbyopia, occur in older adults where the lens cannot readily accommodate aging. In such cases, the client is observed holding reading materials at an increasing distance to focus properly. In case of a cataract, the client should report increased glare, decreased vision, and changes in color perception. Macular degeneration affects the central vision. Myopia is the inability to see things at a distance clearly.

The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?

Retinal Angiography Explanation: The nurse is most correct to instruct the client that his skin and urine may turn yellow following a retinal angiography. Sodium fluorescein is a water-soluble dye that is injected into a vein. The dye then travels to the retinal arteries and capillaries, where pictures are obtained of the vascular supply. The other options do not include a dye injection.

Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear?

Scleral buckle Explanation: The scleral buckle is a procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. The other surgeries do not use this type of procedure.

A client comes to the clinic for an ophthalmologic screening, which will include measurement of intraocular pressure (IOP) with a tonometer. Which statement about this procedure is true?

The tonometer will register the force required to indent or flatten the corneal apex. Explanation: The tonometer will register the force required to indent (using Schiotz's tonometer) or flatten (using an applanation tonometer) the corneal apex. This force varies with firmness of the eye, which fluctuates with IOP. Although the client does direct the gaze forward during tonometry, the tonometer rests on the surface of the cornea, not the sclera. Topical anesthetic drops are administered before, not after, the examination. The client should wear dark glasses after pupil dilation, not tonometry, to protect the eyes from light.

The nurse realizes that a client understands how to correctly instill ophthalmic medications when the client:

pulls the tissue near the cheek downward to instill medication. Explanation: Pull the cheek downward to form a sack in the lower lid. Instill the drops into the conjunctival pocket. The lid and lashes would be wiped in a direction away from the nose to avoid contamination. The tip of the container will be contaminated if it touches eye or eyelid. Do not rub the eye because it may irritate the eye.

A client is having a routine eye examination. The procedure being performed is done by using an instrument to indent or flatten the surface of the eye. This is known as ________ and it is routinely done to test for ________.

tonometry; intraocular pressure Explanation: The procedure being performed is known as tonometry and it measures intraocular pressure.