Saunders 9e Adult Health: Eye
The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1 The right eye is tested, followed by the left eye, and then both eyes are tested. 2 Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3 The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. 4 The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.
1 The right eye is tested, followed by the left eye, and then both eyes are tested. Rationale: Visual acuity is assessed in one eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses, and the client stands at a distance of 20 feet (6 meters) from the chart.
The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? 1 "I need to sleep on my left side." 2 "I would sleep on my right side." 3 "I would sleep with my head flat." 4 "I would not wear my glasses at any time."
1 "I need to sleep on my left side." Rationale: After cataract surgery, the client would not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also needs to be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.
The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures would the nurse include in the plan? Select all that apply. 1 Avoid activities that require bending over. 2 Contact the surgeon if eye scratchiness occurs. 3 Take acetaminophen for minor eye discomfort. 4 Expect episodes of sudden severe pain in the eye. 5 Place an eye shield on the surgical eye at bedtime. 6 Contact the surgeon if a decrease in visual acuity occurs.
1 Avoid activities that require bending over. 3 Take acetaminophen for minor eye discomfort. 5 Place an eye shield on the surgical eye at bedtime. 6 Contact the surgeon if a decrease in visual acuity occurs. Rationale: Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye; these are usually relieved by mild analgesics. If the eye pain becomes severe, the client needs to notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.
A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1 Cardiovascular disease 2 Frequent urinary tract infections 3 A history of migraine headaches 4 Frequent upper respiratory infections
1 Cardiovascular disease Rationale: Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Options 2, 3, and 4 do not identify risk factors associated with this eye disorder.
The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? 1 Client report of blurred vision 2 Client report of "tunnel vision" 3 Client report of ocular erythema 4 Client report of halos around lights
2 Client report of "tunnel vision" Rationale: POAG results from obstruction to outflow of aqueous humor and is the most common type. Assessment findings include painless vision changes and "tunnel vision." Primary angle-closure glaucoma (PACG) is another type of glaucoma that results from blocking the outflow of aqueous humor into the trabecular meshwork. Assessment findings include blurred vision, ocular erythema, and halos around lights.
A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action would the nurse implement based on this finding? 1 Provide the client with materials on legal blindness. 2 Instruct the client about the need glasses when driving. 3 Inform the client of where a white cane with a red tip can be purchased. 4 Inform the client that it is best to sit near the back of the room when attending conferences and lectures.
2 Instruct the client about the need glasses when driving. Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client would be instructed to sit in the front of the room for conferences and lectures to aid in visualization. This is not considered to be legal blindness.
Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What would be the nurse's initial action? 1 Apply normal saline drops. 2 Note the time of day the test was done. 3 Contact the primary health care provider (PHCP). 4 Instruct the client to sleep with the head of the bed flat.
2 Note the time of day the test was done. Rationale: Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is unnecessary to contact the PHCP as an initial action. Flat positions may increase the pressure.
The nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which nursing action is most appropriate? 1 Document the finding. 2 Reinforce the dressing. 3 Contact the surgeon. 4 Mark the site and continue to monitor.
3 Contact the surgeon. Rationale: After enucleation, if the nurse notes any staining or bleeding on the surgical dressing, the surgeon needs to be notified immediately. The remaining options are not appropriate nursing actions for this client.
The nurse is developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care? 1 Avoid overuse of the eyes. 2 Decrease the amount of salt in the diet. 3 Eye medications will need to be administered for life. 4 Decrease fluid intake to control the intraocular pressure.
3 Eye medications will need to be administered for life. Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of their life. Options 1, 2, and 4 are not accurate instructions.
The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem? 1 Total loss of vision 2 Pain in the affected eye 3 A yellow discoloration of the sclera 4 A sense of a curtain falling across the field of vision
4 A sense of a curtain falling across the field of vision Rationale: A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this problem. A retinal detachment is an ophthalmic emergency, and even more so if visual acuity is still normal.
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation would the nurse expect to note in the early stages of cataract formation? 1 Diplopia 2 Eye pain 3 Floating spots 4 Blurred vision
4 Blurred vision Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.
A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription would the nurse anticipate? 1 Allowing bathroom privileges only 2 Elevating the head of the bed to 45 degrees 3 Wearing dark glasses to read or watch television 4 Placing an eye patch over the client's affected eye
4 Placing an eye patch over the client's affected eye Rationale: The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. Therefore, reading and watching television are not allowed. The client's position is prescribed by the primary health care provider; normally, the prescription is to lie flat.
