Functional Ability: Sensory

The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment? A. Complaints of a burst of black spots or floaters B. A sudden sharp pain in the eye C. Total loss of vision D. A reddened conjunctiva

A. Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment.

Which of the following symptoms would occur in a client with a detached retina? A. Flashing lights and floaters B. Homonymous hemianopia C. Loss of central vision D. Ptosis

A. Signs and symptoms of retinal detachment include abrupt flashing lights, floaters, loss of peripheral vision, or a sudden shadow or curtain in the vision. Occasionally visual loss is gradual.

The client with glaucoma asks the nurse is complete vision will return. The most appropriate response is: A. "Although some vision as been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." B. "Your vision will return as soon as the medications begin to work." C. "Your vision will never return to normal." D. "Your vision loss is temporary and will return in about 3-4 weeks."

A. Vision loss to glaucoma is irreparable. The client should be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Option C does not provide reassurance to the client.

A nurse performs an assessment of a client with a diagnosis of macular degeneration of the eye. The nurse would expect the client to report which of the following symptoms? a) loss of peripheral vision b) blurred central vision c) increased clarity when looking at objects d) clear vision when reading

B-The most common symptom of macular degeneration is blurred central vision that often occurs suddenly. Clients complain of difficulty with reading and seeing fine detail. Formation of a central scotoma (blind spot) occurs in some clients. Clients might complain of visual distortion, usually described as a bending or irregularity of straight lines. Peripheral vision is spared, so although affected persons cannot see to read, drive, watch television clearly, or distinguish faces, they do have the ability to walk.

During the nursing history, which assessment data would the nurse expect the client scheduled for surgical correction of chronic open-angle glaucoma to report? A. Seeing flashes of lights and floaters B. Recent motor vehicle crash while changing lanes C. Complaints of headaches, nausea, and redness of the eyes D. Increasingly frequent episodes of double vision

B. Typically, the client with chronic open-angle glaucoma experiences a gradual loss in peripheral vision leading to tunnel vision. Being involved in a motor vehicle crash while changing lanes suggests the disorder. The client may experience insidious blurring, decreased accommodation, mild aching eyes and, eventually, halos around the lights as intraocular pressure increases. Flashes of light and floaters are characteristic of retinal detachment. Nausea, headache, and eye redness are seen with an episode of acute (sudden) closed-angle closure. Double vision occurs when one eye has a lens and other is aphakic

The most common visual field defect in glaucoma is loss of ____________.

peripheral vision

The clinic nurse notes that the following several eye examinations, the physician has documented a diagnosis of legal blindness in the client's chart. The nurse reviews the results of the Snellen's chart test expecting to note which of the following? A. 20/20 vision B. 20/40 vision C. 20/60 vision D. 20/200 vision

D. Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses) or visual acuity of less than 20 degrees of the visual field in the better eye.

During eyedrop instillation, which intervention would the nurse perform to prevent systemic adverse effects from drug absorption? A. Applying pressure on the eyelid rim B. Having the client close his eyes tightly C. Placing the client in the supine position for a few minutes D. Applying pressure on the inner canthus

D. Systemic absorption and subsequent adverse effects may occur if the medication enters the nasolacrimal canal. The nurse therefore applies pressure to the inner canthus, causing occlusion of this canal and minimizing the risk for systemic adverse effects. Applying pressure on the eyelid rim would not occlude this canal. Having the client close his eyes tightly may cause some of the medication to be expelled. Positioning has no effect on the blood flow of medication into the nasolacrimal canal and subsequent absorption.

The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (Select all that apply.) A. Bending over to tie shoes B. Sitting with legs elevated C. Sleeping on more than two pillows D. Blowing the nose frequently E. Lifting objects weighing more than 10 pounds

Answer: A, D, E Rationale: Any action that would increase pressure in the eye should be avoided, such as bending over, excessive blowing of the nose, and lifting heavy objects. Sitting with the legs elevated or sleeping on more than two pillows is not contraindicated in clients with glaucoma.

During patient teaching regarding self-administration of ophthalmic drops, with statement by the nurse is correct? A. "Hold the eyedrops over the cornea, and squeeze out the drop." B. "Apply pressure to the lacrimal duct area for 5 minutes after administration." C. "Be sure to place the drop in the conjuctival sac of the lower lid." D. "Squeeze your eyelid closed tightly after placing the drop into your eye."

Answer: C Rationale: Because the cornea is sensitive, most eye medications are placed inside the lower lid. For systemic osmotic drugs, pressure only needs to be applied to lacrimal duct for 60 seconds.

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder? A. Pain in the affected eye B. Total loss of vision C. A sense of a curtain falling across the field of vision D. A yellow discoloration of the sclera.

C.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 B and D are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress? A. Glaucoma is easily corrected with eyeglasses B. White and Asian individuals are at the highest risk for glaucoma. C. Yearly screening for people ages 20-40 years is recommended. D. Glaucoma can be painless and vision may be lost before the person is aware of a problem.

D. Open-angle glaucoma causes a painless increase in intraocular pressure (IOP) with loss of peripheral vision. A variety of miotics and agents to decrease IOP and occasional surgery are used to treat glaucoma. African Americans have a threefold greater chance of developing with an increased chance of blindness than other groups. Individuals older than 40 should be screened.