Unit 2

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

"Are you able to raise both eyebrows?" 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." 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.

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." 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.

Following an ophthalmologic exam, an anxious client asks the nurse, "How serious is a refraction error?" Which of the following is the best response from the nurse?

"It means corrective lenses are required." Refractive errors can be corrected with glasses or contact lenses. Telling a client that "nothing is serious" does not provide the necessary information to help alleviate fears. The word surgery can increase fears. If the refractive error is associated with aging, this is a normal finding but does not provide information to the condition.

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." 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.

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

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

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 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).

A patient is suspected of having glaucoma. What reading of IOP would demonstrate an increase resulting from optic nerve damage?

21 mm Hg or higher Intraocular pressure of greater than 21 mm Hg is a sign of primary open-angle glaucoma.

A client has undergone tonometry to evaluate for possible glaucoma. Which result would the nurse record as abnormal?

25 mm Hg Normally, intraocular pressure (IOP) ranges between 10 to 21 mm Hg. Any reading greater than 21 mm Hg indicates increased IOP.

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

The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand?

A 20-feet distance The nurse is correct in instructing the client to stand at a 20-feet distance from the Snellen chart. Often, the nurse places tape on the floor to denote the correct distance for the client to stand.

Which type of glaucoma presents an ocular emergency?

Acute angle-closure glaucoma 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.

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

Which term refers to the absence of the natural lens?

Aphakia When a cataract is extracted and an intraocular lens implant is not used, the client demonstrates aphakia. Scotoma refers to a blind or partially blind area in the visual field. Keratoconus refers to a cone-shaped deformity of the cornea. Hyphema refers to blood in the anterior chamber of the eye.

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 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.

Following cataract removal, discharge instructions will be provided to the client. Which of the following instructions is most important?

Avoid any activity that can increase intraocular pressure. For approximately 1 week, the client should avoid any activity that can cause an increase in intraocular pressure. Clients may sleep on back or unaffected side. Clients may use a clean damp cloth to remove eye discharge and wash face. An eye shield is often ordered for the first 24 hours and during the night to prevent rubbing or trauma to the operative eye.

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 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).

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. Blinking expels an instilled eye drop from the conjunctival sac, which interferes wtih 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. 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 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. 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.

A patient has been diagnosed with bacterial conjunctivitis that was sexually transmitted. The nurse informs the patient that the isolated organism is which of the following?

Chlamydia trachomatis Common organisms isolated are Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. Two sexually transmitted agents associated with conjunctivitis are Chlamydia trachomatis and Neisseria gonorrhoeae.

During assessment of a patient with a hearing loss, the nurse notes a defect in the tympanic membrane. The nurse documents this disturbance as a loss known as:

Conductive. A defect in the tympanic membrane or interruption of the ossicular chain disrupts normal air conduction, which results in a conductive hearing loss.

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 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 he 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.

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 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.

A client has been prescribed eye drops for the treatment of glaucoma. At the yearly follow-up appointment, the client tells the nurse that she has stopped using the medication because her vision did not improve. Which action by the nurse is appropriate?

Explain the therapeutic effect and expected outcome of the medication. The nurse needs to explain the therapeutic effect and expected outcome of the medication. The medication is not a cure for glaucoma, but can slow the progression. The client will not see improvements in vision with the use of the medication but should experience little to no deterioration of vision. The doctor may choose to switch the medication, but not because the vision is not improving; it would be based on not obtaining the set intraocular pressure. Administering the medication immediately or referring the client to the emergency department is not appropriate because this is not an emergent situation.

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

Halos and glare After LASIK surgery, symptoms of central islands and decentered ablations can occur that 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.`

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

Hemangioma 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 that commonly appear as a result of skin aging or a lipid disorder. Molluscum contagiosum lesions are flat, symmetric growths along the lid margin caused by a virus that can result in conjunctivitis and keratitis if the lesion grows into the conjunctival sac.

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 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.

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 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.

An ophthalmologist tells a patient that he has a cataract. The nurse explains to the patient that this means there is:

Interference with focusing of a sharp image.

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

Laser-assisted in situ keratomileusis (LASIK) 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 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. Presbyopia is a refractive change that occurs with age. The lens of the eye loses accommodative power. Opacity in the lens indicates a cataract.

A nurse is preparing a presentation for a local senior citizen's group about changes in the eye that accompany aging. Which of the following would the nurse most likely include? Select all that apply.

Loss of lens accommodative power Development of lens opacities Loss of eyelid skin elasticity Age-related changes in the eye include loss of accommodative power of the lens, development of opacities in the lens, decreased orbital fat, shrinkage of the vitreous body, and loss of skin elasticity.

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 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.

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 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 can affect both near and distant vision. Hyperopia, or farsightedness, refers to the client's ability to see distant objects clearly, but sees near objects as blurry. Emmetropia refers to normal eyesight in which the image focuses precisely on the retina.

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

NSAIDs 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.

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

Nonsteroidal anti-inflammatory drugs (NSAIDs) 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.

There are four major types of ophthalmic procedures to complete a glaucoma examination. If the health care provider wants to inspect the optic nerve, the nurse would prepare the patient for:

Ophthalmoscopy. Four major types of examinations are used in glaucoma evaluation, diagnosis, and management: tonometry to measure the IOP, ophthalmoscopy to inspect the optic nerve, gonioscopy to examine the filtration angle of the anterior chamber, and perimetry to assess the visual fields

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

Papilledema 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.

The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder?

Prolonged use of corticosteroids Risk factors associated with glaucoma include prolonged use of topical or systemic corticosteroids, older age, myopia, and a history of cardiovascular disease.

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 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 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.

The nurse is assessing an older client's vision. The nurse integrates knowledge of which of the following during the assessment?

The power of the lens to accommodate will be decreased. In the older adult, the accommodative power of the lens decreases, resulting in the need to hold reading materials at increasing distances to focus. Orbital fat and skin elasticity decrease. The depth of the eyeball does not change with age.

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 Colored halos around lights is a classic symptom of acute-closure glaucoma.

What would the nurse correctly identify as the structure that responds to light through constriction and dilation.

The pupil is the structure that responds to light by constricting and dilating. The lens lies directly behind the pupil and allows for focusing.

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. 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.

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 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.

The school nurse is testing the kindergarten class with the Snellen chart. What is the nurse testing the children for?

Visual acuity Th Snellen eye chart is a simple screening tool for determining visual acuity, the ability to see far images clearly.

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

demonstrate eyedrop instillation. 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.

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

A client has developed diabetic retinopathy and is seeing the physician regularly to prevent further loss of sight. From where do the nerve cells of the retina extend?

optic nerve The nerve cells of the retina extend from the optic nerve.

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 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.

When the client tells the nurse that his vision is 20/200 and then asks what that means, the nurse informs the client 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 The fraction 20/20 is considered the standard of normal vision. Most people can see the letters on an eye chart designated as 20/20 from a distance of 20 feet.

What is the role of the nurse toward a client who is undergoing an eye examination and tests? Select all that apply.

ssuring that the client receives eye care to preserve his or her eye function and prevent further visual loss assessing and obtaining an accurate baseline of the function and structure of the eyes Clients often ask a nurse how often an eye exam should be done. The nurse should provide current recommendations. The nurse, through careful questioning, elicits the necessary information that can assist in diagnosis of an ophthalmic condition. A careful assessment of the function and the structure of the eyes is also important because it provides the nurse with a baseline. Determining further action and advising the client would be a function of an eye specialist. The nurse would review recommendations with the client.