Chapter 20 - Assessment and Management: Visual Problems

The occupational health nurse is caring for an employee who reporting bilateral eye pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse take? a. Apply cool compresses. b. Flush the eyes with saline. c. Apply antiseptic ophthalmic ointment to the eyes. d. Cover the eyes with dry sterile patches and shields.

Answer: b. Flush the eyes with saline. Rationale: In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available. No other interventions should delay flushing the eyes.

The nurse working in the clinic receives telephone calls from several patients who want appointments as soon as possible. Which patient should be seen first? a. 71-yr-old who has noticed increasing loss of peripheral vision. b. 74-yr-old who has difficulty seeing well enough to drive at night. c. 60-yr-old who is reporting dry eyes with decreased tear formation. d. 64-yr-old who states that it is becoming difficult to read news print.

Answer: a. 71-yr-old who has noticed increasing loss of peripheral vision. Rationale: Increasing loss of peripheral vision is characteristic of glaucoma, and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbyopia, decreased tear formation, and impaired night vision.

A patient who underwent eye surgery must wear an eye patch until the scheduled postoperative clinic visit. Which patient problem will the nurse address in the plan of care? a. Risk for falls b. Difficulty coping c. Disturbed body image d. Inability to care for home

Answer: a. Risk for falls. Rationale: The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. This increases the risk for falls. There is no evidence in the assessment data for inability to care for home, disturbed body image, or difficulty coping

Which instruction should the nurse include in a teaching plan for a patient with herpes simplex keratitis? a. Wash hands frequently and avoid touching the eyes. b. Apply antibiotic drops to the eye several times daily. c. Apply a new occlusive dressing to the affected eye at bedtime. d. Use corticosteroid ophthalmic ointment to decrease inflammation.

Answer: a. Wash hands frequently and avoid touching the eyes. Rationale: The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus, and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications.

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. "I will wash my hands often during the day." b. "I will remove my contact lenses at bedtime." c. "I will not share towels with my friends or family." d. "I will monitor my family for eye redness or drainage."

Answer: b. "I will remove my contact lenses at bedtime." Rationale: Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact.

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV. b. Mannitol (Osmitrol) 100 mg IV. c. Betaxolol (Betoptic) 1 drop in each eye. d. Acetazolamide (Diamox) 250 mg orally.

Answer: b. Mannitol (Osmitrol) 100 mg IV. Rationale: The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered.

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eyedrops cause eye burning and visual blurriness after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for a change in dosage of the eyedrops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eyedrops can be prescribed for you."

Answer: b. "The drops are uncomfortable, but it is important to use them to retain your vision." Rationale: Patients should be taught that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use and do not indicate a need for a dosage or medication change.

Which information will the nurse provide to the patient scheduled for refractometry? a. "You should not take any of your eye medicines before the examination." b. "You will need to wear sunglasses for a few hours after the examination." c. "The doctor will shine a bright light into your eye during the examination." d. "The surface of your eye will be numb while the doctor does the examination."

Answer: b. "You will need to wear sunglasses for a few hours after the examination." Rationale: The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control. b. Administration of corticosteroid drops. c. Need for bed rest for 1 to 2 days after the surgery. d. Importance of coughing and deep breathing exercises.

Answer: b. Administration of corticosteroid drops. Rationale: Antibiotic and corticosteroid eyedrops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery, and opioids will not be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery.

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer. b. Application of a warm compress to a patient's hordeolum. c. Instruction about hand washing for a patient with herpes keratitis. d. Checking for eye irritation in a patient with possible conjunctivitis.

Answer: b. Application of a warm compress to a patient's hordeolum. Rationale: Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN.

A 75-yr-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? a. Discuss the increased risk for falls that is associated with impaired vision. b. Ask the patient about what type of vision problems are being experienced. c. Explain that there are many ways to compensate for decreases in visual acuity. d. Suggest ways of improving the patient's safety, such as using brighter lighting.

Answer: b. Ask the patient about what type of vision problems are being experienced. Rationale: The nurse's initial action should be further assessment of the patient's concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment.

What should the nurse assess to evaluate the effectiveness of treatment for the patient's myopia and presbyopia? a. Strength of the eye muscles. b. Both near and distant vision. c. Cloudiness in the eye lenses. d. Intraocular pressure changes.

Answer: b. Both near and distant vision. Rationale: Lenses are prescribed to correct the patient's near and distant vision. The nurse may assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patient's bifocals are effective.

Which action could the registered nurse (RN) who is working in the clinic delegate to a licensed practical/vocational nurse (LPN/VN)? a. Evaluate a patient's ability to administer eyedrops. b. Check a patient's visual acuity using a Snellen chart. c. Inspect a patient's external ear for signs of irritation caused by a hearing aid. d. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D.

Answer: b. Check a patient's visual acuity using a Snellen chart. Rationale: Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice.

What should the nurse teach a patient with repeated hordeolum about how to prevent further infection? a. Apply cold compresses. b. Discard all used eye cosmetics. c. Wash the eyebrows with an antiseborrheic shampoo. d. Be examined for sexually transmitted infections (STIs).

Answer: b. Discard all used eye cosmetics. Rationale: Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for STI testing.

The nurse is caring for a patient diagnosed with adult inclusion conjunctivitis (AIC) caused by C. trachomatis. Which action should be included in the plan of care? a. Applying topical corticosteroids to decrease inflammation. b. Discussing the need for sexually transmitted infection testing. c. Educating about the use of antiviral eyedrops to treat the infection. d. Assisting with applying for community visual rehabilitation services.

Answer: b. Discussing the need for sexually transmitted infection testing. Rationale: Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for sexually transmitted infection testing. AIC is treated with antibiotics. Antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate.

How should the nurse evaluate a patient for improvement after treatment of primary open-angle glaucoma (POAG)? a. Question the patient about blurred vision. b. Note any changes in the patient's visual field. c. Ask the patient to rate the pain using a 0 to 10 scale. d. Assess the patient's depth perception when climbing stairs.

Answer: b. Note any changes in the patient's visual field. Rationale: POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.

Which patient arriving at the urgent care center will the nurse assess first? a. Patient who is reporting that the left eyelid has just started to droop. b. Patient with acute right eye pain that began while using power tools. c. Patient with purulent left eye discharge and conjunctival inflammation. d. Patient who has redness, crusting, and swelling along the lower right lid margin.

Answer: b. Patient with acute right eye pain that began while using power tools. Rationale: The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss.

What should the nurse teach the patient before fluorescein angiography? a. Hold a card and fixate on the center dot. b. Report any burning or pain at the IV site. c. Remain still while the cornea is anesthetized. d. Let the examiner know when images shown appear clear.

Answer: b. Report any burning or pain at the IV site. Rationale: Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. Teach the patient to report any signs of extravasation, such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand-held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines.

The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which action requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

Answer: b. The nurse encourages the patient to cough. Rationale: Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) reporting shortness of breath and severe eye pain. Which action will the nurse take first? a. Assess cranial nerve functions. b. Administer the prescribed analgesic. c. Check the patient's oxygen saturation. d. Examine the eye for evidence of trauma.

Answer: c. Check the patient's oxygen saturation. Rationale: The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is reporting shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take.

The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. What is the nurse's most important action during the initial assessment? a. Obtain more information about the cause of the patient's vision loss. b. Obtain information from the spouse about the patient's special needs. c. Make eye contact with the patient and ask about any need for assistance. d. Perform an evaluation of the patient's visual acuity using a Snellen chart.

Answer: c. Make eye contact with the patient and ask about any need for assistance. Rationale: Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions. The patient (rather than the spouse) should be asked first about any need for assistance. The information about the cause of the vision loss and assessment of the patient's visual acuity are not priorities during the initial assessment.

A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? a. Suggest the patient arrange a ride to the clinic immediately. b. Ask about the presence of "floaters" in the patient's visual field. c. Remind the patient it may take months to restore vision after transplant. d. Teach the patient to continue using prescribed pupil-dilating medications.

Answer: c. Remind the patient it may take months to restore vision after transplant. Rationale: Vision may not be restored for up to 1 year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because "floaters" are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant surgery.

A patient in the emergency department reports being struck in the right eye with a fist. Which finding is a priority for the nurse to communicate to the health care provider? a. The patient reports a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The patient reports "a curtain" over part of the visual field. d. The area around the right eye is bruised and tender to the touch.

Answer: c. The patient reports "a curtain" over part of the visual field. Rationale: The patient's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient's history of being hit in the eye.

The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is important to report to the health care provider before the procedure? a. The patient has had blurred vision for 3 years. b. The patient has not eaten anything for 8 hours. c. The patient takes antihypertensive medications. d. The patient gets nauseated with general anesthesia.

Answer: c. The patient takes antihypertensive medications. Rationale: Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia.

A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will the nurse include in the discharge teaching plan? a. The use of eye patches to reduce movement of the operative eye. b. The need to wear dark glasses to protect the eyes from bright light. c. The purpose of maintaining the head resting in a prescribed position. d. The procedure for dressing changes when the eye dressing is saturated.

Answer: c. The purpose of maintaining the head resting in a prescribed position. Rationale: Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. Dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure.

A patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will use drops to keep my pupils dilated until my appointment." b. "I will need to use brighter lights to read for at least the next week." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will cover up with long-sleeved shirts and pants for the next 5 days."

Answer: d. "I will cover up with long-sleeved shirts and pants for the next 5 days." Rationale: The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment.

In reviewing a patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. What should the nurse plan to assess? a. Visual acuity. b. Pupil reaction. c. Color perception. d. Peripheral vision.

Answer: d. Peripheral vision Rationale: The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma.

The nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by nursing staff. After reviewing the history, physical assessment, and vital signs for a 60-yr-old patient as shown in the accompanying figure, which action should the nurse take first? a. Check the patient's blood glucose level. b. Take the blood pressure on the left arm. c. Use an irrigating syringe to clean the ear canals. d. Report a vision change to the health care provider.

Answer: d. Report a vision change to the health care provider. Rationale: The sudden change in peripheral vision may indicate an acute problem, such as retinal detachment, that should be treated quickly to preserve vision. The other data about the patient are not indicative of any acute problem. The other actions are also appropriate, but the highest priority for this patient is prevention of blindness.

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? a. The patient reports that the vision has not improved. b. The patient requests a prescription refill for next week. c. The patient feels uncomfortable wearing an eye patch. d. The patient reports eye pain rated 5 (on a 0 to 10 scale).

Answer: d. The patient reports eye pain rated 5 (on a 0 to 10 scale). Rationale: Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching or follow-up does not indicate that complications of the surgery may be occurring.

The nurse in the eye clinic is examining a 67-yr-old patient who says, "I see small spots that move around in front of my eyes." Which action will the nurse take first? a. Immediately have the ophthalmologist evaluate the patient. b. Explain that spots and "floaters" are a normal part of aging. c. Warn the patient that these spots may indicate retinal damage. d. Use an ophthalmoscope to examine the posterior eye chambers.

Answer: d. Use an ophthalmoscope to examine the posterior eye chambers. Rationale: Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old patient is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.