Nursing 245 Week 2 Cataracts/Eye Injuries/Glaucoma/

The nurse is discussing eye trauma with a group of high school athletes. Which athlete statement indicates the need for further education? ​"On the archery​ team, we are very careful about the direction of the​ arrows." ​"I am on the track​ team, and eye injuries can come from falling or getting hit in the eyes by the shot put or the pole for the pole​ vault." ​"A football helmet is enough to keep my eyes from getting​ hurt." ​"My baseball helmet protects my head but not my​ eyes."

"A football helmet is enough to keep my eyes from getting​ hurt." Learning Objective Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale Although a football helmet can be effective in prevention of injury to the head and face, a face shield is the best option for protecting the eyes. Falls can cause blunt eye trauma, and projectiles used in track events can cause either penetrating or blunt eye injury. Baseball helmets do not offer eye protection against blunt trauma from the baseball. Arrows can cause penetrating trauma to the eye.

John​ Gleason, a​ 75-year-old client, is experiencing decreased​ vision, nausea, and vomiting. Which question should the nurse ask to determine if Mr. Gleason is experiencing​ angle-closure glaucoma? ​"Are you having severe eye pain or​ headache?" ​"Is a curtain or veil being drawn across your visual​ field?" ​"Is it difficult to see when moving from a light to a dark​ area?" ​"Do lines or reading material appear​ distorted?"

"Are you having severe eye pain or​ headache?" Severe headache and eye pain are symptoms of​ angle-closure glaucoma. Macular degeneration may present with distortion of lines and letters. A curtain being drawn across the visual field is associated with a detached retina. Difficulty adjusting between​ well-lit and darker areas is associated with cataracts.

A nurse is conducting a community meeting on the prevention of eye injuries. Which statements by the group members indicate that the group needs additional teaching? (Select all that apply.) ​"If you get hit in the eye with​ something, apply direct pressure with an ice​ pack." ​"I will always wear a seat​ belt." ​"If your eyes feel gritty while you are wearing contact​ lenses, put rewetting drops in​ them." ​"If a chemical splashes in my​ eye, I will rinse it​ immediately." ​"I will put on safety glasses before stripping the paint off of my​ house."

"If you get hit in the eye with​ something, apply direct pressure with an ice​ pack." "If your eyes feel gritty while you are wearing contact​ lenses, put rewetting drops in​ them."

The school nurse is teaching a group of parents about strategies to prevent eye injuries. Which statement by a parent indicates understanding of the teaching session? ​"My 4-year-old likes to use my office​ supplies, such as paper​ clips, scissors, and rubber​ bands, for crafting​ projects." ​"My husband believes the children are very good marksmen with their BB guns and do not need us to supervise​ them." ​"I am not worried about my toddler playing with our pet​ animals." ​"My son wears a face shield when he plays​ hockey." ​"I should always remove objects that are penetrating the​ eye."

"My son wears a face shield when he plays​ hockey." Learning Objective Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale Eye protection is recommended for all sporting activities to prevent serious eye injuries. Objects that penetrate the eye should be stabilized, not removed; it is important to seek immediate medical attention for these injuries. Scissors, paper clips, pencils, and rubber bands can cause serious eye injuries, and young children should be supervised when using these items. Animals should not be left unsupervised with young children. Adult supervision is recommended for the use of bows and arrows, darts, or BB guns.

The health care provider orders the following medication for Ms. Lawrence during the surgical​ procedure: cephalexin​ (Keflex) 250 mg intravenously in 100 mL of normal saline to infuse over 30 minutes. Using a drop factor of 15​ gtts/mL, how many drops per minute must be​ delivered? Please limit your answer to a numeral. Record your answer rounding to the nearest whole number.

50 (with margin: 0) The formula for this calculation​ is:Volume​ (mL) X drop factor​ (gtts ​/mL)​ equals Drops per Minute​ (Flow Rate)​ Time​ (minutes)100 mL X 15​ gtts/mL (1500) equals​ 50 ​gtts/minute​ ​ 30 minutes

A nurse is providing education to a community group about the cause of cataracts. Which information should the nurse include about the cause of this eye disorder? (Select all that apply.) Accidents Asthma Heredity Aging Alcohol intake

Accidents Heredity Aging

An older adult client with cataracts is asking the nurse about the cause of this eye disorder. Which cause would the nurse provide to the client? Hypertension Gout Age Obesity

Age Learning Objective Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale Cataracts can occur as a result of the normal aging process. Hypertension, gout, and obesity are not causes of cataracts.

What is not a modifiable risk factor for vision​ loss? Ultraviolet light exposure Stress Smoking Aging

Aging Smoking is a modifiable risk factor for many conditions such as cancer and lung​disease, and can alter taste or olfactory​ senses, but is not considered a risk factor for vision loss. Ultraviolet light exposure is a modifiable risk and can cause serious eye problems from​ short-term irritation or corneal burn to the long term effects of serious visual disturbances. Stress is a modifiable factor that may contribute to sensory​ overload, but it does not contribute to vision disturbance or loss. The process of aging does contribute to sensory perception loss including​ vision, and it is not a modifiable factor.

Due to a previous history of corneal​ ulceration, the ophthalmologist schedules Ms. Lawrence for a corneal transplant a few days later. You have agreed to work in the outpatient surgery unit to cover a shortage of​ staffing, and you are assigned to care for Ms. Lawrence in the preoperative and postoperative periods.You are aware that several types of medications are likely to be prescribed for Ms. Lawrence postoperatively. Which types of medications will you include in your teaching plan for Ms. ​Lawrence?​(Select all that apply.) Immunosuppressant agents Anticholinergics Adrenergic agents Antibiotics Analgesics

Antibiotics Analgesics The outer portion of the​ eye, the cornea in​ particular, is extremely​ sensitive, and Ms. Lawrence is likely to receive a prescription for analgesics. Antibiotics are often prescribed prophylactically to avoid postoperative infection. Immunosuppressants are seldom prescribed because transplant rejection risk is low due to the corneas limited blood​ supply, which limits the clients exposure to rejection antibodies. Neither anticholinergic nor adrenergic agents are indicated for corneal transplantation.

A woman brings in her 82-year-old mother for a check-up at the local clinic. The woman reports that her mother does not respond to her appropriately at times, and that she seems to be forgetful. The nurse wants to do a complete sensory-perceptual functioning assessment. What components would the nurse include in her assessment? (Select all that apply.) Asking the daughter about the client​'s social support network Discussing the client​'s history of wearing hearing aids Mental status exam The whisper test Status of the client​'s insurance

Asking the daughter about the client​'s social support network Discussing the client​'s history of wearing hearing aids Mental status exam The whisper test Learning Objective Identify procedures used to determine sensory perception status across the life span. Rationale A complete nursing assessment of the sensory-perceptual functioning includes a client history, a mental exam, a physical exam, social support network, the client 'senvironment, and identifying people at high risk. The whisper test would be included in the physical exam. The client 's history of wearing hearing aids would be appropriate in collection of the client 's medical history. A mental status exam would help the nurse determine whether the client answering her daughter inappropriately is due to senility or a sensory deficit. Insurance status would not be appropriate during the assessment of the client 's sensory function.

An older female client is residing in the nursing home. As the nurse walks into the room to assist the client for evening care, the client calls out, wondering who it is. The nurse introduces herself and enters the room. The client is wearing very thick glasses and has visual deficits. After the nurse has finished her care, what interventions does the nurse do to improve the safety of the client? (Select all that apply.) Turns off the night light to improve sleep quality Asks the client where she would like her glasses placed Moves chair beside the bed so the client has a place to sit if she gets up in the night Encourages the client to call for any needs Puts the call bell within reach of the client

Asks the client where she would like her glasses placed Encourages the client to call for any needs Puts the call bell within reach of the client

A nurse is testing a client for a deficit in cranial nerve I. Which action would the nurse perform? Assess sense of smell Assess sense of vision Assess sense of hearing Assess sense of stereognosis

Assess sense of smell Learning Objective Identify procedures used to determine sensory perception status across the life span. Rationale Cranial nerve I is the olfactory nerve that is responsible for the sense of smell. Have the client occlude one nostril, and pass an alcohol swab by the nostril. Then repeat on the opposite side. A Rosenbaum chart assesses the acuity of a client's near vision acuity. The Weber test is a hearing test to determine whether hearing loss is due to sensorineural loss or conductive loss. Stereognosis is the ability to recognize an object by feel and not sight.

For which health problem is the use of​ beta-adrenergic blocking agents to treat glaucoma​ contraindicated? Gastric acid reflux Asthma Diabetes mellitus Hypertension

Asthma Use of​ beta-adrenergic blocking​ agents, including topical​ use, is contraindicated for clients with asthma because systemic absorption may lead to bronchial constriction. A client with glaucoma and hypertension may be treated successfully using​ beta-adrenergic blockers. Gastric reflux and diabetes mellitus are not conditions in which​ beta-adrenergic blockers are contraindicated.

The nurse is providing home care education to a client who underwent cataract surgery. Which information should the nurse include? Sleep on operative side. Expect eye​ pain, headaches, and redness of the affected eye. Remove eye dressing at night. Avoid strenuous exercise.

Avoid strenuous exercise. Learning Objective Apply the nursing process to provide culturally competent care across the life span. Rationale The nurse should educate the client about the importance of avoiding strenuous exercise. The client needs to sleep on the nonoperative side, not the operative side. The client should not disturb the eye dressing. Eye pain, headaches, and redness of the affected eye are manifestations of complications and should be reported to the healthcare provider immediately.

A nurse is doing teaching at the home of a client that has been diagnosed with an olfactory deficit. What nursing interventions would be appropriate for a client with an olfactory deficit? Checking the expiration dates on food Recommending the client purchase smoke detectors with flashing lights Getting room darkening shades Setting up a schedule for changing the batteries in carbon monoxide detectors Reviewing home cleaning supplies with the client

Checking the expiration dates on food reviewing home cleaning supplies with the client Learning Objective Explain independent and collaborative interventions for clients with sensory perception alterations. Rationale A client who has an olfactory deficit is at risk for activities that involve the sense of smell. Checking the expiration dates on food is important for an individual who cannot smell to detect spoiled food products. Setting up a schedule to change batteries for carbon monoxide detectors is important for general safety. However, carbon monoxide does not have a smell and is not appropriate solely for someone with an olfactory deficit. Flashing smoke detectors are beneficial for someone with a hearing deficit, not an olfactory deficit. Room darkening shades are appropriate for someone that is at risk sensory overload, not olfactory deficit. Reviewing home cleaning supplies with a client with an olfactory deficit is appropriate because the client may not smell the concentration of strong chemicals and become affected before smelling the odor.

The nurse is reviewing discharge orders for a client who sustained a blunt trauma to the eye. Which discharge order should the nurse question? Take diphenhydramine hydrochloride​ (Benadryl) 25 mg by mouth as needed for allergies. Wear the eye patch continuously for 1 week and then during sleep. Take docusate sodium​ (Colace) 100 mg by mouth once daily. Client may resume all normal activities.

Client may resume all normal activities. Learning Objective Apply the nursing process to provide culturally competent care across the life span. Rationale Clients should be instructed to avoid reading and activities that will increase intraocular pressure, such as lifting heavy objects and bending over. Straining can increase intraocular pressure, so the client may be prescribed a stool softener to decrease the risk of straining. Clients should be instructed on the correct use of the eye patch. Coughing and sneezing are activities that will increases intraocular pressure, so the client should be prescribed an antihistamine to treat allergies.

A 36-year-old male, who was at work when he started feeling dizzy and nauseated, presents at the emergency department. The nurse begins her assessment. What cranial nerve involvement would the nurse suspect for these symptoms? Cranial nerve VIII​ (acoustic/vestibulocochlear nerve) Cranial nerve V​ (trigeminal nerve) Cranial nerve XII​ (hypoglossal nerve) Cranial nerve II​ (optic nerve)

Cranial nerve VIII (acoustic/vestibulocochlear nerve) Learning Objective Understand the physiology of sensory perception across the life span. Rationale The most likely nerve involvement for this situation would be cranial nerve VIII, the acoustic/vestibulocochlear nerve. The function of this nerve is related to the sense of balance and the sense of hearing. The nurse would not suspect the cranial nerves XII, II, or V to be involved with these symptoms. The function of cranial nerve XII (hypoglossal nerve) is responsible for movement of the tongue for speech and swallowing. The function of cranial nerve V (trigeminal nerve) is mostly sensation in the scalp, face, and chewing. The function of cranial nerve II (optic) is vision.

A nursing student is preparing to take over the care of 96-year-old client on the long-term care unit. The nursing student is aware that the client may have what sensory changes as part of the aging process? Increased tactile sensation Decreased sense of taste Impaired sense of smell Decreased sense of hearing Increased sense of taste

Decreased sense of taste decreased sense of eharing impaired sense of smell Learning Objective Compare alterations across the life span, concepts related to sensory perception, and prevention. Rationale The effects of aging on sensory perception include a decreased sense of taste, an impaired sense of smell, and a decreased ability to hear. Tactile sensations do not change throughout the aging process unless there is an injury or pathology.

Which clinical manifestation is present with​ cataracts?​(Select all that​ apply.) Decreased visual acuity Photophobia Distorted straight lines Impaired color discrimination Flashes of light

Decreased visual acuity Photophobia Impaired color discrimination Impaired color discrimination between blue and purple is present when a client has cataracts.

Which eye condition is defined as the separation of the sensory portion of the eye from the​ choroid? Detached retina Penetrating trauma Corneal abrasion Blunt trauma

Detached retina A detached retina is defined as the separation of the sensory portion of the eye​(the retina) from the choroid. A corneal abrasion is the disruption of the superficial epithelium of the cornea. Blunt trauma Interrupts the uveal tract of the​ eye, leading to hemorrhage of the anterior chamber. A penetrating wound has a single entrance wound. Layers of the eye spontaneously reapproximate after entry of a​sharp-pointed object.

The nurse is examining a client with cataracts. The client asks how this could have happened. Which risk factor in the client's history will the nurse include in the response to the client? Diabetes mellitus Use of sunglasses Hypertension Use of NSAIDs for pain

Diabetes mellitus Learning Objective Identify collaborative therapies used by interdisciplinary teams. Rationale A history of diabetes mellitus is a risk factor for cataracts. The nurse would base the response to the client on this particular risk factor in the client's health history. Hypertension, the use of NSAIDs for pain, and the use of sunglasses are not associated with the development of cataracts.

Which risk factor contributes to cataract​ progression?​(Select all that​ apply.) Diabetes mellitus Hyperthyroidism Excessive exposure to sunlight Poor diet Smoking

Diabetes mellitus Excessive exposure to sunlight Poor diet Smoking Risk factors for the progression of cataracts include​ smoking, diabetes​ mellitus, poor​ diet, and excessive exposure to sunlight. Having a diagnosis of hyperthyroidism does not contribute to the progression of cataracts.

A nurse in the emergency department admits a client who was involved in a motor vehicle crash with airbag deployment. The nurse assesses the client for which manifestations of blunt trauma to the eye? (Select all that apply.) Diplopia Subconjunctival hemorrhage Photophobia Purulent drainage Ecchymosis around the eye

Diplopia Subconjunctival hemorrhage Ecchymosis around the eye Learning Objective Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale Clients who sustain blunt trauma to the eye may have a hemorrhage in the subconjunctival space. Ecchymosis around the eye, or a black eye, can lead the nurse to suspect blunt trauma. Diplopia can occur with an orbital blowout fracture. Photophobia does not occur with blunt trauma to the eye, and purulent drainage from eye does not result from a blunt trauma injury.

A nurse at the public health center is discussing hearing screening guidelines with a 53-year-old client. How often would the nurse recommend the client getting his hearing checked? Every 3 years Prior to leaving the hospital Annually Every 10 years

Every 3 years Learning Objective Compare alterations across the life span, concepts related to sensory perception, and prevention. Rationale The American Speech-Language-Hearing Association recommendations hearing screenings for individuals over the age of 50 every 3 years. Prior to the age of 50, it is recommended that hearing screens occur every 10 years or for a change in hearing or complaint of hearing loss. Infants are usually screened after their birth, and prior to leaving the hospital. Annual hearing screens for low-risk clients are not recommended.

A client with cataracts is undergoing a procedure to remove the cataracts. About which procedure should the nurse provide client education? Extracapsular extraction Trabeculectomy Gonioplasty Laser photocoagulation

Extracapsular extraction Learning Objective Identify collaborative therapies used by interdisciplinary teams. Rationale The nurse should provide education about an extracapsular extraction because this procedure removes the anterior capsule, nucleus, and cortex of the lens, leaving the posterior capsule intact. A plastic, acrylic, or silicone intraocular lens is implanted to improve binocular vision and depth perception. Laser photocoagulation is a procedure to treat proliferative retinopathy, but it seals leaking microaneurysms and destroys proliferating vessels. Gonioplasty is surgery to treat closed-angle glaucoma. Trabeculectomy is surgery to treat open-angle glaucoma.

A nurse is giving a presentation at the local community center regarding the prevention of vision loss. She wants to discuss modifiable risk factors to help people protect their eyes and vision. What would modifiable risk factors be discussed during this presentation? (Select all that apply.) Eye injuries Ultraviolet light exposure Annual eye exams Isolation Smoking

Eye injuries Ultraviolet light exposure Smoking Learning Objective Compare alterations across the life span, concepts related to sensory perception, and prevention. Rationale Modifiable risk factors for vision loss include decreasing ultraviolet light exposure, not smoking, and preventing eye injuries by using protective eyewear. Isolation of adults is associated with sensory deprivation in both infants and in adults. Isolation is a modifiable risk factor, but it is not associated with vision loss. Annual eye exams may detect early changes in vision loss, but are not considered a risk factor

As the nurse caring for Ms.​ Lawrence, you anticipate which diagnostic procedure will be performed to determine the cause of her eye​ pain? Electrolyte panel and complete blood count Visual acuity test Computed tomography​ (CT) scan of the head Fluorescein stain with slit lamp examination

Fluorescein stain with slit lamp examination To determine the cause of Ms. Lawrence's eye​ pain, the health care provider will perform a fluorescein stain with slit lamp examination for this will show corneal ulcers or abrasions. A CT​ scan, electrolyte​ panels, and complete blood count would not assist in diagnosing the reason for Ms. Lawrence's eye pain. The visual acuity test is a routine part of an eye examination or general physical​ examination, particularly if there is change in vision or a problem with​ vision, but will not determine the cause of Ms. Lawrence's eye pain.

Which is a manifestation of​ open-angle glaucoma?​(Select all that​ apply.) Increased sensitivity to bright lights Gradual diminishing of visual fields Flashes of light Painless visual changes Rapid increase in intraocular pressure

Gradual diminishing of visual fields Painless visual changes Manifestations of​ open-angle glaucoma include a​ painless, gradual loss of visual fields. Flashes of light are associated with retinal detachment. A rapid increase in intraocular pressure is associated with​ closed-angle glaucoma. Increased sensitivity to bright lights is not specific to​ age-related eye disorders.

What condition is caused by increased intraocular pressure in​ open-angle glaucoma? Gradual loss of peripheral vision Intermittent stabbing eye pain Rapid change in visual acuity Progressive reduction of color brightness

Gradual loss of peripheral vision The increased intraocular pressure noted in​ open-angle glaucoma leads to a gradual loss of peripheral vision. Intermittent stabbing eye​ pain, change in color​brightness, and rapid change in visual acuity are associated with​ closed-angle glaucoma.

A home health nurse has been assigned to provide​ follow-up care on an older male client after he was discharged to home from the emergency department after experiencing chest pain. The nurse arrives at the client​'s home and begins filling out the intake paper work. The client reports that he has one living daughter that resides in another​ country, and no nearby​ relatives, but he does have a "few war buddies" in the vicinity. When the nurse inquires about his social​ life, the client replies that he does not go out often and spends most of his time watching TV. The client reports that he has no hearing deficits and wears corrective lenses. What nursing interventions would not be necessary for this​ client? Bringing by a flowering plant Bringing by brochures of local groups and church activities Grouping nursing activities Contacting a local​ pet-visiting program if given permission

Grouping nursing activities Learning Objective Explain independent and collaborative interventions for clients with sensory perception alterations. Rationale The client is at risk for sensory deprivation. Interventions are needed to increase the client 's stimulation, such as introducing him to nearby groups or setting him up with local volunteer groups and visitors. Bringing a fragrant plant to the client 's home would stimulate the olfactory sense Having a pet or a visiting pet will stimulate the tactile senses. The grouping of nursing activities is not necessary unless the nurse is concerned for sensory overload, which is not appropriate in this situation.

A 78-year-old female client presents for an annual exam. The client admits to smoking a ½ a pack of cigarettes per day for the last 50 years. The nurse would expect that the client would also complain of a deficit in what type of sensory stimuli? Tactile Gustatory Visual Auditory

Gustatory Learning Objective Understand the physiology of sensory perception across the life span. Rationale The two most common sensory deficits associated with tobacco use are the sense of taste (gustatory) and the sense of smell (olfactory). Visual, auditory, and tactile senses are not affected.

During sensory​ reception, an intact sensory system receives stimuli from external or internal sources. What stimuli would be considered internal​ stimuli? ​(Select all that​ apply.) Gustatory Stereognosis Visceral Olfactory Visual

Gustatory Stereognosis Visceral Internal stimuli include stereognosis​ (the ability to perceive and understand objects through​ touch), visceral​ (stimuli from a large​ organ), and gustatory​ (data received from​ taste). External stimuli include visual​ (data gathered from​ sight), olfactory​(data collected from​ smell), and gustatory​ (data received from​ taste). Gustatory is considered both an internal and an external stimuli.

The nurse is reviewing medications prescribed for a client with glaucoma. For which client health problem should the nurse question the healthcare​ provider's order for a topical​ beta-adrenergic blocking​ agent? Type 2 diabetes mellitus COPD Heart block Heart failure Arthritis

Heart failure COPD Heart Block Topical​ beta-blockers can have adverse systemic effects and are not recommended for clients with​ COPD, heart​ failure, and heart block. The use of topical​ beta-adrenergic blocking agents is not contraindicated for arthritis or type 2 diabetes mellitus.

A nurse is preparing an educational program for senior community members about glaucoma. Which information should the nurse include about the cause of this ​disorder? Race Heredity Age ​Long-term steroid use Smoking

Heredity Race Long term steroid use Age ​Age, heredity,​ race, and​ long-term steroid use are risk factors for glaucoma. Smoking is not a risk factor.

What disease processes are associated with visual​ defects? ​(Select all that​ apply.) Hypertension Multiple occurrences of otitis media Retinopathy of prematurity Diabetes Treacher Collins Syndrome

Hypertension Retinopathy of prematurity Diabetes Genetic or hereditary conditions associated with visual defects include retinopathy of​ prematurity, diabetes, and hypertension. Retinopathy of prematurity is a common cause of visual impairment or blindness in infants that are born prematurely. Diabetes can lead to blindness. Treacher Collins syndrome is a genetic syndrome associated with hearing​ loss, not vision loss. Hypertension is associated with visual disturbances and loss from excessive pressure on the structures of the eye. Otitis media is the infection of ear and multiple occurrences may be responsible for hearing​ loss, not vision loss.

After an eye​ examination, the health care team suspects that Ms. Lawrence is suffering from a corneal abrasion or corneal ulceration. Which statements made by Ms. Lawrence would help to confirm this preliminary ​diagnosis?​ My eye is swelling and turning blue. I have pain and tearing from my eye. My eye is extremely sensitive to light. I feel twinges in my​ eyelid, and I can barely open my eye. Everything looks yellowish and hazy.

I have pain and tearing from my eye. My eye is extremely sensitive to light. I feel twinges in my​ eyelid, and I can barely open my eye. A corneal abrasion or ulceration usually causes​ discomfort, tearing,​ discharge, and photophobia​ (extreme sensitivity to​ light). Blepharospasm​ (spasm of the eyelid and inability to open the​ eye) frequently develops. Yellow or hazy vision is not associated with corneal irritation. Swelling of the eye and discoloration typically do not occur when the cornea is irritated or inflamed.

A nursing instructor is reviewing sensory perception with the nursing students. The nursing instructor knows that the students have appropriately learned the information when he hears them make what comments regarding the sensory process? (Select all that apply.) ​"If a person can perceive stimuli in the​ environment, and​ respond, that person is exhibiting​ awareness." ​"When I am feeling around my purse with my hand trying to find my​ keys, I am using the process of​ stereognosis." ​"Kinesthetic is the sensation of​ touch." ​"The feeling of my stomach being full after a large meal is an example of a visceral​ sensation." ​"A receptor is not always necessary to process a stimulus to the​ brain."

If a person can perceive stimuli in the​ environment, and​ respond, that person is exhibiting​ awareness." ​"When I am feeling around my purse with my hand trying to find my​ keys, I am using the process of​ stereognosis." "The feeling of my stomach being full after a large meal is an example of a visceral​ sensation."

The nurse is the first to arrive on scene to attend to a client involved in a single-car crash. Upon assessment of the client, the nurse notes that the client is stable but that a piece of glass is protruding from the client's eye. What is the nurse's best action? Attempting to remove the glass from the eye Applying an eye patch to the affected eye Immobilizing the glass and placing a paper cup over the eye Applying a gauze pad soaked in normal saline solution to the affected eye

Immobilizing the glass and placing a paper cup over the eye* *RationaleIf a foreign body is sticking out of the​ eye, it needs to be removed surgically. Do not attempt to remove a foreign body because it could cause loss of ocular contents. The priority action is to immobilize the foreign​ body; a paper cup may be used to protect the eye from further injury. Do not apply anything to the affected eye that will press on the eye. An eye patch may cause pressure in the eye enabling the foreign body to embed deeper into the eye.

The family of a client with glaucoma asks how the condition develops. What information should the nurse include when responding to the​ family? Vitreous that leaks under the retina Loss of lens clarity associated with aging Increased intraocular pressure Inflammation caused by bacterial or viral exposure

Increased intraocular pressure Glaucoma is characterized by increased intraocular pressure caused by increased production of vitreous humor or decreased outflow leading to damage of the optic nerve and optic disc. Cataracts occur when transparency of the crystalline lens is​ lost, causing opacity and cloudy vision. Retinal detachment is the separation of the sensory retinal layers with vitreous leaks under the​ retina; this is a condition caused by insult or injury to the eye. Conjunctivitis is inflammation of the conjunctive due to bacterial or viral exposure.

The nurse is teaching a client newly diagnosed with glaucoma about the disorder. What should the nurse include in this ​teaching? ​(Select all that​ apply.) It is a​ painless, gradual loss of peripheral vision. It is caused by the loss of lens​ clarity, which results in cloudy vision. There are two types of​ glaucoma: closed angle and open angle. Persons with this condition are required to maintain a medication regimen to manage pain symptoms associated with pupillary accommodation. It can eventually lead to blindness.

It is a​ painless, gradual loss of peripheral vision. There are two types of​ glaucoma: closed angle and open angle. It can eventually lead to blindness. There are two types of glaucoma​ , open-angle and​ closed-angle. Open-angle glaucoma is a​ painless, gradual loss of peripheral vision resulting from increased intraocular pressure and destruction of optic​ fibers, and is the most common form. Glaucoma causes progressive narrowing of the visual field and eventual blindness. Cataracts cause the loss of lens​ clarity,which leads to cloudy vision. Clients with glaucoma take medications to manage intraocular pressure not to manage pain symptoms.

Which is a potential complication following cataract​ surgery? ​(Select all that​ apply.) Ptosis Loss of vitreous humor Increased ocular pressure Retinal detachment Displacement of the implanted lens

Loss of vitreous humor Increased ocular pressure Retinal detachment Displacement of the implanted lens Loss of vitreous​ humor, increased ocular​ pressure, retinal​ detachment, and displacement of the implanted lens are all potential complications following cataract surgery.​ Ptosis, which is drooping of the​ eyelid, is not a complication following cataract surgery.

A nurse is discussing prenatal risk factors with a prenatal group. She is encouraging her clients to remain healthy and avoid illnesses throughout their pregnancy. Which response would indicate to the nurse that her group is in need of further education? ​"If my infant is born​ premature, she may have to wear​ glasses." ​"I should avoid changing my​ cat's litter box when I am​ pregnant, to protect my infant from hearing or vision​ loss." ​"I had the rubella vaccine to prevent the rubella infection during my​ pregnancy, to protect my infant from hearing or vision​ loss." ​"My blood type is A​ negative, and that may increase my​ infant's chance of having hearing or vision​ problems."

My blood type is A​ negative, and that may increase my​ infant's chance of having hearing or vision​ problem Learning Objective Compare alterations across the life span, concepts related to sensory perception, and prevention. Rationale When a client has a negative blood type, they are at risk for an Rh incompatibility with their fetus. However, Rh incompatibilities are not associated with vision or hearing loss in the newborn. Infants who are born prematurely may have visual or hearing deficits associated with their immature development. Toxoplasmosis is an infection transmitted through cat litter. Avoiding changing cat litter is a good strategy to prevent toxoplasmosis transmission and infection during pregnancy. Toxoplasmosis is an infection in the fetus associated with hearing and vision loss. Being vaccinated for rubella may prevent rubella infection during pregnancy. Rubella is an infection associated with vision or hearing loss in infants.

Tonya Conner is a​ 41-year-old female who presents for her annual exam. The nurse asks Tonya about any problems she is having with reading. Tonya replies that she feels like she is having trouble seeing things at​ night, and her vision is not as good as it used to be. The nurse performs a Snellen​ exam, and Tonya is unable to correctly read the row of numbers that is on the​ 20/20 line. What is the most likely diagnosis associated with these​ results? Myopia Ptosis Nystagmus Accommodation

Myopia Myopia is the most likely diagnosis for an individual that has changes in her distance vision. If the client is unable to read the​ 20/20 line, she is having difficulty with her distance vision​ (nearsightedness). Accommodation is the term used for the pupils constricting and converging as an object that is midline is moved closer to the face. Ptosis is the drooping of one eyelid. Nystagmus is the condition of involuntary movement of the eyes that is usually associated with a neurological disorder.

Following​ surgery, Ms. Lawrences eyes are both patched even though her right eye received the corneal transplant. She asks you why both eyes are covered with eye patches. How will you​ respond? Intraocular pressure is maintained when both eyes are patched. Your left eye was patched to prevent another corneal ulceration during surgery. Patching both eyes reduces the risk for infection in both eyes. Patching both eyes reduces eye movement and irritation of the affected eye.

Patching both eyes reduces eye movement and irritation of the affected eye. Patching both eyes decreases all eye movement and allows healing of the affected eye to occur. Patching both eyes is not a preventative measure to reduce the risk for corneal ulceration. A corneal infection is not prevented by patching the​ eyes, nor is intraocular pressure maintained.

Four aspects must be present for an individual to sense his surroundings. Which aspect is not a part of the sensory perception​ process? Impulse conduction Perception Peripheral neuropathy Receptor

Peripheral neuropathy For an individual to experience sensory perception there must be a stimulus​(something to stimulate the​ nerve), a receptor​ (a nerve cell that converts the stimulus to a nerve​ impulse),an impulse conduction​ (a path for the impulse to travel along the nerve to the spinal cord or​ brain), and perception​ (the brain​'s ability to recognize or interpret the​ stimuli).Peripheralneuropathy is a condition interrupting communication between the brain and body. This condition effects sensory​ perception, but is not an aspect required in the sensory perception process.

Which nursing diagnosis is the priority for the nurse to initiate when planning care for a client diagnosed with cataracts? Ineffective coping Anxiety Potential for injury Acute pain

Potential for injury Learning Objective Apply the nursing process to provide culturally competent care across the life span. Rationale When planning care, the priority nursing diagnosis for the nurse to initiate is potential for injury due to visual impairment from the cataracts. Ineffective coping and anxiety may need to be addressed, but they are not the priority diagnosis. Acute pain is not a diagnosis associated with cataracts.

The nurse is preparing to assess a client with cataracts. Which test will the nurse include in the health history portion of the nursing assessment? Snellen chart Prescribed medications Color of pupil Presence of red reflex

Prescribed medications Learning Objective Apply the nursing process to provide culturally competent care across the life span. Rationale During the health history portion of the nursing assessment, the nurse would ask the client about prescribed medications. The Snellen chart would be used during the physical examination. The presence of red reflex and the color of the pupil would also be noted during the physical examination.

While conducting a health​ history, the nurse identifies that the client is at risk for developing glaucoma. What did the nurse learn during the health history to make this​ decision? Prescribed steroids for the​ long-term treatment of inflammatory bowel disease Recent hospitalization for pneumonia Treatment for hypertension for 10 years Wears corrective lenses for an astigmatism

Prescribed steroids for the​ long-term treatment of inflammatory bowel disease Risk factors for the development of glaucoma include a history of​ long-term steroid use.​ Hypertension, pneumonia, and astigmatism are not risk factors for the development of glaucoma.

What is the priority nursing intervention for a client newly diagnosed with​ glaucoma? Preventing injury Reducing anxiety Supporting​ self-care Teaching about the disease process

Preventing injury The priority intervention for a client with newly diagnosed glaucoma is preventing injury. Supporting​ self-care, reducing​ anxiety, and teaching about the disease process are all​ important, but they are not priorities.

Maria Domingo is a​ 78-year-old Hispanic woman who was recently diagnosed with cataracts in both eyes. Her initial symptoms presented as visual changes during the past several months and were described as cloudy vision and difficulty reading even with her glasses. Mrs. Domingo dismisses these changes as part of the aging​ process, but comes to the clinic at the request of her daughter. During the​ visit, she asks​ you, "How did I get this​ condition?" Which characteristic of the disease process related to cataracts will guide your response to Mrs.​ Domingo? Episodes of vertigo may result from distortion of straight lines. Colors may become dull and distorted because of irregular scar tissue development. Proteins clump and cloud the lens of the eye as the lens ages. There may be a reduction in peripheral vision because of thickened ocular blood vessels.

Proteins clump and cloud the lens of the eye as the lens ages. Assessing the client is often part of the​ nurse's responsibility.​ Therefore, understanding the pathophysiology of cataracts can help you provide better care. Most cataracts are considered​ senile, or forming as a normal part of the aging process. As the lens​ ages, fibers and proteins change and degenerate. The proteins clump and cloud the lens. This process usually begins at the periphery of the lens and spreads to involve the central portion. As the cataract continues to​develop, the entire lens may become opaque. The lens may also discolor over​time, which affects the ability to discriminate color. The other answers do not address the​ client's question.

Jules is a​ 14-year-old boy who has been diagnosed with​ red-green color blindness. The clinic nurse is doing some teaching regarding the color blindness. The nurse starts out by educating Jules that people who can see all colors have all of the pigments present in the cones in the​ retina, and people who have inherited color blindness are missing pigments within the cones of the retina. The nurse is knowledgeable about the four aspects necessary for the sensory process. Which step in the process is not functioning in the diagnosis of color​ blindness? Stimulus Perception Receptor Impulse conduction

Receptor The four aspects that are required in the sensory process are​ stimulus, receptor, impulse​ conduction, and perception. With color​ blindness, the step that is affected is the receptor aspect. There is a lack of or dysfunctional call to convert the stimulus to a nerve impulse. The​ impulse, conduction, and perception aspects are unaffected.

The nurse identifies the diagnosis of risk for injury as appropriate for a client with glaucoma. Which action by the nurse addresses this client ​problem? Placing the call light within the​ client's reach Elevating the head of the bed 30 degrees Assisting with ambulation Removing fall hazards from the floor Removing the scatter rug from the bathroom

Removing the scatter rug from the bathroom Placing the call light within the​ client's reach Removing fall hazards from the floor Assisting with ambulation Actions to reduce the risk for injury include assisting with​ ambulation, removing fall hazards and scatter rugs from the​ floor, and placing the call light within the​ client's reach. Raising the head of the bed to a​ 30-degree angle does not reduce the risk for injury.

The nurse is reviewing the orders for a client who had a piece of glass surgically removed from the right eye. Which prescribed order should the nurse question? Call the healthcare provider for a temperature greater than 100.4°F​ ​(38°​C) Place an eye patch on the affected eye Resume regular activities Apply tobramycin sulfate eye drops as directed

Resume regular activities Learning Objective Apply the nursing process to provide culturally competent care across the life span. Rationale Resuming regular activity in not an appropriate​ order; activities that require bending or straining should be restricted following an eye injury. An infection is a potential complication following an eye​ injury, so notifying the healthcare provider about a temperature greater than 100.4°F​ (38°​C) is an appropriate order. Tobramycin sulfate is an antibiotic and is an appropriate medication after surgery. An eye patch on the affected eye is an appropriate order to prevent further injury.

The nurse is providing home care for an​ 88-year-old man named Thomas Pitts. The nurse calls out a greeting to Mr.​ Pitts, but she does not hear him answer. As the nurse enters the​ home, the nurse can hear that the volume of the TV is very loud. The nurse knows that Mr. Pitts has a hearing deficit. What intervention would not be appropriate for the nurse to perform with someone with a hearing​ deficit? Shout so the client can hear. Decrease the back ground noise. Stand or sit in front of the client. Use​ short, succinct phrases.

Shout so the client can hear. Shouting is not an effective way to communicate to a client with a hearing deficit. Shouting does not make the sounds more distinct and may make it more difficult for the client to comprehend the speech. A moderate tone of​ voice, with​ well- articulated words is more appropriate. Long phrases are easier to understand than short ones. Appropriate interventions for a client with a hearing deficit include decreasing the background​ noise, and sitting or standing in front of the client so the client can see the individual and potentially read the lips.

The nurse is performing a focused assessment. Which information should the nurse obtain when performing a health history on a client with possible cataracts? History of Addison disease Social use of alcohol Use of furosemide​ (Lasix)Smoking history

Smoking history Learning Objective Apply the nursing process to provide culturally competent care across the life span. Rationale When completing a health history, the nurse needs to obtain information on the client's smoking history, because this is a risk factor for cataracts. A history of Addison disease and furosemide (Lasix) use are not risk factors and are not essential information to obtain when completing a health history. Heavy alcohol use, not social use, contributes to the progression of cataracts.

The nurse is performing a physical assessment on a client reporting visual changes. Which diagnostic exam will best aid in the diagnosis of cataracts? Convergence Snellen chart Accommodation Cardinal fields of vision

Snellen chart Learning Objective Identify collaborative therapies used by interdisciplinary teams. Rationale Utilizing a visual acuity test, such as the Snellen chart, is the simplest way to diagnose cataracts. Cardinal fields of vision will test extraocular eye movement and does not aid in the diagnosis of cataracts. Convergence indicates a neuromuscular disorder or improper eye alignment. Accommodation tests are used for neurological problems.

Jenny​ Floyd, a​ 10-year-old girl, fell from her bike onto a bush and sustained a penetrating injury of her right eye by a twig. She is in the emergency department awaiting surgery. What is your priority​ action? Putting Jenny in a hospital gown Stabilizing the twig as much as possible Teaching the parents about the importance of eye rest Applying steroidal eye drops

Stabilizing the twig as much as possible To minimize the extent of​ damage, the priority action is stabilizing the twig and keeping​ Jenny'shands from her face. It is important to teach the parents about discharge​ care, to include promoting eye​ rest, but it is not a priority at this time. Jenny needs to be put in a hospital gown and prepared for​ surgery, but after the twig is stabilized. An​ anesthetic, not a​ steroidal, eye drop is appropriate but also secondary to stabilizing the twig.

A nursing student is performing an eye exam on a newborn infant. The nursing student notices that the infant has strabismus. When he reports his finding to the nursing​ instructor, what would be the instructor​'s best​ response? Strabismus in a newborn is not a normal​ finding, and this infant needs an exam by an ophthalmologist. Strabismus in a newborn is an indication of blindness. Strabismus in a newborn is not a normal​ finding, and we should give the mother exercises to perform with her newborn. Strabismus in a newborn is a normal​ finding, and it should resolve by 3 months of age.

Strabismus in a newborn is a normal​ finding, and it should resolve by 3 months of age. Strabismus is a normal finding in a newborn and should resolve spontaneously by 3 months of age. At 3 months of​ age, if the strabismus is still​ detectable, then an ophthalmologist consult is recommended. Recommending exercises would not be an effective or appropriate intervention for strabismus. Strabismus is not a sign of​ blindness, but may indicate other pathologies if detected over the age of 3 months.

What is the client position of choice before surgical correction for a detached​ retina? Prone Supine High Fowler ​Side-lying on the side of the affected eye

Supine Before surgery for a detached​ retina, place the client in the supine position so that the detached area of the retina is aligned with the​ choroid, and the pressure of the eye and head helps the retina make contact with the choroid. The prone position creates the opposite effect of the therapeutic supine position by directing the detached retina away from the choroid. The​ side-lying position on the side of the affected eye does not place the retina in alignment with the choroid. The ​high-Fowler position is not significantly therapeutic.

Which treatment option is the most beneficial for a client with​ cataracts? Eye drops Dietary changes Surgery Increase in physical activity

Surgery Surgery is the most beneficial treatment option for clients with cataracts. Surgery is typically done when the cataracts interfere with activities of daily living. There is no pharmacologic treatment for cataracts. Dietary changes and increased physical activity are not considered treatments for cataracts.

A nurse is evaluating an older adult client in the emergency department after a fall at home. The client sustained a facial injury after tripping on her carpet, and the right side of her face struck the coffee table. The client has no penetrating or blunt trauma eye injuries. The nurse suspects a detached retina based on which information? The client reports​ "a veil" being drawn across her field of vision. The nurse observes purulent drainage at the inner canthus of the right eye. A detached retina can result from trauma or age. The client reports diplopia. The nurse notices reddened area on the conjunctiva.

The client reports​ "a veil" being drawn across her field of vision. A detached retina can result from trauma or age. Learning Objective Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale A detached retina can be caused by aging or trauma. Clients with a detached retina usually report a veil being drawn across the field of vision, or floaters. Diplopia is common with a blunt trauma eye injury, it is not a symptom of detached retina. A reddened area on the conjunctive is more likely to be seen in a client with a subconjunctival hemorrhage. Purulent drainage at the eye is suggestive of infection not detached retina.

A client newly diagnosed with glaucoma asks why eye medication must be used every day. How should the nurse respond to the​ client? ​"The drops lower intraocular pressure in the​ eye." ​"The drops cure glaucoma and restore your​ vision." ​"The drops are prescribed by your​ physician, so I recommend you use​ them." ​"The drops moisten your eyes and make you feel more​ comfortable."

The drops lower intraocular pressure in the​ eye ​"Medications prescribed for glaucoma are used to decrease intraocular pressure rather than to provide moisture and​ comfort." Medications do not cure​ glaucoma, but help to manage glaucoma. Stating that the client should use the medication because it has been prescribed by the healthcare provider does not address the​ client's question.

When a nurse assesses the cardinal fields of​ vision, the nurse gains valuable information regarding what part of the​ eye? The pupil response The internal structures of the eye The visual acuity The extraocular muscles

The extraocular muscles When the nurse assesses the cardinal fields of vision by moving an object through all six​ fields,she gathers information regarding the function of the ocular eye movements and the muscles of the eye. The internal structures of the eye are assessed through the use of an opthalmoscope. Visual acuity is tested through the use of a Snellen or E chart.Pupils are assessed using a pen light. Normally functioning pupils will constrict and dilate equally.

A nurse is observing a student care for a client just admitted to the emergency department after getting hit in the eye with a baseball bat. Which action by the student requires intervention by the nurse? The student applies the ordered dose of acetazolamide​ (Diamox). The student applies an eye patch to the unaffected eye. The student applies an eye shield to the affected eye. The student places the client in the Trendelenburg position.

The student places the client in the Trendelenburg position. Learning Objective Identify collaborative therapies used by interdisciplinary teams. Rationale Clients with blunt trauma to the eye should be placed in a​ semi-Fowler position. Acetazolamide​ (Diamox) is a carbonic anhydrase inhibitor that is prescribed to decrease intraocular pressure. An eye patch to the unaffected eye minimizes eye movement in a client who has sustained blunt trauma to the eye. An eye shield protects the affected eye from further injury.

After reviewing the results of the​ procedure, the health care provider is able to confirm that Ms. Lawrence is suffering from severe corneal ulceration of the right eye. She will be referred to an ophthalmologist for examination first thing in the morning. She asks you if the ulceration could become infected and how to prevent this from happening. What is your best​ response? Be sure to increase your fluid intake to 3 liters per day. Thoroughly wash your hands before instilling any eye medications. Use moistened cotton swabs to cleanse the cornea 2 Keep the eye patched for one week to avoid infection.

Thoroughly wash your hands before instilling any eye medications. The most important measure Ms. Lawrence can take to prevent ocular infection is meticulous hand washing prior to instilling any eye medication. Increasing her fluid intake will not reduce her risk for infection. An eye patch helps to prevent rubbing or additional trauma of the eye. Using a cotton swab on the eye will cause further corneal damage and is prohibited.

When providing postoperative​ instructions, you inform Ms. Lawrence that she should apply warm compresses to the right eye for 15​ minutes, three to four times a day. What is the rationale for use of warm compresses following corneal​ transplant? To increase edema formation of the intraocular structures To decrease circulation and promote healing To avoid scarring of the newly transplanted cornea To reduce inflammation and promote comfort

To reduce inflammation and promote comfort Warm compresses reduce inflammation and promote comfort. Warm compresses will be more likely to increase circulation than decrease​ it, and thus promote healing. Edema formation would not be created by the application of a warm​ compress, and scarring of the cornea is not a concern with the newly transplanted cornea.

The nurse is instructing a client newly diagnosed with glaucoma on​ self-administration of eye medication. The nurse teaches the client to apply pressure over the lacrimal sac after administering which​ medication? Topical​ beta-adrenergic blocking agents Carbonic anhydrase inhibitors Prostaglandin analogs Adrenergic agonists

Topical​ beta-adrenergic blocking agents The client needs to apply pressure over the lacrimal sac after administrating topical​ beta-adrenergic blocking agents. This is important to prevent systemic absorption of the medication. The client does not need to apply pressure after administrating adrenergic​ agonists, carbonic anhydrase​ inhibitors, or prostaglandin analogs.

John Gleason presents to his healthcare provider complaining of blurred vision and seeing flashes of light for the past several hours. Based on these​ symptoms, which diagnostic test do you anticipate for this​ client? Facial​ x-ray CT scan Ultrasonography Visual acuity test

Ultrasonography Based on these​ symptoms, the client requires a diagnostic test to confirm a detached retina. Ultrasonography is used to diagnose this condition. Visual acuity​test, facial​ x-ray, and a CT scan are not.

You are preparing a written list of discharge instructions for Ms. Lawrence. Which instructions will you​ include?(Select all that apply.) Use eye protection during activities that can damage the eye. ​Follow-up with the ophthalmologist as directed. Avoid rubbing or scratching the eye. Apply an eye shield at night. Dangle on the side of the bed before rising each morning.

Use eye protection during activities that can damage the eye. ​Follow-up with the ophthalmologist as directed. Avoid rubbing or scratching the eye. Apply an eye shield at night. Rubbing or scratching may damage the corneal graft. An eye shield helps prevent inadvertent rubbing or trauma to the eye during sleep. Trauma increases the risk of infection and scarring of the cornea.​ Follow-up care is critical to detect problems associated with the transplantation. Dangling before rising each morning is not necessary and not appropriate to include in Ms.​ Lawrence's discharge instructions.

The nurse is teaching a client with cataracts about nonpharmacologic treatments. Which nonpharmacologic treatment should the nurse discuss with the client? Using a brighter light when reading Utilizing an eye patch Maintaining bed rest Wearing sunglasses indoors

Using a brighter light when reading Learning Objective Identify collaborative therapies used by interdisciplinary teams. Rationale Early cataracts can be managed by using a magnifying glass, stronger prescription lenses, or using a brighter light when reading. Maintaining bed rest, utilizing an eye patch, and wearing sunglasses indoors are not ways to manage a cataract.

Amelia Martin is a​ 32-year-old client who presents to the urgent care clinic. Amelia tells the nurse that she has been having trouble with her balance for the past 2 days. She reports that when she stands​ up, she is feeling​ "like the room is​ spinning" and complains of nausea. Amelia is most likely suffering from which alteration in sensory​ perception? Impaired olfactory Color blindness Vertigo Taste disturbance

Vertigo The symptoms that Amelia is experiencing including loss of​ balance, nausea, and​"the room​ spinning" are signs of vertigo. These symptoms are not associated with color​ blindness,impaired olfactory​ function, or taste disturbance.

Which diagnostic tests are helpful in determining the extent and cause of an eye​ injury? ​(Select all that​ apply.) Culture and sensitivity Visual acuity Facial​ x-ray CT scan Fluorescein stain

Visual acuity Facial​ x-ray CT scan Fluorescein stain Visual acuity is used to determine if the injury has impacted the vision. Fluorescein stains are used to identify corneal ulcerations or abrasions and foreign bodies. Facial​ x-rays are used to identify orbital fractures. CT scans are used to identify foreign bodies within the globe. Culture and sensitivity is not commonly used to assess the extent and cause of an eye injury.

A client presents to the emergency department with complaints of eye pain. The client is a welder on an oil pipeline and admits to not wearing appropriate eye gear on the job today. Which diagnostic tests should the nurse anticipate may be ordered for this client? Ophthalmoscopic examination Ultrasound Visual acuity test Facial​ x-ray Slip lamp and fluorescein stain

Visual acuity test Slip lamp and fluorescein stain Ophthalmoscopic examination Learning Objective: Identify collaborative therapies used by interdisciplinary teams. Rationale: The client may have a foreign body or a corneal abrasion from welding while not wearing a face shield. A visual acuity test determines if the injury has affected the vision. A slit lamp and fluorescein stain identify corneal abrasions and ulcerations or foreign bodies. An ophthalmoscopic examination is helpful in detecting hemorrhage or trauma to the interior chamber of the eye. Facial x-rays are used with orbital fractures and are not warranted if a foreign body is suspected. Ultrasonography is used to detect a detached retina or vitreous hemorrhage.

What health promotion concept regarding corneal transplantation will you include in Ms. Lawrence's discharge​ teaching? Wear dark sunglasses with ultraviolet​ (UV) protection when​ outdoors, even on cloudy days. Avoid reading all printed material for 6-8 weeks after surgery. Expect double vision for 2 - 3 weeks after your surgery. Avoid steam​ baths, saunas, and extreme temperatures.

Wear dark sunglasses with ultraviolet​ (UV) protection when​ outdoors, even on cloudy days. Bright light can cause eye​ pain, which may be minimized by wearing dark sunglasses with ultraviolet​ (UV) protection when​ outdoors, even on cloudy days.​ Initially, Ms. Lawrence may be told to avoid long periods of strenuous reading to avoid eye strain.​ However, it would be impractical to instruct her to avoid all reading. Steam​ baths, saunas, and extreme temperatures are not likely to affect the transplanted cornea. Double vision is not a normal occurrence post corneal transplantation.

A nurse is testing the six cardinal fields of vision while having the client follow an object with her eyes. What nerves does the nurse know are intact when the client is able to move her eyes in all directions? Cranial nerve III​ (oculomotor) Cranial nerve IV​ (trochlear) Cranial nerve X​ (vagus) Cranial nerve II​ (optic) Cranial nerve VI​ (abducens)

cranial nerve IV(trochlear) Cranial Nerve VI(abducens) Cranial Nerve III (oculomotor) Learning Objective Understand the physiology of sensory perception across the life span. Rationale Cranial nerves III (oculomotor), IV (trochlear), VI (abducens) are involved in moving the eye in all six cardinal fields of vision. Cranial nerve II (optic) is involved in the process of vision, not movement. Cranial nerve X (vagus) is involved in swallowing, digestion, heart rate, respirations, digestion, and sense of taste, but not in ocular movement.

A nurse is doing discharge teaching for a client who has had a spinal cord injury in the lower back. The client is a young adult male, who has lost tactile sensation from the umbilicus to the toes. What teaching would not be appropriate for this client? Suggesting adequate lighting Checking the temperature of the water for a bath with a thermometer Recommending shifting position often Adjusting the temperature on the hot water heater

suggesting adequate lighting Learning Objective Explain independent and collaborative interventions for clients with sensory perception alterations. Rationale A client that has impaired tactile sensation is at risk for burns and pressure ulcers due to the inability to feel temperatures or pressure that may be damaging. Checking water temperatures or adjusting the temperature on the hot water heating prior to bathing or showers are appropriate interventions for this client. Recommending that the client shift positions frequently is appropriate to prevent damage to the skin when the client is unable to feel pressure. Suggesting adequate lighting is an appropriate intervention for someone with a visual deficit and is not necessary for this client.

The nurse is planning care for a client newly diagnosed with glaucoma. Which treatment approach should the nurse expect to be prescribed for this ​client? ​(Select all that​ apply.) Avoid the use of corrective lenses Application of warm soaks to the orbits ​High-dose iron and copper supplements Topical eye medication Surgery to correct the condition

topical eye medication Surgery to correct the condition Treatment approaches for glaucoma include topical eye medication and surgery to correct the condition. Warm​ soaks, high-dose iron and copper​ supplements, and avoiding the use of corrective lenses are not treatment approaches for glaucoma.

A child is brought into the pediatric emergency department for evaluation. The mother reports that her 9-month-old daughter has had a fever, is irritable, and "keeps tugging on her ear". The nurse is preparing equipment for the exam. What equipment should the nurse gather? Otoscope Tympanogram Opthalmoscope Tuning fork Thermometer

tympanogram otoscope thermometer

A nurse is instructing a client on safe administration of antibiotic eye drops following a diagnosis of a corneal abrasion. Which statements by the client indicate appropriate understanding? ​"I should tilt my head slightly backward while administering the eye​ drops" ​"I should look down when placing the drops in my​ eye." ​"Following the eye drop​ administration, I should close my eyes for 2 or 3​ minutes." ​"I need to touch the applicator to my eye to make sure the eye drops are distributed​ evenly" ​"I need to wash my hands before administering eye​ drops."

​"Following the eye drop​ administration, I should close my eyes for 2 or 3​ minutes."​ "I should tilt my head slightly backward while administering the eye​ drops" ​"I need to wash my hands before administering eye​ drops." Learning Objective: Apply the nursing process to provide culturally competent care across the life span. Rationale: Safe administration of eye drops includes washing the hands before administration, tilting the head backward while placing the drops, and closing the eye for 2 to 3 minutes after the eye drops have been placed. The applicator should not be touched directly by the finger or to the eye to prevent infection. Looking up facilitates the ease of placing the eye drops.

Mr. Elias presents to the​ ophthalmologist's office because of eye pain. He works in a grain elevator and has noticed increasing eye pain and a cloudy discharge. He does not wear contact lenses. He has been diagnosed with a corneal​ abrasion, and he wants to know what that means. What is your best​ response? ​"It is damage to the surface level of the​ cornea." ​"It is serious and can lead to​ perforation." ​"It is a destruction of both scleral and corneal​ tissue." ​"It is an infection caused by a​ virus."

​"It is damage to the surface level of the​ cornea." Corneal abrasions are commonly caused by small foreign​ bodies, such as grain​dust, that irritate and damage the surface of the cornea. They do not involve the sclera. A corneal abrasion is not the same as an infection. Although corneal abrasions are painful and must be​ treated, they are not as serious as corneal​ulcerations, which can lead to perforation of the​ cornea; a corneal abrasion cannot.

The nurse is identifying diagnoses appropriate for a client with glaucoma. Which diagnosis should the nurse identify as lowest priority for this client​'s ​care? ​Self-care deficit Risk for injury Anxiety Altered nutrition

Altered nutrition Risk for​ injury, anxiety, and​ self-care deficit are all common nursing diagnoses for a client with glaucoma. Risk for altered nutrition has the lowest priority for this client.

A client goes to a healthcare clinic for possible cataracts. When completing a physical examination of the eye, which manifestation will assist in making a diagnosis of cataracts? Colored halos around lights Cloudy vision or halos Blurred central vision Intact peripheral vision

Cloudy vision or halos Learning Objective Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale Cloudy vision or halos are a manifestation of cataracts. Intact peripheral vision and blurred central vision are manifestations of macular degeneration, not cataracts. Colored halos around lights are not a clinical manifestation of cataracts.

Which are common causes of corneal​ abrasion? ​(Select all that​ apply.) Dust Ultraviolet rays Contact lenses Alkaline injury Eyelashes

Dust Contact lenses Eyelashes Foreign particles such as eyelashes and dust can cause a corneal abrasion. Contact​ lenses,particularly if left in too​ long, can cause a corneal abrasion as well. Alkaline injury and ultraviolet rays cause eye​ burns, not corneal abrasions.

Which diagnostic test is used to identify corneal​ abrasions? Serum laboratory tests Conjunctival scrapings Fluorescein stain Culture and sensitivity

Fluorescein stain Fluorescein stains are used to identify corneal damage. Conjunctival scrapings are used to identify the underlying causative organism of an infection. Serum laboratory tests are used to determine underlying infectious or autoimmune processes. Culture and sensitivity is used to determine the presence of infection and to identify the infecting organism.

The nurse is teaching a client newly diagnosed with glaucoma. Which client statement indicates that additional instruction is​ needed? ​"I will be blind in less than 6​ months." ​"There are resources available to help me do grocery shopping and get to​ appointments." ​"I still need to see my eye doctor every year to monitor the pressure in my​ eyes." ​"I may need some help around the house as my vision gets​ worse."

I will be blind in less than 6​ months Glaucoma can be treated to help slow the progression of the​ disease; a client with newly diagnosed glaucoma will not be blind in 6 months. Resources are available for clients with​ glaucoma, and it is important for the client to have yearly eye exams and pressure checks.

The nurse is identifying interventions appropriate for a client with glaucoma. Which intervention should the nurse include in this client​'s plan of​ care? ​(Select all that​ apply.) Explaining the need to reduce sodium in the diet Reviewing the disease process Orienting to the environment Assisting with​ self-care activities Emphasizing the need for medication compliance

Reviewing the disease process Orienting to the environment Assisting with​ self-care activities Emphasizing the need for medication compliance Interventions that may be appropriate for inclusion in the plan of care for the client with glaucoma include orienting to the​ environment, assisting with​ self-care activities, reviewing the disease​process, and emphasizing the need for medication compliance. Sodium restriction is not a part of glaucoma treatment

A client has sustained an extensive chemical burn to the left eye and is being prepared for surgery. Which surgeries are appropriate for a client with this type of injury? (Select all that apply.) Tissue grafting Corneal transplant Removal of a foreign body Debridement Cryotherapy

Tissue grafting Corneal transplant Debridement

Which test is used to diagnose​ glaucoma?​(Select all that​ apply.) Visual field testing Gonioscopy Fluorescein angiography Tonometry Funduscopy

Visual field testing Gonioscopy Tonometry Funduscopy ​Tonometry, funduscopy, visual field​ testing, and gonioscopy are all used to diagnose glaucoma. Fluorescein angiography is used to diagnose macular degeneration.

Marian Lawrence is a​ 33-year-old junior executive at a growing cosmetic company. Due to the nature of her​ job, she must always look as attractive as possible. She invests in expensive hairstyles and clothing to promote her success. Ms. Lawrence's life is​ fast-paced, with many deadlines and​ stressful, work-related social engagements.​Recently, after a long day at​ work, she returned to her apartment and went straight to​ bed, after taking an​ over-the-counter sleep medication and turning on the electric fan that she uses as white noise. When she woke the next​ morning, she realized that she had neglected to remove her disposable contact lenses before going to bed.​ Immediately, she took out the​ lenses, donned her eye​ glasses, and prepared to go to work.On her way to​ work, Ms. Lawrence began to experience some slight itching and discomfort of her right eye. To relieve the​ discomfort, she applied saline based lubricating drops.​ However, as the day went​ on, her eye​ discomfort steadily increaseD, and the saline drops seemed to make her eye burn even worse. By the end of the​ day, she was​ experiencing extreme pain in her right eye and asked her friend Jessie to take her to the emergency department for treatment. You are the triage nurse and the first health care provider to come in contact with Ms. Lawrence.As the triage​ nurse, you need to determine if there are any risk factors that might be the possible cause of Ms. Lawrence's ocular pain. Which data in her history would indicate risk factors contributing to her eye​ pain? Wears contact lenses daily Uses high doses of​ over-the-counter headache relief medication Recent occurrence of herpes zoster​ (shingles) Recurrent bacterial eye infection Smokes 2 packs of cigarettes per day

Wears contact lenses daily Eye pain can be caused by a number of​ conditions, such as recurrent bacterial eye​ infections, trauma, or misuse of contact lenses. Herpes​ viruses, including herpes zoster​ (shingles), can cause pain which may be due to corneal ulcers. Although the other factors such as smoking and using high doses of​ over-the-counter pain medication may not be the healthiest choices for Ms.​ Lawrence, they would be unlikely to cause eye pain.

The nurse is educating a student nurse about individuals who are at risk for eye disorders. Which client is at greatest risk for developing cataracts? Hispanics Men Women Caucasians

Women Learning Objective: Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale: Women are affected more frequently than men and are at greater risk for developing cataracts. African Americans are affected more frequently by cataracts than Caucasians and Hispanics.

The nurse is visiting the home of Aida​ Johanson, an​ 85-year-old client newly diagnosed with​ open-angle glaucoma. What information should the nurse provide to Mrs. Johanson about home​ safety? ​"The furniture should not be moved or​ rearranged." ​"The library might have books with large print so that you can continue to​ read." ​"The eye medication must be used as​ prescribed." ​"There are local transportation companies available so that you can arrive safely to your scheduled​ appointments."

"The furniture should not be moved or​ rearranged." For the client with impaired​ vision, it can be difficult to adapt to changes in the​environment, so maintaining the same position of belongings is important for client safety.​ Large-print books,​ transportation, and medication compliance are not directly related to home safety.

Mr. Leonard is an older African American man who has been diagnosed as having bilateral cataracts. He has experienced decreased visual acuity and an increase in glare over the past year. He had the right cataract removed and a lens implant performed​ today, and you are reviewing his discharge instructions with him. When you discuss the need for a stool softener to reduce straining while​ stooling, he is confused and asks why this pill is needed. Which is your best response to Mr.​ Leonard's question? ​"Straining when having a bowel movement may result in nausea and​ vomiting." ​"This pill will act as a laxative and reduce the risk of​ constipation, which may occur as side effects of other​ medications." ​"Blood vessels in your eye may burst when​ defecating, causing intraocular hemorrhage and potential​ blindness." ​"Pressure builds up in your eye and could cause problems with the surgical repair of your right eye if you strain when having a bowel​ movement."

​"Pressure builds up in your eye and could cause problems with the surgical repair of your right eye if you strain when having a bowel​ movement." Addressing the connection between straining when having a bowel movement and increasing pressure in the​ eye, as well as the desire for a​ positive, expected surgical​ outcome, enhances compliance with taking the medication. Stating the action of the medication in simple terms increases the likelihood of compliance. The stool softener is not a laxative. Using strong terms with medical​ implications, such as​ "intraocular pressure,"​ "intraocular hemorrhage," and​ "potential blindness," which may not be understood by the​ client, may instill fear or disregard for the instructions. Although there is a correlation between actions that increase intraocular and intracranial​ pressure, increased intracranial pressure is not of concern to this client and serves to confuse the instructions.

Angelique​ Apreku, a​ 75-year-old client scheduled to have a laser trabeculoplasty for​ glaucoma, asks how the surgery will treat the problem. How should the nurse​ respond? ​"The procedure will improve the flow of aqueous​ humor-the fluid in your​ eye-from the back to the front of your eye chamber and decrease the pressure within your​ eye." ​"The procedure will seal the leaking of​ tiny, weakened blood vessels in your​ eye." ​"It will stimulate the growth of new and stronger blood vessels to replace those that are​ degenerating." ​"Pressure is placed on the back of your eye to sustain contact of the retina with the​ choroid."

​"The procedure will improve the flow of aqueous​ humor-the fluid in your​ eye-from the back to the front of your eye chamber and decrease the pressure within your​ eye." Laser trabeculoplasty is the treatment of choice and is performed by multiple laser burns within the trabecular​ meshwork; the scarring from these burns causes tension and stretching of the meshwork. This procedure enhances the outflow of aqueous humor from the posterior to the anterior chamber of the​ eye, which reduces the intraocular pressure. Blood vessels are not degenerating in​ glaucoma, and the surgical procedure is not intended to stimulate growth of new and stronger blood vessels. Leaking ocular aneurysms are common in retinopathy. Maintaining contact of the retina with the choroid explains surgical correction for a detached retina.

You are performing a health assessment of Mrs.​ Apreku, who is scheduled to have an extracapsular extraction performed to surgically correct her cataract. She shows you the paper with the name of the surgery spelled out and​ says, "I know it is a treatment of​ choice, but I​ don't know how it will help my cataract. What will it​ do?" Which response will reinforce Mrs.​ Apreku's understanding of the surgical​ procedure? ​"The procedure will improve vision by removing the anterior​ capsule, nucleus, and cortex of the​ lens, and a silicone intraocular lens is implanted to repair depth​ perception." ​"The procedure will place pressure on the back of your eye to sustain contact of the retina with the​ choroid." ​"The procedure will seal the leaking of tiny weakened blood vessels in your​ eye." ​"The procedure will stimulate the growth of new and stronger blood vessels to replace those that are​ degenerating."

​"The procedure will improve vision by removing the anterior​ capsule, nucleus, and cortex of the​ lens, and a silicone intraocular lens is implanted to repair depth​ perception." Surgical removal of cataracts occurs when vision is compromised and affecting activities of daily living. Surgery is done in an outpatient setting with local anesthesia. The client may be hospitalized overnight if they have undergone general anesthesia. In a process called extracapsular​ extraction, the anterior​ capsule, nucleus, and cortex of the lens are​ removed, leaving the posterior capsule intact. After removal of the​ lens, the eye can no longer focus light on the​ retina, and vision is seriously impaired.​ Commonly, a​ plastic, acrylic, or silicone intraocular lens is implanted. The implant repairs binocular vision and depth perception. The procedure will not stimulate growth of blood​ vessels, seal weakened blood​ vessels, or place pressure on the eye.