Exam 6
The nurse has given a community group a presentation on eye health. Which statement by a participant indicates a need for further instruction?
" I always lose my sunglasses, so I don't wear them"
A client has been taught about retinitis pigments a (RP). What statement by the client indicates a need for further teaching?
"Since I'm going blind, sunglasses are not needed anymore."
A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important?
A. "Avoid reading, writing, or close work as sewing"
A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?
A. "Because eye pressure was too high, the tissue died."
The nurse working in the ophthalmology clinic sees client's with eyelid and eye problems. What information should the nurse understand about these disorders?
A. A chalazion is an inflammation of an eyelid sebaceous gland D. A hordeolum is an infection of the eyelid sweat gland E. Keratoconjunctivitis sic a is caused by drugs or diseases
A client has a foreign body in the eye. What action by the nurse takes priority?
A. Administering ordered antibiotics
The student learning about vision should remember which facts related to the eyes?
A. Aqueous humor controls intraocular pressure C. Glaucoma occurs due to increased pressure in the eye D. Muscles of the iris control light entering the eye E. Rods work in low light conditions
The nurse reads on a client's chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis?
A. Bulging eyes
A client had cataract surgery. What instructions should the nurse provide?
A. Call the doctor for increased pain B. Do not bend over from the waist C. Do not lift more than 10 pounds E. Uses stool softeners to avoid constipation
A client has a corneal ulcer. What information provided by the client most indicates a potential barrier to home care?
A. Chronic use of sleeping pills
The nurse enters an examination room to help with an eye adam inaction. The client is directed toward the assessment chart shown below: What is the provider assessing?
A. Color vision
A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing should the nurse prepare the client?
A. Corneal staining
The nursing student learns that age-related changes affect the eyes and vision. Which changes does this include?
A. Decreased eye muscle tone B. Developement of Arbus senillis D. Decrease in general color perception E. Increase in point of near vision
A clients chart indicates anisocoria. For what should the nurse assess?
A. Difference in pupil size
A client had proxmetacaine (Ocu-Caine) instilled in one eye in the emergency department. What discharge instruction is most important ?
A. Do not touch or rub the eye until it is no longer numb.
A nurse has delegated applying a warm compress to a client's eye. What actions by the unlicensed assistive personal (UAP) warrant intervention by the nurse?
A. Heating the wet washcloth in the microwave B. Holding the cloth on the client using an ACE wrap
The nursing student studying the eye learns that which cranial nerves control its functions?
A. II B. III C. VI
A nurse assess client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection?
A. Shortness of breath B. Abnormal bloating C. New-onset bradycardia
After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assess the clint's understanding. Which client statement indicates a need for additional teaching?
B. " I will have my teeth cleaned by my dentist in 2 weeks."
A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in the clients discharge teaching?
B. "Avoid large crowds and people who are sick"
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond?
B. "Blood clots form more easily in artificial replacement valves."
A client has been prescribed brinzolamide (Azopt). What assessment by the nurse requires consultation with the provider?
B. Allergy to. Sulfonamides
A nurse assess a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?
B. Atrial Fibrillation
A nurse is seeing client's in the ophthalmology clinic. Which client should the nurse see first?
B. Client who has had cataract surgery and has worsening vision
A nurse assess a client with mitral valve stenosis. What clinical manifestation should alert the nurse the possibility that the client's stenosis has progressed?
B. Dyspnea on exertion
A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority?
B. Ensure the client's has a patent airway
An older client has decided to give up driving due to cataracts. What assessment information is most important to collect?
B. Feelings related to loss of driving
The nurse is administering eye drops to a client with an infection in the right eye. The drops go in both eyes, and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the right eye. What action by the nurse is best?
B. ObtaiN a new bottle of eye drops
A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate a good understanding of home management of this condition?
C. "I will throw away all my eye makeup when I get home" D. "I won't touch the tip of the eye drop bottle to my eye"
A nurse who is applying eye drops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best?
C. "This prevents systemic absorption"
A client who is near blind is admitted to the hospital. What action by the nurse is most important?
C. Orient the client to the room using a focal point
A client's intraocular pressure (IOP) is 28 mmHg. What action by the nurse is best?
C. Plan to teach about about drugs for glaucoma
After teaching a client who is recovering from a heart transplant to change positions slowly. The client asks , "Why is this important?" How should the nurse respond?
C. Your new heart is not connected to the nervous system and is unable to respond to decrease in blood pressure caused by position changes
A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know my transplant is my last chance, but I don't want to become a vegetable." How should the nurse respond?
D. "Would you like information about advance directives?"
A client is taking timolol (Timoptic) eye drops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority?
D. Hold the eye drops and notify the provider
A client is in preoperative holding area waiting for cataract surgery. The client says, "Oh, yeah, I forgo to tell you that I take clopidogel, or Plavix". What action by the nurse is most important?
D. Notify the surgeon immediately
