Exam 2: Chapter 11

Question 1

You have four rooms to choose from for your older client to be admitted this afternoon. Which room would you choose?

a. A brightly lit, blue room with cozy throw rugs
b. An orange-carpeted room with soft lighting and yellow walls
c. A brightly lit, blue room with an EZ-Glide wax floor
d. A fluorescent-lighted room with green walls and a glossy, tiled floor

Answer 1

ANS: B
Light colors such as red, orange, and yellow are more easily seen by aging eyes. Softer lighting will help reduce some of the glare and is also easier seen by aging eyes. Fidelity of color is less accurate with the blues, greens, and violets of the spectrum, and the slowed ability of the pupils to adjust to light makes glare a problem. Glare can come from sunlight, but a brightly waxed floor and glossy tile can also cause glare.

Question 2

An older adult client shares with the nurse that, “I don’t know what it is but it seems that I need more light for reading or even watching television as I get older.” The nurse explains that aging may cause this change due to the:

a. slower ability of the pupil to adjust to changes in lighting.
b. impact arcus senilis has on visual acuity
c. flattening and thinning of the cornea.
d. retinal changes that begin to occur with aging.

Answer 2

ANS: A
A slowed ability of the pupil to accommodate to changes in light accounts for the need of this patient to have more light in order to read. Arcus senilis does not affect vision. It is true that the cornea becomes flatter and thinner with aging, which results in astigmatism. Astigmatism
does not account for the need for increased light that this patient is reporting. The changes in the retina do not account for the need for increased light that this patient is reporting.

Question 3

A 77-year-old client being treated for glaucoma asks the nurse what causes glaucoma. The nurse’s response is:

a. the exact etiology of glaucoma is variable and often unknown.
b. spasms of the orbicular muscle.
c. changes to the suspensory ligaments, ciliary muscles, and parasympathetic nerves.
d. bits of broken coalesced vitreous from the peripheral or central part of the retina.

Answer 3

ANS: A
The etiology of glaucoma is variable and often unknown. However, when the natural fluids of the eye are blocked by ciliary muscle rigidity and the buildup of pressure, damage to the optic
nerve occurs. Spasms of the orbicular muscle can cause the lower lid to turn inward. If it stays this way, it is called entropion. The changes described contribute to decreased accommodation. Bits of coalesced vitreous that have broken off from the peripheral or central
part of the retina is the definition of floaters.

Question 4

An older man tells a nurse, “The doctor says I have something wrong with my eyes,
something called presbyopia. Can you explain why I have this? I was always fortunate to have
good eyesight.” The nurse formulates a response based on the knowledge that:
a. the lens of the eye loses elasticity causing a loss of focus for near objects.
b. the cornea of the eye becomes thicker and less curved causing an increase in astigmatism.
c. the lens of the eye increases in opacity causing a decrease in light refraction.
d. the cornea of the eye forms a gray ring at the edges.

Answer 4

ANS: A
Presbyopia is the loss of focus for near objects, caused by a loss of elasticity and hence a loss of accommodation of the lens of the eye. All of the other options are normal age-related
changes; however, they are not related to presbyopia.

Question 5

An older resident in a long-term care facility reports to the nurse that she has been noticing changes in her vision, including the appearance of halos around objects and a yellow tint to
most objects. The nurse knows that these complaints are most often associated with:
a. cataracts.
b. glaucoma.
c. diabetic retinopathy.
d. age-related macular degeneration.

Answer 5

ANS: A
Signs of cataracts include the appearance of halos around objects as light is diffused, blurring, decreased perception of light and color giving a yellow tint to most objects, and a sensitivity
to glare.

Question 6

An older patient reports the following symptoms to a nurse during a routine visit to the geriatric clinic: blurry vision, the need for more light when reading, and blind spots in the
middle of his visual field. He also states, “Strangely enough my peripheral vision continues to
be pretty good.” The nurse suspects that the patient has which of the following?
a. Glaucoma
b. Age related macular degeneration
c. Diabetic retinopathy
d. Cataracts

Answer 6

ANS: B
Blurry vision, needing more light, and blind spots in the middle of the visual field (scotomas) are all characteristics of age related macular degeneration. The other three eye diseases do not present with these symptoms.

Question 7

A nurse is providing glaucoma education for a group of older adults in a senior center. The
nurse knows that the following groups are most likely to develop glaucoma. (Select all that
apply.)
a. African Americans
b. Mexican Americans
c. Individuals with a family history of glaucoma
d. Individuals with diabetes
e. Asian Americans

Answer 7

ANS: A, B, C, D
African Americans are at risk of developing glaucoma at an earlier age than other racial and ethnic groups. Mexican Americans, individuals with a family history of glaucoma, and
individuals with diabetes are among the other groups. Asian Americans are more
likely to lose eyesight from age-related macular degeneration than other groups.

Question 8

A nurse is performing preoperative teaching for an older adult who is scheduled to have a
cataract extraction and lens implant. The nurse includes which of the following in the teaching
plan? (Select all that apply.)
a. Avoid lifting heavy objects after the surgery
b. Avoid bending from the waist after the surgery
c. Take stool softeners as needed
d. Maintain strict control of your blood sugar and blood pressure
e. Maintain a dry sterile dressing over the eye for 10 days

Answer 8

ANS: A, B, C
Post cataract surgery the individual needs to avoid heavy lifting, straining, and bending from the waist. Fall prevention is also very important as is complying with eye drop administration.
Maintaining strict blood sugar and blood pressure control is most important for diabetic
retinopathy, not cataract extraction. There usually is not a dressing over the operative site, and not for 10 days.

Question 9

An older patient is diagnosed with diabetic retinopathy. The patient asks a nurse: “Is there
anything that I can do to prevent progression of this disease and blindness?” The nurse includes which of the following into the response? (Select all that apply.)
a. Strict control of blood glucose levels is important in slowing disease progression
b. Laser photocoagulation treatments can stop progression of the disease
c. Control of blood pressure and cholesterol levels are important steps slowing
disease progression
d. Wearing sunglasses to protect the eyes from ultraviolet light can stop disease progression
e. Eating a diet high in beta-carotene can stop disease progression

Answer 9

ANS: A, B, C
Constant strict control of blood pressure, blood glucose, and cholesterol and laser photocoagulation treatments can halt progression of the disease. Laser treatment can reduce
vision loss in 50% of patients. Neither protecting the eyes from ultraviolet light nor eating a diet high in beta-carotene has been proven to be effective in stopping disease progression.

Question 10

A nurse is conducting an assessment of an older patient’s eyes. The nurse expects to see
which of the following normal age-related changes of the external eye? (Select all that apply.)
a. The eyelids are less elastic and droopy
b. The eyes are very dry
c. The eyelids may not close completely
d. There is a loss of eyelashes
e. The lower lid may be turned outward

Answer 10

ANS: A, B, C, E
Normal age-related changes in the external eye include a loss of elasticity causing drooping. Eyes become drier, and the eyelids may not close completely. Decreases in orbital muscle strength may result in entropion, the outward turning of the lower lid. Loss of eyelashes is not
a normal age-related change.

Question 11

An older adult patient reports burning and itching eyes. On assessment, the nurse notes
swelling of the eyelid margins bilaterally. What additional data are necessary to confirm the
nurses suspicion of blepharitis?
a. The patient reports visual disturbances such as rainbow halos.
b. The eyelids are reddened from seborrhea.
c. The patient is being treated with anticoagulants.
d. Small corneal hemorrhages are present.

Answer 11

B - Blepharitis is a chronic inflammation of the eyelid margins that is commonly found in older
adults. It can be caused by seborrheic dermatitis or infection. The symptoms include red, swollen
eyelids, matting and crusting along the base of the eyelash at the margins, small ulcerations
along the lid margins, and complaints of irritation, itching, burning, tearing, and photophobia.
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Question 12

The morning of her scheduled cataract extraction and intraocular lens placement of the right
eye, an older adult patient expresses concern that she will not remember her instructions for
home care. Which statement is the best response to the patients concern?
a. Is your family going to be here while youre in surgery?
b. Are you anxious about the surgery?
c. Ill reinforce the important points.
d. We will provide you with written instructions

Answer 12

D - Postoperative care requires teaching the patient and family home care procedures for the period
after cataract surgery and should be given orally as well in written form. The patient may or may
not have family present. Asking about anxiety could be important, but yes/no questions are not
therapeutic. The nurses idea of what are the important points may differ from the patients.
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Question 13

Your 88-year-old patient is hospitalized for a retinal detachment. He is on bed rest, and both
eyes are covered with patches. Which nursing diagnosis takes priority at this time?
a. Self-esteem disturbance related to decreased independence
b. High risk for altered thought processes related to visual impairment
c. High risk for injury related to altered sensory perception
d. Impaired social interaction related to visual deficit

Answer 13

C - If the eyes are patched, safety precautions, such as keeping call lights, side rails, and necessary
items within reach, must be instituted. Finally, assistance must be provided with activities of
daily living (ADLs) and walking as needed to promote comfort and safety. The other diagnoses
may be appropriate for selected patients.
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Question 14

A 66-year-old patient has been diagnosed with type 2 diabetes mellitus and related vision loss.
Which statement demonstrates the ability to manage her condition?
a. I schedule my yearly eye examination for the week of my birthday.
b. When I notice haloes around lights, Ill know Im developing a problem with
retinopathy.
c. My sister had diabetic retinopathy, and the vessels in her eyes were scarred.
d. I understand that the eye problems need to be diagnosed with an ophthalmoscopic
exam.

Answer 14

A - Patients with diabetes should have a yearly examination by an ophthalmologist. Scheduling the
exam for the week of her birthday will keep the patient from forgetting to do so. The other
statements are not related to management.
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Question 15

A 77-year-old patient who is quiet and withdrawn may have a hearing deficit related to
impacted cerumen. During the nursing assessment, the nurse confirms supporting evidence of the
condition when noting:
a. frothy drainage from the patients ears.
b. patient reports of dizziness.
c. patient reports of a feeling of fullness in the ears.
d. gray, metallic-appearing tympanic membrane.

Answer 15

C - Patients with cerumen buildup may complain of ear fullness, itching, and difficulty hearing. The
patient will not have frothy drainage, dizziness, or metallic-appearing tympanic membrane from
cerumen.
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Question 16

An older adult patient reports ringing in the ears. What additional data should the nurse gather
to help determine the cause of the patients problem?
a. History of ear surgery
b. Use of prescription medications
c. Exercise and sleep patterns
d. Nutritional status, especially protein intake

Answer 16

B - Tinnitus can be a result of damage to inner structures caused by the toxic effect of certain drugs.
The other assessment findings are not as important for this problem.
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Question 17

An older patient with presbycusis has been advised to purchase a hearing aid and asks about
its function and use. Which information is most accurate to give the patient about the function of
hearing aids?
a. Hearing aids amplify sound but do not improve the ability to hear.
b. Hearing aids improve the ability to hear by intensifying the duration of sound
waves.
c. Hearing aids control the input of sound waves to eliminate extraneous noise.
d. Hearing aids intensify sound waves and improve the ability to hear

Answer 17

A - Hearing aids amplify sound but do not improve the ability to hear. The other statements are not
accurate regarding hearing aids.
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Question 18

An older adults chart documents that she has been diagnosed with macular dysequilibrium.
Based on an understanding of this condition and the resulting vertigo, the nurse suggests that the
patient:
a. turn her head very slowly when looking from right to left.
b. dangle her legs at the bedside before getting out of bed.
c. use the wall for stabilization when ambulating in the hallway.
d. be careful to be seated when flexing or hyperextending her neck

Answer 18

B - Macular disequilibrium is vertigo precipitated by a change of head position in relation to the
direction of gravitational force (e.g., severe dizziness when rising from bed). Dangling at the
bedside and changing positions slowly will decrease the chance of injury. The other interventions
do not relate to this disorder.
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Question 19

A 96-year-old patient reports symptoms of xerostomia. The nurse attempts to minimize the
effects of the condition by:
a. providing appropriate fluids with the patients meals.
b. cutting the patients meat into small bite-sized pieces.
c. elevating the head of the patients bed at mealtimes.
d. assisting the patient with oral care before each meal.

Answer 19

A - Xerostomia, commonly referred to as dry mouth, is a subjective sensation of abnormal oral
dryness. Reduced salivary flow is a common complaint of older adults. Dry mouth in the older
adult can lead to an increased risk of serious respiratory infection, impaired nutritional status,
and reduced ability to communicate. Offering appropriate fluids with meals will assist with
proper nutrition. The other options will not provide relief for this condition.
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Question 20

The preferred way for the nurse to communicate with a 72-year-old hearing-impaired patient
is to:
a. speak loudly into the patients unaffected ear.
b. exaggerate the form of each word.
c. provide all communication in written form.
d. speak clearly and directly, facing the person.

Answer 20

D - Interventions for the patient with a hearing impairment focus on aural rehabilitation and
facilitation of communication. Patients should be spoken to using a clear voice and face to face,
which gives the patient an unobstructed view of the speakers face and lips. The other techniques
are not as helpful.
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Question 21

A patient in a nursing home is confused, nonverbal, but pleasant. The nurse notes the patient
has suddenly become agitated and is screaming and scratching at the eyes. While the nurse is
examining the patient, the patient vomits. What action by the nurse is best?
a. Consult the provider about an ophthalmologic exam.
b. Sedate the patient so she wont injure herself.
c. Place mitts on the patients hands to avoid scratches.
d. Give the patient a prn medication for pain.

Answer 21

A - The patient could be having an episode of acute angle closure glaucoma, manifested by severe
pain, nausea and vomiting, and visual disturbances. Because the patient is nonverbal, the nurse
must assess for pain with behavioral changes. The nurse should contact the provider about
obtaining an ophthalmologic exam to determine if the patient has glaucoma. The other
interventions will not help determine the cause of the problem. The nurse should attempt to
discover the source of the behavior, not just try to control it.

Question 22

A patient has been admitted to the postanesthesia care unit after a trabeculectomy. What
assessment takes priority?
a. Airway
b. Pain
c. Eye patch
d. Blood pressure

Answer 22

A -
Airway always comes first when prioritizing care.
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Question 23

A patient had cataract surgery without a lens implant. What teaching point is most important?

a. Keep your follow-up appointment with the surgeon.
b. Instill your eyedrops just like we have practiced.
c. Do not drive and be careful going up or down stairs.
d. Take acetaminophen (Tylenol) for pain.

Answer 23

C - If cataract surgery was performed without a lens implant, the patient will wear glasses or contact
lenses but will have a decrease in depth perception. The patient should not drive and should use
extra caution negotiating stairs. The other instructions are appropriate for any patient having
cataract surgery.
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Question 24

A patient has Mnire disease. What statement by the patient indicates a good ability to manage
the condition?
a. Because its from dehydration, I can increase salt in my food.
b. There are no medications, so I just have to learn to live with it.
c. If I get dizzy I should lie down immediately and hold my head still.
d. Because I have asthma, I cannot take any medications for Mnire disease.

Answer 24

C - If the patient gets dizzy, he or she should lie down and hold the head still. A low-salt diet may
help with fluid retention in the ear. There are several medications for Menire disease, but
because of the anticholinergic properties of some of them, people with asthma, glaucoma, or
BPH should be monitored closely.
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Question 25

A patient had a chemical splash into the eye at work. What action by the occupational health
nurse takes priority?
a. Begin flushing the patients eye with cool water.
b. Call emergency medical services.
c. Ask about the patients tetanus status.
d. Tape the eye closed to prevent injury.

Answer 25

A - The nurse should begin flushing the eye immediately. While the eye is being irrigated, the nurse
can call 9-1-1 and inquire about the patients last tetanus shot. The eye should not be taped shut.
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Question 26

A patient with glaucoma is on timolol (Timoptic). The patient also takes metoprolol (Toprol)
for hypertension. The patient reports to the clinic nurse that the eyedrops Make me dizzy. What
assessment by the nurse is most appropriate?
a. Assess the patients eyedrop instillation technique.
b. Determine how long the patient has been on the drops.
c. Assess the patients gait and balance while walking.
d. Ask the patient if breakfast is eaten prior to applying the eyedrops.

Answer 26

A - The patient should be using punctal occlusion (closing the lacrimal duct) when instilling these
eyedrops to avoid a cumulative, systemic effect from the combination of both beta-blockers. The
nurse can assess the other factors as well, but this is the most likely cause of the dizziness.
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Question 27

When assessing the patients vision, the nurse should understand that older adults may report
common aging changes, including which of the following? (Select all that apply.)
a. My eyelids droop so unattractively.
b. The whites on my eyes seem a bit yellow.
c. The vision in my right eye seems blurry.
d. Ive started to use over-the-counter eye moisturizing drops.
e. I have noticed the night driving has become more difficult.

Answer 27

A,B,D,E - The eyelids lose tone and become lax, which may result in ptosis of the eyelids, redundancy of
the skin of the eyelids, and malposition of the eyelids. The conjunctiva thins and yellows in
appearance. In addition, this membrane may become dry because of the diminished quantity and
quality of tear production. Peripheral vision decreases, night vision diminishes, and sensitivity to
glare increases.
DIF: Analysis (Analyze) REF: N/A
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Question 28

An older adult diagnosed with Mnire disease is prescribed meclizine (Antivert) and
hydrochlorothiazide (HCTZ). The nurses educational instructions include which of the
following? (Select all that apply.)
a. The need to avoid alcoholic beverages
b. Instructions to take the medication with food
c. Symptoms of electrolyte imbalances
d. That drowsiness is a common side effect
e. Stopping the medication if chest pain occurs

Answer 28

A,C,D - Meclizine may cause drowsiness; patients should be instructed to avoid alcoholic beverages
while taking this drug. A patient on a diuretic such as hydrochlorothiazide (HCTZ) needs to be
monitored for evidence of fluid or electrolyte imbalances.
DIF: Application (Apply) REF: N/A
TOP: Nursing Process: Implementation| Drug-Related Responses
MSC: Safe and Effective Care Environment

Question 29

Which of the following are appropriate steps to take when removing cerumen from an older
persons ear? (Select all that apply.)
a. Instill a softening agent first.
b. Use hot water and hydrogen peroxide.
c. Use a Waterpik inserted just inside the meatus.
d. Have the patient lean backward.
e. Drain water by having the patient lean forward toward the affected side.

Answer 29

A,C,E - The nurse instills a softening agent and uses warm (not hot) water mixed with hydrogen peroxide
or saline to irrigate the ear. A Waterpik or other irrigating equipment is used and is inserted just
inside the meatus so the tip is still visible. Tip the patients head toward the side being irrigated.
When draining, the patient can lean forward and toward the affected side.
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Question 30

A nurse is assessing a patient who reports moderate tinnitus. The nurse should assess the
patient for which of the following? (Select all that apply.)
a. Use of ibuprofen (Motrin)
b. History of excessive cerumen
c. Drinking carbonated beverages
d. History of frequent headaches
e. Presence of hypertension

Answer 30

A,B,D,E - Beverages with caffeine are assessed; the patient may be drinking decaffeinated cola products.
The other assessments are appropriate.

Question 31

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
b. Impaired near vision
c. Slightly shaking hands
d. Use of contact lenses

Answer 31

ANS: A
Antibiotic eyedrops are often needed every hour for the first 24 hours for corneal ulceration. The client who uses sleeping pills may not wake up each hour or may awaken unable to perform this task. This client might
need someone else to instill the eyedrops hourly. Impaired near vision and shaking hands can both make administration of eyedrops more difficult but are not the most likely barriers. Contact lenses should be
discarded.

Question 32

An older client has decided to give up driving due to cataracts. What assessment information is most important to collect?

a. Family history of visual problems
b. Feelings related to loss of driving
c. Knowledge about surgical options
d. Presence of family support

Answer 32

ANS: B
Loss of driving is often associated with loss of independence, as is decreasing vision. The nurse should assess
how the client feels about this decision and what its impact will be. Family history and knowledge about surgical options are not related as the client has made a decision to decline surgery. Family support is also useful information, but it is most important to get the clients perspective on this change.

Question 33

A client is in the preoperative holding area waiting for cataract surgery. The client says Oh, yeah, I forgot to
tell you that I take clopidogrel, or Plavix. What action by the nurse is most important?
a. Ask the client when the last dose was.
b. Check results of the prothrombin time (PT) and international normalized ratio (INR).
c. Document the information in the chart.
d. Notify the surgeon immediately.

Answer 33

ANS: D
Clopidogrel is an antiplatelet aggregate and could increase bleeding. The surgeon should be notified immediately. The nurse should find out when the last dose of the drug was, but the priority is to notify the provider. This drug is not monitored with PT and INR. Documentation should occur but is not the priority.

Question 34

4. 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.
   b. Glaucoma always leads to permanent blindness.
   c. The traumatic damage to your eye was too great.
   d. The infection occurs so quickly it cant be treated.

Answer 34

ANS: A
Glaucoma is caused when the intraocular pressure becomes too high and stays high long enough to cause tissue ischemia and death. At that point, vision loss is permanent. Glaucoma does not have to cause blindness. Trauma can cause glaucoma but is not the most common cause. Glaucoma is not an infection.

Question 35

A clients intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best?

a. Educate the client on corneal transplantation.
b. Facilitate scheduling the eye surgery.
c. Plan to teach about drugs for glaucoma.
d. Refer the client to local Braille classes.

Answer 35

ANS: C
This increased IOP indicates glaucoma. The nurses main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time.

Question 36

A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important?

a. Avoid reading, writing, or close work such as sewing.
b. Dim the lights in your house for at least a week.
c. Keep the follow-up appointment with the ophthalmologist.
d. Remove your eye patch every hour for eyedrops.

Answer 36

ANS: A
After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because they cause rapid eye movements. Dim lights are not indicated. Keeping a postoperative appointment is important for any surgical client. The eye patch is not removed for eyedrops.

Question 37

A client has been taught about retinitis pigmentosa (RP). What statement by the client indicates a need for further teaching?

a. Beta carotene, lutein, and zeaxanthin are good supplements.
b. I might qualify for a retinal transplant one day soon.
c. Since Im going blind, sunglasses are not needed anymore.
d. Vitamin A has been shown to slow progression of RP.

Answer 37

ANS: C

Sunglasses are needed to prevent the development of cataracts in addition to the RP. The other statements are accurate.

Question 38

A client has a foreign body in the eye. What action by the nurse takes priority?

a. Administering ordered antibiotics
b. Assessing the clients visual acuity
c. Obtaining consent for enucleation
d. Removing the object immediately

Answer 38

ANS: A
To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

Question 39

A client who is near blind is admitted to the hospital. What action by the nurse is most important?

a. Allow the client to feel his or her way around.
b. Let the client arrange objects on the bedside table.
c. Orient the client to the room using a focal point.
d. Speak loudly and slowing when talking to the client.

Answer 39

ANS: C
Using a focal point, orient the client to the room by giving descriptions of items as they relate to the focal point. Letting the client arrange the bedside table is a good idea, but not as important as orienting the client to the room for safety. Allowing the client to just feel around may cause injury. Unless the client is also hearing impaired, use a normal tone of voice.

Question 40

A client had proxymetacaine (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.
b. Monitor the eye for any bleeding for the next day.
c. Rinse the eye with warm saline solution at home.
d. Use all the eyedrops as prescribed until they are gone.

Answer 40

ANS: A
This drug is an ophthalmic anesthetic. The client can injure the numb eye by touching or rubbing it. Bleeding is not associated with this drug. The client should not be told to rinse the eye. This medication was given in the emergency department and is not prescribed for home use.

Question 41

A client is taking timolol (Timoptic) eyedrops. The nurse assesses the clients pulse at 48 beats/min. What action by the nurse is the priority?

a. Ask the client about excessive salivation.
b. Assess the client for shortness of breath.
c. Give the drops using punctal occlusion.
d. Hold the eyedrops and notify the provider.

Answer 41

ANS: D
The nurse should hold the eyedrops and notify the provider because beta blockers can slow the heart rate. Excessive salivation can occur with cholinergic agonists. Shortness of breath is not related. If the drops are given, the nurse uses punctal occlusion to avoid systemic absorption

Question 42

A client has been prescribed brinzolamide (Azopt). What assessment by the nurse requires consultation with the provider?

a. Allergy to eggs
b. Allergy to sulfonamides
c. Use of contact lenses
d. Use of beta blockers

Answer 42

ANS: B
Brinzolamide is similar to sulfonamides, so an allergic reaction could occur. The other assessment findings are not related to brinzolamide.

Question 43

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?

a. Administer a tetanus booster shot.
b. Ensure the client has a patent airway.
c. Prepare to irrigate the clients eye.
d. Turn the client on the unaffected side.

Answer 43

ANS: B
Airway always comes first. After ensuring a patent airway and providing cervical spine precautions (do not turn the client to the side), the nurse provides other care that may include administering a tetanus shot. The clients eye may or may not be irrigated.

Question 44

A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first?

a. Client with intraocular pressure reading of 24 mm Hg
b. Client who has had cataract surgery and has worsening vision
c. Client whose red reflex is absent on ophthalmologic examination
d. Client with a tearing, reddened eye with exudate

Answer 44

ANS: B
After cataract surgery, worsening vision indicates an infection or other complication. The nurse should see this client first. The intraocular pressure is slightly elevated. An absent red reflex may indicate cataracts. The client who has the tearing eye may have an infection.

Question 45

The nurse working in the ophthalmology clinic sees clients with eyelid and eye problems. What information should the nurse understand about these disorders? (Select all that apply.)

a. A chalazion is an inflammation of an eyelid sebaceous gland.
b. An ectropion is the eyelid turning inward.
c. An entropion is the eyelid turning outward.
d. A hordeolum is an infection of the eyelid sweat gland.
e. Keratoconjunctivitis sicca is caused by drugs or diseases.

Answer 45

ANS: A, D, E
A chalazion is an inflammation of one of the sebaceous glands in the eyelid. A hordeolum is an infection of a sweat gland in the eyelid. Keratoconjunctivitis sicca can be caused by drugs or diseases. An ectropion is an outward turning and sagging eyelid, while an entropion is an inward turning of the eyelid.

Question 46

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? (Select all that apply.) a. As long as I don’t wipe my eyes, I can share my towel.

b. Eye irrigations should be done with warm saline or water.
c. I will throw away all my eye makeup when I get home.
d. I wont touch the tip of the eyedrop bottle to my eye.
e. When the infection is gone, I can use my contacts again.

Answer 46

ANS: C, D
Bacterial conjunctivitis is very contagious, and re-infection or cross-contamination between the clients eyes is possible. The client should discard all eye makeup being used at the time the infection started. When instilling eyedrops, the client must be careful not to contaminate the bottle by touching the tip to the eye or face. The client should be instructed not to share towels. Eye irrigations are not needed. Contacts being used when the infection first manifests also need to be discarded.

Question 47

A client had cataract surgery. What instructions should the nurse provide? (Select all that apply.) a. Call the doctor for increased pain.

b. Do not bend over from the waist.
c. Do not lift more than 10 pounds.
d. Sexual intercourse is allowed.
e. Use stool softeners to avoid constipation.

Answer 47

ANS: A, B, C, E
The client should be taught to call the physician for increased pain as this might indicate infection or other complication. To avoid increasing intraocular pressure, clients are taught to not lift more than 10 pounds, to avoid bending at the waist, to avoid straining at stool, and to avoid sexual intercourse for a time after surgery.

Question 48

A nurse has delegated applying a warm compress to a clients eye. What actions by the unlicensed assistive personnel (UAP) warrant intervention by the nurse? (Select all that apply.)

a. Heating the wet washcloth in the microwave
b. Holding the cloth on the client using an Ace wrap
c. Turning the cloth so it remains warm on the client
d. Using a clean washcloth for the compress
e. Washing the hands on entering the clients room

Answer 48

ANS: A, B
The washcloth should be warmed under running warm water. Microwaving it can lead to burns. Gentle pressure is used to hold the compress in place. The other actions are correct.