NCLEX Review About The Aging Eye (31-35)

NCLEX Review About The Aging Eye

31. The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment?

a) total loss of vision
b) a reddened conjunctiva
c) a sudden sharp pain in the eye
d) complaints of a burst of black spots or floaters

32. The client arrives in the emergency room following an automobile accident. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse places the client in which position?

a) flat on bed rest
b) semi-fowler's on bed rest
c) lateral on the affected side
d) lateral on the unaffected side



33. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately?

a) notify the physician
b) apply ice to the affected eye
c) irrigate the eye with cool water
d) accompany the client to the emergency room

34. The client arrives in the emergency room with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding form the eye. What is the initial nursing action?

a) apply an eye patch
b) perform visual acuity tests
c) irrigate the eye with sterile saline
d) remove the piece of wood using a sterile eye clamp

35. The client arrives in the emergency room after sustaining a chemical eye injury from a splash of battery acid. The initial nursing action is to:

a) begin visual acuity testing
b) cover the eye with a pressure patch
c) swab the eye with antibiotic ointment
d) irrigate the eye with sterile normal saline




NCLEX Review About The Aging Eye:
ANSWERS AND RATIONALE

31) D

- Complaints of a sudden burst of black spots or floaters indicates that bleeding has occurred as a result of the detachment. Options A, B, and C are not signs of bleeding.

32) B

- A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler’s position to assist gravity in keeping the hyphema away from the optical center of the cornea.

33) B

- Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries.

34) B

- If the laceration is the result of a penetrating injury, an object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea.

35) D

- Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the emergency department, the irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed. Options B and C are not a component of initial care.


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