A client has angle-closure glaucoma. Once the intraocular pressure has been temporarily reduced, an iridectomy is performed. When the nurse assesses the operative eye following surgery, which finding is most expected?
The pupil appears cloudy and gray.
The pupil is a fixed size and shape.
There is absence of colored area of the iris.
A section of the iris appears black.
The Correct Answer is C
Angle-closure glaucoma is an acute, vision-threatening condition caused by sudden blockage of aqueous humor flow, leading to rapid increases in intraocular pressure. After an iridectomy, a portion of the iris is surgically removed to create an opening for fluid drainage. The absence of colored iris tissue at the surgical site is an expected finding postoperatively. The nurse should monitor for normal healing and potential complications while recognizing this expected change.
Rationale for correct answer:
3. There is absence of colored area of the iris: During iridectomy, a small section of the iris is removed, resulting in a visible area where the colored iris is absent, which is normal post-surgery.
Rationale for incorrect answers:
1. The pupil appears cloudy and gray: Cloudiness or graying may indicate corneal edema or infection, which is not an expected finding.
2. The pupil is a fixed size and shape: Pupillary fixation can indicate iris or nerve damage, which is abnormal after iridectomy.
4. A section of the iris appears black: A black area is not normal; the operative site should show absence of colored iris, not blackened tissue.
Take home points
- Post-iridectomy: absence of colored iris tissue at surgical site.
- Monitor for signs of complications such as infection, bleeding, or corneal edema.
- Expected pupil changes include a small opening in the iris, not cloudiness or blackening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Cataract surgery is generally safe, and clients are expected to have mild discomfort postoperatively, but severe eye pain and nausea are abnormal findings. These symptoms may indicate increased intraocular pressure (IOP) or other complications such as hemorrhage. Because of the risk of permanent vision loss, immediate reporting to the provider is essential. Nurses must differentiate between expected mild discomfort and dangerous postoperative signs.
Rationale for correct answer:
1. Notify the provider: Severe eye pain and nausea can signal increased IOP or hemorrhage, which are surgical emergencies. Prompt notification of the provider is the priority nursing action to prevent complications.
Rationale for incorrect answers:
2. Administer an analgesic: Analgesics may relieve pain but do not address the underlying cause of increased IOP. Administering an analgesic is not the priority nursing action in this situation.
3. Administer an antiemetic: Nausea may be present, but the cause is likely related to eye complications, not the stomach. Administering an antiemetic is not the priority nursing action here.
4. Turn the client onto the operative side: Positioning does not resolve severe pain and nausea from eye pressure. Turning the client is not the priority nursing action after cataract surgery.
Take home points
- Severe eye pain and nausea after cataract surgery are abnormal.
- They may indicate increased IOP or hemorrhage.
- The nurse must notify the provider immediately rather than masking symptoms with medications.
Correct Answer is ["A","B","C","D"]
Explanation
When a client reports constant itchiness in one eye, the nurse should ask focused questions to determine the cause and rule out conditions such as allergies, infection, or irritation. Key questions include asking about history of similar symptoms, duration, involvement of the other eye, and any associated drainage. These help identify whether the problem is acute, chronic, allergic, or infectious in nature.
Rationale for correct answers:
1. Has this happened before? Asking about recurrence helps identify if the issue is chronic, seasonal, or related to allergies.
2. How long have you had this problem? Duration helps determine whether the condition is acute or long-standing, guiding diagnosis.
3. Is the other eye ever itchy? Involvement of both eyes suggests allergic or systemic causes, while one eye may suggest localized irritation or infection.
4. Is there any drainage? Drainage can indicate infection or allergic response, making this a critical question.
Rationale for incorrect answer:
5. Do any family members have eye conditions? Family history is important for chronic diseases like glaucoma or macular degeneration, but it does not provide direct information about acute eye itchiness.
Take home points
- Key assessment questions → onset, duration, recurrence, involvement of both eyes, presence of drainage.
- Family history is useful for chronic eye conditions, not acute itching.
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