During a routine eye examination, an older client reports decreased peripheral vision and is found to have elevated intraocular pressures. Ophthalmic drops are prescribed for primary open-angle glaucoma (POAG). Which intervention(s) should the nurse include in this client's plan of care? Select all that apply.
Review written and verbal instructions for a reduced sodium diet.
Teach strategies for aseptic administration of the eye drops.
Describe how the use of the eye drops will help improve peripheral vision.
Teach to apply pressure over the inner eye corner after eye drops.
Explain the need to continue eye drops for the rest of their life.
Correct Answer : B,D,E
Choice A reason: Reviewing written and verbal instructions for a reduced sodium diet is not directly related to the management of primary open-angle glaucoma (POAG). While a healthy diet can contribute to overall well-being, dietary sodium does not have a significant impact on intraocular pressure or glaucoma management. Therefore, this intervention does not directly address the client's primary condition of POAG.
Choice B reason: Teaching strategies for aseptic administration of the eye drops is a critical intervention for clients with POAG. Proper administration of ophthalmic drops is essential to avoid contamination and infection. Aseptic techniques include washing hands before administering the drops, avoiding touching the dropper tip to any surface (including the eye), and ensuring that the dropper cap is replaced tightly after use. These measures help maintain the sterility of the medication and prevent complications such as eye infections, which can exacerbate the client's condition.
Choice C reason: Describing how the use of the eye drops will help improve peripheral vision is not entirely accurate in the context of POAG. The primary goal of ophthalmic drops for POAG is to lower intraocular pressure and prevent further damage to the optic nerve, thereby preserving the remaining vision. These drops do not typically improve peripheral vision that has already been lost. Educating the client with accurate information about the purpose and benefits of the drops helps set realistic expectations and encourages adherence to the treatment regimen.
Choice D reason: Teaching the client to apply pressure over the inner eye corner (punctal occlusion) after administering eye drops is an important intervention. Punctal occlusion helps prevent the medication from draining into the tear duct and being absorbed systemically. This technique increases the contact time of the medication with the eye, enhancing its effectiveness and reducing potential systemic side effects. Clients should be instructed to gently press the inner corner of the eye for a few minutes after instilling the drops to ensure maximum benefit.
Choice E reason: Explaining the need to continue eye drops for the rest of their life is essential for clients with POAG. Glaucoma is a chronic condition that requires lifelong management to control intraocular pressure and prevent progression of the disease. Discontinuing the medication can lead to elevated intraocular pressures and irreversible vision loss. Clients should understand the importance of adherence to their prescribed treatment regimen and the lifelong commitment to managing their condition to preserve their vision and quality of life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Reports of a bad taste in the mouth can be associated with various conditions, including metabolic imbalances, but it is not typically an immediate concern in the context of AKI.
Choice B reason: Low concentrated urine output (oliguria) is a common finding in AKI and indicates decreased kidney function. While it is an important assessment finding, it does not usually require immediate intervention compared to signs of severe complications.
Choice C reason: Dyspnea (difficulty breathing) and sinus tachycardia (rapid heart rate) can indicate fluid overload or pulmonary edema, which are serious complications of AKI. These symptoms require immediate intervention to prevent respiratory distress and potential cardiac complications.
Choice D reason: A productive cough and fever may suggest an infection, which is important to address but not necessarily an immediate life-threatening issue compared to dyspnea and tachycardia in the context of AKI.
Correct Answer is D
Explanation
Choice A reason: Biliary duct obstruction can cause symptoms similar to those described, such as abdominal pain and vomiting. However, the key indicators of acute pancreatitis are the elevated serum amylase and lipase levels, which are significantly higher than normal. These enzymes are typically elevated in cases of pancreatitis, making this the more accurate diagnosis.
Choice B reason: Surgical site infection could cause fever and pain, but it would not typically result in elevated serum amylase and lipase levels. These enzymes are specific to pancreatic inflammation and damage, which is characteristic of acute pancreatitis. Therefore, surgical site infection is less likely given the lab results.
Choice C reason: Hepatorenal failure involves liver and kidney dysfunction, which can present with various symptoms, including abdominal pain and vomiting. However, it does not typically cause a significant increase in serum amylase and lipase levels. These elevated levels are more indicative of pancreatic inflammation, pointing towards acute pancreatitis.
Choice D reason: Acute pancreatitis is characterized by upper abdominal pain radiating to the back, vomiting, fever, and significantly elevated serum amylase and lipase levels. These symptoms and lab results align with the diagnosis of acute pancreatitis, making it the correct choice.
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