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: Encouraging deep breathing and coughing exercises is generally important postoperatively to prevent respiratory complications. However, it is not specific to eye surgery and does not address the immediate care needs following the removal of glass from the eye.
Choice B reason: Obtaining vital signs every 2 hours during hospitalization is a standard postoperative procedure to monitor for complications. While important, it is not an intervention specific to eye surgery and does not directly address the protection and care of the operated eye.
Choice C reason: Providing an eye shield to be worn while sleeping is a crucial intervention immediately following eye surgery. The eye shield protects the operated eye from accidental injury, rubbing, or pressure during sleep. This helps to prevent complications and promotes healing by keeping the eye safe from potential harm while the client is unaware.
Choice D reason: Teaching a family member to administer eye drops is important for ongoing postoperative care. However, it is not the immediate priority following the surgery. The first step is to ensure the protection of the eye, which can be achieved by providing an eye shield. Teaching about eye drop administration can be done later as part of the discharge instructions.
Correct Answer is B
Explanation
Choice A reason: A cerebrovascular accident (CVA), commonly known as a stroke, occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. Although a severe headache might be a symptom of a stroke, it does not typically present with fever, nuchal rigidity, and a petechial rash, which are more indicative of an infection or inflammatory process.
Choice B reason: Meningococcal meningitis is a bacterial infection that causes inflammation of the membranes covering the brain and spinal cord. Symptoms often include a severe headache, fever, neck stiffness (nuchal rigidity), and a petechial rash, which is a distinguishing feature. This condition is a medical emergency and requires prompt antibiotic treatment to prevent serious complications or death.
Choice C reason: Intracerebral hemorrhage is bleeding within the brain tissue itself, which can be caused by various factors such as hypertension, aneurysms, or trauma. While it can cause a severe headache and neurological symptoms, it does not typically present with fever, nuchal rigidity, and a petechial rash, which suggest an infectious etiology rather than a hemorrhagic one.
Choice D reason: Rocky Mountain spotted fever is a tick-borne illness caused by the bacterium Rickettsia rickettsii. It can present with fever, headache, and a rash, but the rash is typically more generalized and not petechial. Additionally, the presence of nuchal rigidity and severe headache are more characteristic of meningitis rather than Rocky Mountain spotted fever.
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