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 D
Explanation
Choice A reason: Osmolarity is a measure of the concentration of solutes in the blood. While it can be important in certain contexts, it is not the primary concern when monitoring a client with Addison's disease who is on hydrocortisone therapy.
Choice B reason: Platelets are a component of blood involved in clotting. Monitoring platelet count is important in certain conditions, but it is not the primary focus for a client with Addison's disease on hydrocortisone therapy.
Choice C reason: Albumin is a protein in the blood that helps maintain osmotic pressure and transport substances. While it is important to monitor albumin levels in some conditions, it is not the primary concern for a client with Addison's disease on hydrocortisone therapy.
Choice D reason: Glucose levels are crucial to monitor in clients with Addison's disease on hydrocortisone therapy. Hydrocortisone can affect glucose metabolism, potentially leading to hyperglycemia. Monitoring glucose levels helps ensure that the client's blood sugar remains within a safe range and allows for timely intervention if necessary.
Correct Answer is B
Explanation
Choice A reason: Jugular vein distension is often associated with right-sided heart failure, where the right ventricle fails to pump effectively, leading to increased pressure in the veins and fluid backup. While it can occur in advanced cases of left ventricular dysfunction, it is not as directly indicative as lower extremity edema.
Choice B reason: Lower extremity edema is a common finding in left ventricular dysfunction. When the left ventricle fails to pump blood efficiently, it leads to a buildup of fluid in the lungs and eventually in the extremities. This results in swelling, particularly in the lower legs and feet. This symptom is a key indicator of congestive heart failure.
Choice C reason: Hepatomegaly, or enlargement of the liver, is more commonly associated with right-sided heart failure due to congestion of blood flow in the liver. While it can occur in severe cases of left ventricular dysfunction, it is not as typical an initial finding as lower extremity edema.
Choice D reason: Fatigue is a non-specific symptom that can be associated with various conditions, including heart failure. However, it is not as immediately indicative of left ventricular dysfunction as lower extremity edema, which is more directly related to the underlying issue of fluid retention and heart failure.
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