The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately?
1. Notify the physician.
2. Apply ice to the affected eye.
3. Irrigate the eye with cool water.
4. Accompany the client to the emergency department.
Contusions
Description
Bleeding into the soft tissue as a result of an injury.
A contusion causes a black eye; the discoloration disappears in about 10 days.
Pain, photophobia, edema, and diplopia may occur.
Interventions
Place ice on the eye immediately.
Instruct the client to receive a thorough eye examination.
The client arrives in the emergency department 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?
1. Flat on bedrest
2. Semi-Fowler’s on bedrest
3. Lateral on the affected side
4. Lateral on the unaffected side
Hyphema
Description
Presence of blood in the anterior chamber that occurs as a result of an injury
The condition usually resolves in 5 to 7 days.
Interventions
Encourage rest with the client in a semi-Fowler’s position.
Avoid sudden eye movements for 3 to 5 days to decrease the likelihood of bleeding.
Administer cycloplegic eye drops as prescribed to relax the eye muscles and place the eye at rest.
Instruct the client in the use of eye shields or eye patches as prescribed.
Instruct the client to restrict reading and limit watching television.
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:
1. Diplopia
2. Eye pain
3. Floating spots
4. Blurred vision
Cataracts
Description
A cataract is an opacity of the lens that distorts the image projected onto the retina and that can progress to blindness.
Causes include the aging process (senile cataracts), inherited (congenital cataracts), and injury (traumatic cataracts); cataracts also can result from another eye disease (secondary cataracts).
Causes of secondary cataracts include diabetes mellitus, maternal rubella, severe myopia, ultraviolet light exposure, and medications such as corticosteroids.
Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affects his or her lifestyle.
Assessment
Blurred vision and decreased color perception are early signs
Diplopia, reduced visual acuity, absence of the red reflex, and the presence of a white pupil are late signs. Pain or eye redness is associated with age-related cataract formation.
Loss of vision is gradual.
Interventions
Surgical removal of the lens, one eye at a time, is performed.
With extracapsular extraction, the lens is lifted out without removing the lens capsule; the procedure may be performed by phacoemulsification, in which the lens is broken up by ultrasonic vibrations and extracted.
With intracapsular extraction, the lens and capsule are removed completely.
A partial iridectomy may be performed with the lens extraction to prevent acute secondary glaucoma.
A lens implantation may be performed at the time of the surgical procedure.
The client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client complaint associated with a disorder involving this part of the ear?
1. Pruritus
2. Tinnitus
3. Hearing loss
4. Burning in the ear
Inner ear
The inner ear contains the semicircular canals, cochlea, and distal end of the eighth cranial nerve.
The semicircular canals contain fluid and hair cells connected to sensory nerve fibers of the vestibular portion of the eighth cranial nerve.
The inner ear maintains sense of balance or equilibrium.
The cochlea is the spiral-shaped organ of hearing.
The organ of Corti (within the cochlea) is the receptor and organ of hearing.
Eighth cranial nerve
The cochlear branch of the nerve transmits neuroimpulses from the cochlea to the brain, where they are interpreted as sound.
The vestibular branch maintains balance and equilibrium.
The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which of the following would the nurse expect to observe?
1. A pink-colored tympanic membrane
2. A pearly colored tympanic membrane
3. A transparent and clear tympanic membrane
4. A red, dull, thick, and immobile tympanic membrane
Otoscopic examination
The client’s head is tilted slightly away and the otoscope is held upside down as if it were a large pen; this permits the examiner’s hand to lay against the client’s head for support.
In an adult, pull the pinna up and back to straighten the external canal.
Visualize the external canal while slowly inserting the speculum.
The normal external canal is pink and intact, without lesions and with varying amounts of cerumen and fine little hairs.
Assess the tympanic membrane for intactness; the normal tympanic membrane is intact, without perforations, and should be free from lesions.
The tympanic membrane is transparent, opaque, pearly gray, and slightly concave.
A fluid line or the presence of air bubbles is not normally visible.
If the tympanic membrane is bulging or retracting, the edges of the light reflex will be fuzzy (diffuse) and may spread over the tympanic membrane.
The otoscope is never introduced blindly into the external canal because of the risk of perforating the tympanic membrane.