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HESI: Mrs Hoffman

Terms in this set (26)

You are a nurse who works in the Eye, Ear, Nose, and Throat (EENT) Clinic and in the Same-Day Surgery Center.
Mrs. Sylvia Hoffman arrives at the clinic for her first appointment with the ophthalmologist. Mrs. Hoffman informs you that her healthcare provider (HCP) suspects the formation of a cataract in her left eye.
Mrs. Hoffman is alert and oriented to person, time, and place. She maintains good eye contact, and she readily answers your admission questions. She tells you that she is anxious about the appointment because she doesn't want her eye condition to interfere with her independent lifestyle. At 75 years old, Mrs. Hoffman is extremely active.
1. You obtain assessment data from Mrs. Hoffman, taking note of risk factors that could predispose a person to cataract formation. Which of the condition could increase Mrs. Hoffman's risk for cataracts?

- Diabetes
- Myopia
- Bifocal use
- Obesity
- Diabetes

People with diabetes are predisposed to cataracts. Sorbitol, a byproduct of excess glucose, can accumulate within the lens, attracting water and clouding the lens. People with diabetes develop cataracts at a younger age than persons without diabetes. When cataracts appear, they quickly progress. Cataracts may also be associated with aging, genetic factors, smoking, hypothyroidism, exposure to radiation or ultraviolet sunlight, retinal detachment, electrical shock, eye trauma, glaucoma surgery, and long-term corticosteroid use.
Most cataracts are a result of aging, usually forming after age 70. Age-related degeneration of the lens fibers result in the breakdown of molecules small enough to exert osmotic effects and attract water into the lens. This causes a clouding and may interfere with light transmission.
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2. While you interview Mrs. Hoffman, you also inspect the condition of both eyes. Which objective sign is consistent with a cataract?

- Drainage from the left eye
- Redness in the left eye
- Constriction of the left pupil
- Grey color of the left pupil
- Grey color of the left pupil

As the crystalline lens becomes increasingly opaque as a consequence of a cataract, the color of the lens changes from black to opaque. Greying of Mrs. Hoffman's pupil is noted.
3. As you continue to interview Mrs. Hoffman, she asks you what a cataract is and what causes it. Which explanation is accurate?

- "Chemical changes in the lens cause it to become cloudy."
- "A cloudy membrane grows over the lens and blocks entry of light."
- "The lens hardens, requiring its removal and replacement."
- "Cholesterol plaques build up on the lens, causing it to become cloudy."
- "Chemical changes in the lens cause it to become cloudy."

With a cataract, chemical changes in the lens (alteration of metabolism and transport of nutrients) create a cloudiness that causes the lens to no longer be transparent.
4. Which symptoms would the nurse expect Mrs. Hoffman to report that are consistent with lens changes found in cataracts?

- Periocular pain
- Seeing floating particles
- Diplopia
- Cloudy vision
- Cloudy vision

Normally, the lens changes shape to focus rays of light on the retina. With a cataract, the lens loses its transparency. Entry of light into the eye is impeded and vision becomes cloudy, especially at night or in bright light. Glare testing is usually part of vision testing for cataracts.
The ophthalmologist examines Mrs. Hoffman and confirms that she has a cataract of the left eye and recommends that the opacified lens be removed and replaced with an artificial lens implant.
Cataract removal surgeries include extraction of the cataract made by a small incision followed by the implantation of a prosthetic intraocular lens. Lenses have the power calculated based on the size of the eye and the curvature of the cornea, usually to correct for distance vision.
Mrs. Hoffman's surgery will be performed as an outpatient procedure at the Same-Day Surgery Center.
You schedule Mrs. Hoffman for testing to be done before surgery. Special testing is needed to determine the size and type of intraocular implant needed.
Mrs. Hoffman is given a prescription for antibiotic eye drops, which she will need to use starting three days before surgery.
Mrs. Hoffman asks you about anesthesia. You advise her that cataract surgery is commonly performed using local anesthesia that is instilled directly into the eye. An IV may be used to administer fluids and light sedation or other medication as needed. If she is on anticoagulants, they need to be stopped prior to surgery.
5. The nurse is preparing the client for surgery and is conducting pre-op teaching. Which comments about the cataract procedure are accurate?

Select all that apply (there are 5 correct answers).

- "You must lie very still during surgery."
- "Your blood pressure will be checked frequently during surgery."
- "You can expect to hear the doctors and nurses talking during your surgery."
- "You will need to stay in bed for 24 hours after the surgery."
- "You will be given strong narcotics for pain relief after surgery."
- "Optimal vision will not occur for several weeks after surgery."
- "Reading glasses will still be needed after surgery."
- "You must lie very still during surgery."
Mrs. Hoffman will be awake during surgery. Eye surgery is very delicate and she will need to be still.

- "Your blood pressure will be checked frequently during surgery."
Systemic absorption of the local anesthetic used for cataract surgery is possible. If this occurs, blood pressure could decrease. Also, Mrs. Hoffman will receive a mydriatic topical eye medication. In the elderly, mydriatics can cause an elevated blood pressure. For these reasons, Mrs. Hoffman's blood pressure will bemonitored frequently during surgery.

- "You can expect to hear the doctors and nurses talking during your surgery."
Mrs. Hoffman will be awake during surgery. She may be surprised at the casual conversation that occurs in the operating room. Learning about this preoperatively can help prevent any related anxiety.

- "Optimal vision will not occur for several weeks after surgery."
It is important for Mrs. Hoffman to know that her vision will not be greatly improved immediately after surgery. Vision may be blurry for a few weeks.

- "Reading glasses will still be needed after surgery."
After surgery, Mrs. Hoffman will still need glasses for vision correction, as she does now.
It is the morning of Mrs. Hoffman's surgery. She is admitted two hours before surgery, accompanied by her daughter. Mrs. Hoffman states that she used the antibiotic eye drops for the last three days.
Mrs. Hoffman's left eye is marked as the correct site for surgery by a member of the surgical team. All protocols for site marking are followed.
6. A mydriatic topical eye medication is administered into Mrs. Hoffman's left eye during surgery. Which of the following responses is expected from an anticholinergic drug that produces mydriasis?

- Decreased secretion from the affected eye
- Clouding over the pupil
- Dilation of the pupil
- Constriction of the pupil
- Dilation of the pupil

Mydriatic eye drops cause the pupil to dilate, which can aid in the extraction of the cataract.
Which of the following nursing actions is indicated after instilling mydriatic eye drops into Mrs. Hoffman's left eye?

- Mrs. Hoffman should be turned on her left side
- An eye patch should be placed on Mrs. Hoffman's left eye
- Lighting in the room should be increased
- Massage of Mrs. Hoffman's left eyeball
- An eye patch should be placed on Mrs. Hoffman's left eye

Mydriatic eye drops dilate the pupil and allow extra entry of light, which can be uncomfortable. An eye patch placed over the left eye would enable Mrs. Hoffman to see more clearly from her right eye and avoid any left eye discomfort from the room lights.
8. What is the purpose of administering the mydriatic medication preoperatively to Mrs. Hoffman?

- facilitate removal of the lens
- secure the intraocular implant
- prevent intraoperative bleeding
- promote postoperative drainage
- facilitate removal of the lens

Mydriatics dilate the pupil and pull the iris away from the lens. This facilitates removal of the lens and helps prevent injury to the iris.
Mrs. Hoffman's surgery is successfully completed. Surgery involved removal of the lens, with the lens capsule left intact. A plastic intraocular lens was then placed within the empty lens capsule.
Working in Same-Day Surgery Recovery today, you recognize Mrs. Hoffman. She is alert, with a protective shield covering her operative left eye, and not complaining of any discomfort.
9. Which of the following apply to Mrs. Hoffman during the immediate postoperative phase?

Select all that apply (there are 2 correct answers).

- Disturbed Body Image
- Risk for Deficient Fluid Volume
- Impaired Verbal Communication
- Risk for Acute Pain
- Risk for Aspiration
- Risk for Impaired Skin Integrity
- Risk for Injury
- Risk for Acute Pain
Mrs. Hoffman may experience some discomfort as a result of her surgery, after the effects of the topical anesthetic wear off. Any surgery involves some trauma and subsequent inflammation and discomfort. Risk for Acute Pain applies to Mrs. Hoffman's immediate postoperative care as a collaborative problem, to be addressed with medical and nursing interventions.

- Risk for Injury
Mrs. Hoffman's left eye will probably be covered for a minimum of 24 hours postoperatively, creating a sensory deficit that puts her at risk for injury. Therefore, Risk for Injury is relevant to Mrs. Hoffman's care at this time, and after she is discharged home.
10. To prevent trauma to the operative left eye, which nursing action is implemented with Mrs. Hoffman in the recovery area?

- Mrs. Hoffman is positioned on her left side
- The head of Mrs. Hoffman's bed is elevated
- Mrs. Hoffman is encouraged to deep breathe and cough.
- An eye shield is placed over Hoffman's right eye
- The head of Mrs. Hoffman's bed is elevated

Elevating the head of the bed slightly would promote eye drainage by gravity, minimize eye swelling and discomfort, and reduce the likelihood of eye trauma.
Mrs. Hoffman's daughter is allowed to be with Mrs. Hoffman in the recovery area.
Mrs. Hoffman is assisted to the bathroom, and has some fluids to drink. She will be discharged this afternoon, 3-4 hours after surgery.
Mrs. Hoffman says she feels so good that she can't wait to return to her usual activities. Although she was planning to stay at her daughter's home for a few days, she's not sure it's necessary.
You are concerned that Mrs. Hoffman may return to usual activities too quickly.
11. Given Mrs. Hoffman's comments, which approach is best to use when providing Mrs. Hoffman with discharge instructions for her postoperative care?

- Discuss ways that Mrs. Hoffman can remain independent while gradually recovering from surgery
- Insist that Mrs. Hoffman stay with her daughter for at least a day or two
- Have the HCP talk with Mrs. Hoffman's about activity restrictions
- Warn Mrs. Hoffman that if she does not limit her activity after surgery serious complications may occur
- Discuss ways that Mrs. Hoffman can remain independent while gradually recovering from surgery

Mrs. Hoffman is an independent person who wants to remain active and responsible for her own care. She will be most inclined to comply with postoperative care instructions if her independence can be maintained. Mrs. Hoffman needs to be reminded that postoperatively, her activity will be limited and she may require assistance with activities of daily living. If Mrs. Hoffman can maintain some independence while staying with her daughter, who can provide assistance, she may be more likely to stay with her daughter for a few days.
12. After talking with Mrs. Hoffman about activities that are permitted and those that are limited as she recovers from cataract surgery, she agrees that it would be best to stay with her daughter, at least for a day or two.
Reassured, you provide written postoperative instructions, which are reviewed with Mrs. Hoffman and her daughter.
Which restriction should be included in the written instructions for Mrs. Hoffman?

- Avoid solid foods for 3 days
- Avoid laxatives
- Avoid visitors
- Avoid bending at the waist and lifting
- Avoid bending at the waist and lifting

Bending at the waist and lifting (anything over five pounds initially) increase intraocular pressure and should be avoided to prevent injury to the healing surgical site. Straining with bowel movements should also be avoided.
Which of the following would indicate that Mrs. Hoffman needs further postoperative instruction before she is discharged?

Select all that apply (there are 3 correct answers).

- Mrs. Hoffman's statement to her daughter that her eye shield can be removed at night
- Mrs. Hoffman's request to drive home
- Mrs. Hoffman's request to have a TV in her room at her daughter's home
- Mrs. Hoffman's statement that she should lay on her left side in bed
- Mrs. Hoffman's statement to her daughter that her eye shield can be removed at night
This statement by Mrs. Hoffman would indicate a need for further instruction. To prevent injury from rubbing the operative eye while asleep, Mrs. Hoffman should wear an eye shield at night.

- Mrs. Hoffman's request to drive home
This statement by Mrs. Hoffman would indicate a need for further instruction. It would not be safe for Mrs. Hoffman to drive home with one eye covered with a shield.

- Mrs. Hoffman's statement that she should lay on her left side in bed
This statement would indicate that Mrs. Hoffman needs to be reminded about positions that are best for her. When in bed, Mrs. Hoffman should lay on her back with her head slightly elevated or on her right side to minimize pressure and swelling at the operative site.
Postoperative medications include antibiotic eye drops to prevent infection, and corticosteriod eye drops to limit postoperative inflammation.
Mrs. Hoffman learned the procedure for administering eye drops before surgery.
14. Which of the following instructions about preventing infection should you give Mrs. Hoffman?

- Wash hands before touching near the eye
- Rub the eye only with a tissue
- Wear sunglasses during the day
- Avoid washing around the eye
- Wash hands before touching near the eye

Handwashing before touching the eye, and before eye drops are administered, is critical to avoid infection. Mrs. Hoffman and her daughter should also be taught to wash the periorbital area each day, cleansing in an outward motion. Dripping water into the eye should be avoided. With bathing, it is important that water or shampoo not get into the eye. Splashing of water into the eye can be avoided by closing the eye while showering or bathing.
Mrs. Hoffman is also taught to wear sunglasses when outside during the day. Sunglasses prevent discomfort from light sensitivity, which can occur after cataract surgery.
Mrs. Hoffman is aware of the need to immediately report any signs of possible complications. These include fever, bleeding, pain above or in the eye, onset of eye redness or swelling, purulent drainage from the eye, persistent eye discomfort, or visual changes.
You see Mrs. Hoffman again when she returns to the HCP for a postoperative exam. Although her vision remains blurry, she states that it has improved. She is healing as expected.
Mrs. Hoffman asks about macular degeneration. Her friend has just developed this eye disorder.
Mrs. Hoffman, and all older persons, should routinely be evaluated for cataracts and other age-related eye problems, including macular degeneration.
Macular degeneration is a major cause of legal blindness in the elderly.
Macular degeneration results in painless loss of vision that may be gradual, or happen abruptly.
15. Which of the following characterizes vision loss in age-related macular degeneration?

- Peripheral vision loss
- Central vision loss
- Central vision loss

Macular degeneration involves central vision loss.
Macular degeneration usually starts in one eye, but the other eye may become affected as well. The "dry" nonexudative form of macular degeneration usually develops gradually. With the "wet" exudative form of macular degeneration, sudden onset of blurred vision with central vision loss is more common.
Various treatments (laser photocoagulation, eye injections) may be useful in arresting vision loss associated with exudative macular degeneration. Prompt treatment with onset of symptoms is very important in arresting vision loss.
Measures to prevent macular degeneration include vitamin supplements, although these may be of limited value. An Amsler grid can be used to detect changes in vision between eye exams.
Mrs. Hoffman is glad to hear that her yearly eye exam includes screening for macular degeneration.
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