During an assessment, the nurse notices that an older adult ...

[Zoey63294]

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling dry and itchy.
 
  Which action by the nurse is correct?
  a.
  Assessing the eye for a possible foreign body
  b.
  Documenting the finding as ptosis
  c.
  Assessing for other signs of ectropion
  d.
  Contacting the prescriber; these are signs of basal cell carcinoma

Question 2

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:
 
  a. Retinal detachment.
  b. Diabetic retinopathy.
  c. Acute-angle glaucoma. d.
  Increased intracranial pressure.

[kthug]

Answer to Question 1

ANS: C
The condition described is known as ectropion, and it occurs in older adults and is attributable to atrophy of the elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot effectively siphon tears; excessive tearing results. Ptosis is a drooping of the upper eyelid. These signs do not suggest the presence of a foreign body in the eye or basal cell carcinoma.

Answer to Question 2

ANS: D
Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.

[Zoey63294]

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