A nurse is caring for a client with acute angle-closure glaucoma. Which nursing intervention should be the highest priority?
A 65-year-old client presents to the emergency department with severe eye pain, blurred vision, and nausea. The client reports seeing halos around lights and has a rock-hard eyeball upon palpation.
1Administer prescribed analgesics for pain relief
2Prepare the client for immediate ophthalmologic intervention✓ 정답
3Apply cool compresses to the affected eye
4Educate the client about long-term glaucoma management
해설
Acute angle-closure glaucoma is an ophthalmologic emergency requiring immediate intervention to prevent permanent vision loss. Preparing for ophthalmologic intervention is the priority over pain management, cool compresses, or education.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing action for a patient with Acute angle-closure glaucoma. This condition is a Key Point!true medical emergency where a sudden, complete blockage of the eye's drainage angle (Iridocorneal angle) causes a rapid and dangerous rise in Intraocular pressure (IOP). The classic symptoms presented—severe pain, blurred vision, halos, nausea, and a "rock-hard" eyeball—are hallmark signs of this crisis. The pathophysiology involves the iris being pushed forward against the cornea, trapping aqueous humor and causing IOP to spike, which can compress and damage the Optic nerve within hours, leading to irreversible vision loss.
Answer Rationale: The highest priority is Preparing the client for immediate ophthalmologic intervention. The goal is to lower the IOP as quickly as possible to save vision. This intervention is definitive and time-sensitive. It may include procedures like Laser peripheral iridotomy (LPI) to create a new drainage pathway or administration of potent IOP-lowering medications (e.g., osmotic agents, carbonic anhydrase inhibitors). All other nursing actions, while important, are secondary to facilitating this urgent, sight-saving treatment.
Distractor Analysis:
Watch out for confusion! While pain is severe, Administering analgesics (Option 1) addresses a symptom but does not treat the underlying, vision-threatening cause. Pain relief will follow effective IOP reduction. Watch out for confusion!Applying cool compresses (Option 3) might provide minor comfort but is contraindicated as it can cause vasoconstriction and is not a therapeutic intervention for high IOP. It is a non-priority, supportive measure. Watch out for confusion!Educating about long-term management (Option 4) is crucial for chronic open-angle glaucoma but is entirely inappropriate during an acute emergency. Education occurs during the stabilization and follow-up phase, not during the crisis.
Related Concepts: Understanding the difference between Acute angle-closure glaucoma (sudden, painful, emergency) and Primary open-angle glaucoma (POAG) (slow, painless, "silent thief of sight") is critical for the NCLEX. The priority for POAG is lifelong medication adherence and monitoring, not emergency intervention.
Concept Summary: Acute Angle-Closure Glaucoma = Sudden IOP spike → Optic nerve damage risk → Ophthalmologic EMERGENCY → Priority is immediate intervention to lower pressure.
Side-by-Side Comparison!:
Feature
Acute Angle-Closure Glaucoma
Primary Open-Angle Glaucoma (POAG)
Onset
Sudden, acute emergency
Slow, progressive, chronic
Pain
Severe eye pain, headache
Usually painless
Pupil
Mid-dilated, fixed, non-reactive
Normal initially
IOP
Markedly elevated (>30-40 mmHg)
Mildly to moderately elevated
Priority Nursing Action
Prepare for immediate intervention (Laser/surgery)
Education on lifelong medication adherence
Anatomy, Physiology & Pharmacology Points: The Iridocorneal angle is where the iris meets the cornea; it houses the Trabecular meshwork, the eye's drainage system. Blockage here stops aqueous humor outflow. Emergency drugs include Osmotic agents (Mannitol IV) to pull fluid from the eye, Carbonic anhydrase inhibitors (Acetazolamide) to reduce aqueous production, and Miotics (Pilocarpine) to constrict the pupil and pull the iris away from the angle.
Memory Tips: Remember "ACUTE = ACT NOW". A: Angle is closed. C: Crisis. U: Urgent intervention. T: Time is vision. E: Emergency. Also, the "rock-hard" eyeball is a classic tactile clue you must recognize.
High-Frequency NCLEX Topics: NCLEX loves testing nursing priorities in emergencies. Acute angle-closure glaucoma is a classic example where the correct answer is the action that directly treats the life- or organ-threatening problem (lowering IOP), not just managing symptoms (pain) or providing routine care (education).
Watch Out for Question Variations!: The same concept can be tested by: 1) Asking for the expected medical treatment (Laser iridotomy). 2) Asking which medication to administer first (often an osmotic diuretic like Mannitol). 3) Presenting a similar scenario but for chronic glaucoma and asking for the priority (then it would be education on medication adherence).
Nursing Clinical Practice GuideClinical Scenario: You are the triage nurse in the ED. Mr. Johnson, 65, is clutching his right eye, visibly distressed. He states, "My eye feels like it's going to explode, I can't see clearly, and I feel sick to my stomach." Quick assessment reveals a fixed, mid-dilated pupil and palpable firmness of the globe.
Nursing Intervention Strategy:
1Immediate Assessment & CommunicationRecognize this as an ophthalmologic emergency. Immediately alert the physician/ophthalmologist and ED charge nurse. Do not delay. Document vital signs and a focused neuro-ocular assessment (vision, pupil reaction, eye pain).
2Priority Action - Facilitate Definitive CareYour primary role is to expedite the process. This means: starting an IV line as ordered for emergency medications, assisting with arranging immediate transfer to an ophthalmology suite or preparing the bedside for a potential laser procedure, and ensuring informed consent is obtained quickly.
3Supportive CareWhile preparing for intervention, keep the patient in a semi-Fowler's position to slightly lower IOP via gravity. Provide an emesis basin and quiet environment due to nausea. Do not leave the patient alone; anxiety and pain are high.
Patient Safety and Precautions: Key Point!Never administer medications that can dilate the pupil (anticholinergics, sympathomimetics) as this can worsen the angle closure. Always check medication orders against this critical contraindication.
Nursing Procedure & Medication Flow:
For Mannitol IV: Administer via a large-bore IV as a rapid infusion. Monitor for fluid overload and electrolyte imbalance (especially potassium). Urinary output will increase dramatically.For Acetazolamide (Diamox) IV/PO: Monitor for side effects: metabolic acidosis, hypokalemia, paresthesias (tingling in fingers/toes).For Pilocarpine Eyedrops: Instill as ordered to constrict the pupil. Be aware it may cause blurred vision and brow ache.
A Word from Your Senior Nurse: "In emergencies like this, your ability to recognize 'red flag' symptoms and act as the crucial link to definitive care is what saves function—in this case, vision. That 'rock-hard' eyeball finding is not just a textbook term; it's a palpable sign of a ticking clock. On the NCLEX and in practice, always ask yourself: 'What is the immediate threat to this patient's life or organ function?' The answer to that question is almost always your priority nursing action. Think: 'Time is vision.'"
Intraocular Pressure — The fluid pressure inside the eye. Normal range is 10-21 mmHg. Dangerously high in angle-closure glaucoma.
Laser Peripheral Iridotomy — The definitive emergency procedure for acute angle-closure glaucoma. A laser creates a small hole in the iris to allow aqueous humor to bypass the blocked drainage angle.
Optic Nerve — The nerve that carries visual information from the eye to the brain. Sustained high IOP compresses and damages this nerve, leading to permanent vision loss.
Miotics (e.g., Pilocarpine) — Eye drops that constrict (miose) the pupil. In angle-closure glaucoma, this pulls the iris away from the drainage angle, helping to open it.
Osmotic Agent (e.g., Mannitol) — IV medication that increases blood osmolarity, drawing fluid out of the eye and into the bloodstream to rapidly lower intraocular pressure.