# A nurse is assessing a 68-year-old client diagnosed with primary open-angle glaucoma. Which assessment finding would be most concerning and require immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541562 > language: ko > subject: Adult Health ## 문제 A nurse is assessing a 68-year-old client diagnosed with primary open-angle glaucoma. Which assessment finding would be most concerning and require immediate intervention? ## 보기 1. Complaints of mild eye fatigue after reading for extended periods 2. Sudden onset of severe eye pain with nausea and vomiting **✔ 정답** 3. Gradual decrease in peripheral vision over the past 6 months 4. Intraocular pressure reading of 22 mmHg on current medication regimen **정답: 2** ## 해설 Sudden severe eye pain with nausea/vomiting indicates acute angle-closure glaucoma, an ophthalmologic emergency requiring immediate intervention to prevent vision loss. Other options describe chronic or mild findings manageable with routine care. ## 심화 해설 Understanding the Clinical Scenario The client has a known diagnosis of primary open-angle glaucoma (POAG). This condition is characterized by a chronic, progressive optic neuropathy. The drainage angle of the eye remains open, but the trabecular meshwork gradually becomes less efficient at draining aqueous humor. This leads to a slow, insidious rise in intraocular pressure (IOP), causing gradual peripheral vision loss. The key clinical point is that POAG is typically asymptomatic in its early and moderate stages; it does not cause acute pain. The question asks for the finding that is most concerning and requires immediate intervention. This directs us to identify a sign or symptom that represents an acute change or a complication distinct from the expected chronic course of POAG. Analysis of Assessment Findings 1. Complaints of mild eye fatigue after reading for extended periods This is a nonspecific symptom commonly associated with presbyopia or general eye strain, particularly in a 68-year-old client. While it can be uncomfortable, it is not an emergency and does not indicate an acute glaucomatous process or a threat to vision. It is an expected finding that can be managed with rest and proper lighting, not an immediate intervention. 2. Sudden onset of severe eye pain with nausea and vomiting This is a classic triad for acute angle-closure glaucoma (AACG). In this emergency, the drainage angle becomes mechanically blocked, often by the iris, causing a sudden and dramatic spike in IOP. The provided evidence supports this as a critical finding. The case report by Moran et al. describes a patient with acute angle-closure glaucoma secondary to vitreous prolapse who presented with "acute left eye pain, nausea, and vision loss" with an IOP of 59 mmHg [1]. This presentation is a medical emergency requiring immediate treatment to prevent permanent optic nerve damage and vision loss. In a client with pre-existing POAG, the sudden onset of these symptoms is alarming and suggests a superimposed acute crisis, not an exacerbation of their chronic disease. 3. Gradual decrease in peripheral vision over the past 6 months This is the hallmark, expected progression of primary open-angle glaucoma. The chronic, elevated IOP damages the optic nerve, leading to a slow, painless loss of peripheral vision, often described as "tunnel vision." While this finding confirms disease progression and requires long-term management adjustments, it is a chronic issue, not an immediate emergency requiring intervention within minutes to hours. 4. Intraocular pressure reading of 22 mmHg on current medication regimen An IOP of 22 mmHg is above the typical target range (often 10-21 mmHg) and indicates that the current medication regimen is not achieving optimal IOP control. This is a significant finding that necessitates a follow-up appointment with the ophthalmologist to adjust therapy. However, in the context of chronic POAG, this pressure alone does not constitute an immediate, minute-to-minute emergency like an acute angle-closure attack. The risk of rapid, irreversible damage is lower than with the symptom cluster in option 2. Why the Correct Answer is the Priority The sudden onset of severe eye pain with nausea and vomiting is the most concerning finding because it is pathognomonic for an acute, vision-threatening crisis superimposed on a chronic condition. The urgency is driven by the pathophysiology: a rapid, extreme elevation in IOP can cause irreversible ischemic damage to the optic nerve and retina within hours. The case report of a patient with an IOP of 59 mmHg presenting with these exact symptoms highlights the severity of such an event [1]. This requires immediate nursing action, such as notifying the physician or nurse practitioner emergently, as the definitive treatment involves rapidly lowering the IOP with medications like hyperosmotic agents and topical miotics, followed by laser iridotomy. Delaying this intervention can lead to permanent blindness.References (research sources) - [1]Acute Angle-Closure Glaucoma Secondary to Vitreous Prolapse Following Ocular Trauma.Research articleMoran C, Uhm SY, Diala FGI, Patel V, Groth S. (2026) · DOI: 10.1155/crop/9483412 ## 임상 시나리오 Clinical Application: Differentiating Glaucoma Emergencies Scenario A 68-year-old client with a history of primary open-angle glaucoma (POAG) calls the clinic reporting a sudden onset of severe right eye pain, blurred vision, and seeing halos around lights. The client also reports feeling nauseous and has vomited once. The current medications include latanoprost eye drops at bedtime. Nursing Assessment & Critical Thinking - **Key Symptom Analysis:** The classic triad of acute eye pain, nausea/vomiting, and visual disturbances (halos) in a client with glaucoma is a red flag for acute angle-closure glaucoma (AACG), not an exacerbation of their chronic POAG. This constitutes an ophthalmic emergency. - **Pathophysiology Connection:** In AACG, the iris bows forward and physically blocks the trabecular meshwork, preventing aqueous humor drainage. This causes intraocular pressure (IOP) to spike rapidly, often to 60-80 mmHg, leading to ischemic damage of the optic nerve and irreversible vision loss if not treated within hours. Priority Nursing Actions - **Immediate Triage:** Instruct the client to seek emergency care immediately. Do not suggest waiting for an office appointment. Time is vision. - **Systemic Assessment:** Anticipate severe pain that may cause vagal responses (bradycardia, hypotension) in addition to nausea and vomiting. Prepare to manage pain and prevent aspiration. - **Medication Review & Preparation:** Be aware that emergency treatment typically involves topical miotics (pilocarpine) to constrict the pupil and pull the iris away from the angle, topical beta-blockers, alpha-agonists, or carbonic anhydrase inhibitors to reduce aqueous production, and systemic hyperosmotic agents (mannitol IV) to rapidly lower IOP. - **Avoid Harmful Interventions:** Do not administer mydriatic (dilating) eye drops, as these can worsen the angle closure. Dim lighting may also help by naturally causing pupil constriction. Patient Education & Follow-Up - **Warning Signs Education:** Teach all clients with glaucoma that the sudden onset of severe eye pain, headache, nausea, vomiting, or seeing halos around lights is a medical emergency, distinct from their usual chronic condition. - **Post-Crisis Care:** After the acute episode is resolved, definitive treatment often involves laser peripheral iridotomy to create a new drainage pathway, preventing recurrence. Emphasize the importance of lifelong monitoring and adherence to prescribed eye drops for the unaffected eye. ## 핵심 개념 - **Primary Open-Angle Glaucoma (POAG)** — A chronic, progressive optic neuropathy with an open drainage angle, characterized by gradual, asymptomatic peripheral vision loss due to inefficient aqueous humor outflow. - **Acute Angle-Closure Glaucoma (AACG)** — An ophthalmic emergency where the iris blocks the drainage angle, causing a sudden, dramatic rise in intraocular pressure with symptoms of severe eye pain, headache, nausea, vomiting, and blurred vision. - **Intraocular Pressure (IOP)** — The fluid pressure inside the eye, normally ranging from 10-21 mmHg; elevated pressure is a major risk factor for glaucoma and can damage the optic nerve. ## 같은 주제 문제 - [A nurse is assessing a 68-year-old client who presents to the emergency department with se…](https://mymerci.kr/pages/nclex_q.php?qn_id=541561) - [A nurse is assessing a 72-year-old client with suspected acute angle-closure glaucoma who …](https://mymerci.kr/pages/nclex_q.php?qn_id=541563) - [A nurse is caring for a client with acute angle-closure glaucoma who presents to the emerg…](https://mymerci.kr/pages/nclex_q.php?qn_id=541564) - [A nurse is caring for a client with acute angle-closure glaucoma. 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