Health Assessment Chapter 16

An adult client tell the nurse that he has been experiencing gradual vision loss. The nurse should a. ask about the clients diet b. determine whether thee is a history of glaucoma c. check the clients blood pressure d. ask the client if he has any known allergies

c. check the cliet's blood pressure

Photoreceptors of the eye are located in the eye's a. ciliary body b. lens c. retinal layer d. optic layer

c. retina

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for a. viral infection b. double vision c. allergic reactions d. lacrimal obstruction

d. lacrimal obstruction

Straight movements of the eye are controlled by the a. lacrimal muscles b. oblique muscles c. corneal muscles d. rectus muscles

d. rectus muscles

The meibomian gland secrete a. an oily substance to lubricate the eyes b. sweat c. hormones d. clear liquid tears

a. an oily substance to lubricate the eyes

A client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his righ eye. The nurse should a. examine the area of head trauma b. refer the clent to a opthalmologist c. assess the client for double vision d. ask the clent if he sees "halos"

b. refer the clent to a opthalmologist

What does the confrontation test assess? a.Visual acuity b.Presbyopia c. Peripheral vision d.Pupillary response

c. Peripheral vision

What is the correct technique for using the ophthalmoscope? a.Nurse use right eye to examine client's right eye b.Nurse use left eye to examine client's left eye c.Righthanded nurse use right eye to examine client's left and right eyes d.Lefthanded nurse use left eye to examine client's left and right eyes e. a and b f. c and d

e. a and b

What is the appearance of the normal optic disc? a.Creamy color b.Margins of the disc are blurry c.Round with well-defined borders d.Plump and blood-filled e. a and c f. c and d

e. a and c

The middle layer of the eye is known as the a. choroid layer b. scleral layer c. retinal layer d. optic layer

a. choriod layer

While assessing the eye of an adult cleint, the nurse observes an inward turning of the client's left eye. The nurse should document the client's a. esotropia b. strabismus c. phoria d. exotropia

a. esotropia

An adult tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluationof possible a. glaucoma b. increased intracranial pressure c. bacterial infection d. migraine headaces

a. glaucoma

The tarsal plates of the upper eyelid contain a. meibomian glands b. sebacious glands c. tear ducts d. ocular muscles

a. meibomian glands

The optic nerves from each eyeball cross at the a. optic chiasma b. vitreous humor c. optic disc d. visual cortex

a. optic chiasma

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should a. position the client 20 ft away from the chart b. ask the client to remove his glasses c. aske the clent to read each line with both eyes open d. instruct the client to begin reading from the botom of the chart

a. position the client 20 ft away from the chart

A 45 yo client tells the nurse that he occasionally sees spots in from of his eyes. The nurse should a. tell the client that these often occur with aging b. refer the client to an opthalmologist c. re-examine the client in 2 weeks d. assiss the client for signs of diabetes

a. tell the client that these often occur with aging

What the purpose of testing the red reflex? a.Check for cataracts b.Check for ectropion c.Check for glaucoma d.Check for macular degeneration

a.Check for cataracts

What is the name of the test where the nurse covers one eye at a time with an opaque card and quickly removes it? a.Cover-uncover test b.Corneal light reflex test c.Positions test d.Strabismus test

a.Cover-uncover test

The nurse is caring for a healthy adult client with no history of vision problems. The nurse should tell the client that a thorough eye examination is recommended every a. year b. 2years c. 3years d. 4years

b. 2years

The nurse has tested the near visual acuity of a 45 yo client. The nurse explains to the client that the client has impaired near vision and dexcusses a possible reason for the condition. The nurse determines that the client has understood the instrucitons when the client says that the presbyopia is usually due to a. congenital cataracts b. decreased accommodation c. muscle weakness d. constant misalignment of the eyes

b. decreased accommodation

An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the clent to a physician for evaluation of possible a. glaucoma b. increased intracranial pressure c. hypertension d. ophthalmic migraine

b. increased intracranial pressure

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is a. lack of vitamin C in the diet b. ultraviolet light exposure c. obesity d. use of antibiotics

b. ultraviolet light exposure

What is the name of the test where the nurse instructs the client to hold his head steady and to follow a pencil or a finger while the pencil or finger moves as if to make a large "X" with a line through it or a large "H"? a.Accomodation test b. Optic disc test c. Positions test for extraocular movement d.Glaucoma test

c. Positions test for extraocular movement

The bony orbit and fat cushion of the eye serves as a a. caruncle b. channel c. protector d. filter

c. protector

The nurse is examining an adlt client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test a. assesses the muscle strength of the eye b. assesses the functioning of the cranial nerves innervating the eye muscles c. requires the covering of each eye separately d. requires the client to focus on an object

c. requires the covering of each eye separately

What does cyanosis of the palpebral conjunctiva suggest? a.Anemia b.Diabetes c.Heart disorder d.Thyroid disorder

c.Heart disorder

What does PERRLA mean? a.Pupil equillibrium retina retention association b.Peripheral pupillary reaction related to accomodation c. Presbyoptic eye reaction retained accentuation d. Pupils equal round reactive to light and accomodation

d. Pupils equal round reactive to light and accomodation

An adult client tells the nurse that she frequently experiences burning and iching of both eyes. The nurse should assiss the client for a. foreign body b. recent trauma c. blind spots d. allergies

d. allergies

The conjunctiva of the eye is divided into the palpebral portion and the a. canthus portion b. intraocular portion c. nasolacrimal portion d. bulbar portion

d. bulbar portion

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and a. trasmit light rays b. maintain the retinal vessels c. change refractory of the lens d. cleanse the cornea and the lens

d. cleanse the cornea and the lens

While assissing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's a. eyelid reflexes b. refractory mechanism c. lacrimal reflexes d. corneal reflexes

d. corneal reflexes

An adult client vitis the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in vision are often associated with a. diabetes b. the aging process c. hypertension d. head trauma

d. head trauma

When the nurse is assessing the corneal light reflex, what is being tested? a. The speed with which the light reflex responds b.The speed of the pupillary and corneal response to the light c.When the cornea reacts to light reflected on it d.Where light reflects off of the corneas

d.Where light reflects off of the corneas

An adult client tells the nurse that his eyes are painful because he left his contact lenes in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to a. retinal damage b. cataracts c. myopia d. corneal damage

d. corneal damage

The functional reflex that allows the eyes to focus on near objects is termed a. pupillary reflex b. accommodation c. refraction d. indirect reflex

a. accommodation

An adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. The nurse should assess the client for a. recent exposure to irritants b. increased intracranial pressure c. excessive tearing d. a foreign body in the eye

d. a foreign body in the eye

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degress in both eyes. The nurse should a. refer the client for further evaluation b. examine the client for other signs of glaucoma c. ask the client if there is a genetic history of blindness d. document the findings in the client's records

d. document the findings in the client's records

A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should a. document the results in the client's record b. ask the client to read a handheld vision chart c. ask the client to return in 2 weeks for another examination d. refer the client to an optometrist

d. refer the client to an optometrist

A client tells the burse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with a. retinal deterioration b. head trauma c. migraine headaches d. vitamin A deficiency

d. vitamin A deficiency

When the nurse palpates the lacrimal apparatus, what is the normal finding? a.Clear drainage is seen b. White drainage is seen c.Yellow drainage is seen d.No drainage is seen

d.No drainage is seen