Chapter #15: Eyes
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When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding: a. Is expected. b. May indicate a problem with extraocular muscles. c. May result in problems with tearing. d. Indicates increased intraocular pressure.
A is expected The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.
A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would: a. Consider this a normal finding. b. Assess the pupillary light reflex for possible blindness. c. Continue with the examination, and assess visual fields. d. Expect that a 2-week-old infant should be able to fixate and follow an object.
A. Consider this a normal finding. By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy.
A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have: a. Macular degeneration. b. Vision that is normal for someone her age. c. The beginning stages of cataract formation. d. Increased intraocular pressure or glaucoma.
A. Macular degeneration. Macular degeneration is the most common cause of blindness. It is characterized by the loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not consistent with vision that is considered normal at any age.
The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? a. Optic disc that is a yellow-orange color b. Optic disc margins that are blurred around the edges c. Presence of pigmented crescents in the macular area d. Presence of the macula located on the nasal side of the retina
A. Optic disc that is a yellow-orange color The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the accumulation of pigment in the choroid.
The nurse is testing a patient's visual accommodation, which refers to which action? a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light
A. Pupillary constriction when looking at a near object The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.
When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: a. Consider this a normal finding. b. Refer the individual for further evaluation. c. Document this finding as an asymmetric light reflex. d. Perform the confrontation test to validate the findings.
A. consider this a normal finding Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.
A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: a. Has poor vision. b. Has acute vision. c. Has normal vision. d. Is presbyopic.
A. has poor vision Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision.
The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? a. The outer layer of the eye is very sensitive to touch. b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. d. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.
A. the outer layer of the eye is very sensitive to touch The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.
Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? a. Increased night vision b. Dark retinal background c. Increased photosensitivity d. Narrowed palpebral fissures
B. Dark retinal background An ethnically based variability in the color of the iris and in retinal pigmentation exists, with darker irides having darker retinas behind them.
A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: a. Chalazion. b. Hordeolum (stye). c. Dacryocystitis. d. Blepharitis.
B. Hordeolum (stye). A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling. Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids (see Table 14-3).
During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of: a. Hypopyon. b. Hyphema. c. Corneal abrasion. d. Pterygium.
B. Hyphema. Hyphema is the term for blood in the anterior chamber and is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. (See Table 14-7 for descriptions of the other terms.)
The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? a. Degeneration of the cornea b. Loss of lens elasticity c. Decreased adaptation to darkness d. Decreased distance vision abilities
B. Loss of lens elasticity The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.
The nurse is performing the diagnostic positions test. Normal findings would be which of these results? a. Convergence of the eyes b. Parallel movement of both eyes c. Nystagmus in extreme superior gaze d. Slight amount of lid lag when moving the eyes from a superior to an inferior position
B. Parallel movement of both eyes A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of the CN that innervates it.
A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: a. Loss of central vision. b. Shadow or diminished vision in one quadrant or one half of the visual field. c. Loss of peripheral vision. d. Sudden loss of pupillary constriction and accommodation.
B. Shadow or diminished vision in one quadrant or one half of the visual field. With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.
The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets the vision for the right eye. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.
B. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.
A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: a. At 30 feet the patient can read the entire chart. b. The patient can read at 20 feet what a person with normal vision can read at 30 feet. c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.
B. The patient can read at 20 feet what a person with normal vision can read at 30 feet. The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.
The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? a. Decrease in tear production b. Unequal pupillary constriction in response to light c. Presence of arcus senilis observed around the cornea d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles
B. Unequal pupillary constriction in response to light Pupils are small in the older adult, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.
During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply. a. Patient may experience sensitivity to light, nausea, and halos around lights. b. Patient experiences tunnel vision in the late stages. c. Immediate treatment is needed. d. Vision loss begins with peripheral vision. e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision. f. Virtually no symptoms are exhibited.
B. patient experiences tunnel vision in the late stages. D. vision loss begins with peripheral vision F. virtually no symptoms are exhibited Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are exhibited. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.
9. A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: a. "Vision is not totally developed until 2 years of age." b. "Infants develop the ability to focus on an object at approximately 8 months of age." c. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object." d. "Most infants have uncoordinated eye movements for the first year of life."
C. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object." Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate simultaneously on a single image with both eyes.
The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: a. Check for the presence of exophthalmos. b. Suspect that the patient has hyperthyroidism. c. Ask the patient if he or she has a history of heart failure. d. Assess for blepharitis, which is often associated with periorbital edema.
C. Ask the patient if he or she has a history of heart failure. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.
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
C. Assessing for other signs of ectropion 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.
In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would: a. Suspect that an opacity is present in the lens or cornea. b. Check the light source of the ophthalmoscope to verify that it is functioning. c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. d. Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.
C. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. The red glow filling the person's pupil is the red reflex and is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b. Assess the individual's near vision. c. Observe the distance between the palpebral fissures. d. Perform the corneal light test, and look for symmetry of the light reflex.
C. Observe the distance between the palpebral fissures. Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis.
When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for: a. Drainage from dacryocystitis. b. Presence of conjunctivitis over the iris. c. Presence of shadows, which may indicate glaucoma. d. Scattered light reflex, which may be indicative of cataracts.
C. Presence of shadows, which may indicate glaucoma. The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This method is not correct for the assessment of dacryocystitis, conjunctivitis, or cataracts.
In a patient who has anisocoria, the nurse would expect to observe: a. Dilated pupils. b. Excessive tearing. c. Pupils of unequal size. d. Uneven curvature of the lens.
C. Pupils of unequal size. Unequal pupil size is termed anisocoria. It normally exists in 5% of the population but may also be indicative of central nervous system disease.
When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.
C. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.
The nurse is assessing color vision of a male child. Which statement is correct? The nurse should: a. Check color vision annually until the age of 18 years. b. Ask the child to identify the color of his or her clothing. c. Test for color vision once between the ages of 4 and 8 years. d. Begin color vision screening at the child's 2-year checkup.
C. Test for color vision once between the ages of 4 and 8 years. Test boys only once for color vision between the ages of 4 and 8 years. Color vision is not tested in girls because it is rare in girls. Testing is performed with the Ishihara test, which is a series of polychromatic cards.
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test. b. Ask the patient to read the print on a handheld Jaeger card. c. Use the Snellen chart positioned 20 feet away from the patient. d. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.
C. Use the Snellen chart positioned 20 feet away from the patient. The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.
When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: a. Causes pupillary constriction. b. Adjusts the eye for near vision. c. Elevates the eyelid and dilates the pupil. d. Causes contraction of the ciliary body.
C. elevates the eyelid and dilates the pupil Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.
The nurse is assessing a client's eyes during a comprehensive health assessment. Which assessment finding would require immediate intervention? 1. Acute glaucoma. 2. Blepharitis. 3. Periorbital edema. 4. Anisocoria.
Correct Answer: 1 Global Rationale: Acute glaucoma results from a sudden increase in intraocular pressure caused by a blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate interventions to prevent further eye damage. Blepharitis is when the eyelid becomes inflamed. The eye burns, itches, and tears but does not require an immediate intervention. Periorbital edema is when the eyelid becomes puffy and swollen. It can be related to crying, infection, or systemic problems. It does not require an immediate intervention. Anisocoria refers to unequal pupil size, which may be a normal finding or it may indicate that the client has a central nervous system disease.
The nurse is performing a visual examination on a client due to the client's complaints of black dots appearing in the visual field. Which statement by the nurse is most appropriate in this situation? 1. "The black dots are known as floaters and are usually normal." 2. "We need to refer you to an eye surgeon immediately." 3. "You may have glaucoma." 4. "You may have a cataract."
Correct Answer: 1 Global Rationale: Black dots or spots are known as floaters. Floaters are considered normal unless they obstruct vision, so they should not be immediately referred to a healthcare provider. Halos around lights are associated with glaucoma. Floaters are not seen with cataracts.
The nurse is assessing the fundus of the older adult client's eye with an ophthalmoscope. The nurse determines that there is a cyst within the macula. Which client symptom does the nurse anticipate? 1. Impaired central vision. 2. Impaired peripheral vision. 3. Consistently elevated serum glucose levels. 4. Uncontrolled hypertension.
Correct Answer: 1 Global Rationale: Degeneration of the macula can be related to cysts located in this area. It is more common in older adults and results in impaired central vision. Impaired peripheral vision can be related to problems with the rods that are located in the retina. Elevated serum glucose levels may be associated with diabetic retinopathy. Uncontrolled hypertension can be associated with hypertensive retinopathy.
The nurse is assessing an African American adult client who is experiencing visual changes. Which question to the client is the priority? 1. "Have you or anyone in your family ever been diagnosed with diabetes?" 2. "Do you wear sunglasses when you are outside?" 3. "Did your mother have a vaginal infection at the time of your delivery?" 4. "Do you see any halos around lights?"
Correct Answer: 1 Global Rationale: Diabetic retinopathy is the leading cause of blindness in the United States. It is important for the nurse to determine if the client has a personal or family history of diabetes. Type 2 diabetes occurs more frequently in African Americans, Asian Americans, Hispanic Americans, and Native Americans than in Caucasian clients. This will assist the nurse to determine if the client may be suffering visual changes as a result of diabetic retinopathy. The nurse can ask about the client's behaviors to determine his risk of developing problems associated with ultraviolet radiation. When the nurse is assessing an infant, the nurse should inquire about whether the mother of the infant had a vaginal infection at the time of delivery because this can result in eye infections in the newborn. Clients who see halos around lights may be suffering from glaucoma and increased intraocular pressure.
After a comprehensive eye examination, it is determined that the client requires corrective lenses for myopia. Which explanation by the nurse to the client is the most appropriate? 1. "Your glasses will help you to see objects in the distance." 2. "Your glasses will help you to see objects that are very close to you." 3. "Your glasses will help you to improve your eyes' ability to focus and reduce your blurred vision." 4. "Your age has made it more difficult to read items that are at close range. Your new glasses will help."
Correct Answer: 1 Global Rationale: Myopia is the inability to see objects in the distance. Hyperopia is the inability to see objects at close range. Astigmatism causes blurred or double vision when the eyes attempt to focus. Presbyopia causes the client to experience difficulty focusing on items that are at close range. Presbyopia affects people who are over 45 years old.
A client is referred to the clinic with complaints of blurred vision. Which initial question to the client is the priority? 1. "Would you please tell me about your vision today?" 2. "Do you experience double vision?" 3. "Have you had any eye pain?" 4. "What kinds of activities do you perform at work?"
Correct Answer: 1 Global Rationale: The best way to start the focused interview is to begin with open-ended questions that provide the client with an opportunity to describe his own perceptions about his vision. All of the other questions are appropriate to ask at some point during the focused interview but are not the best way to start the interview. It is important to determine if the client has experienced double vision. Double vision can be caused by muscle or nerve problems and some types of medications. It is important to determine if the client is experiencing eye pain because it can be associated with glaucoma or other eye problems. It is important to determine the client's occupation because some types of occupations put the client at risk for eye injury or eyestrain.
The nurse is assessing the client's pupillary responses. The client is found to have no consensual response. Which conclusion by the nurse is the most appropriate? 1. Cranial nerve III may not be functioning appropriately. 2. This is a normal finding. 3. This is evidence of increased intracranial pressure. 4. This is evidence of optic nerve damage.
Correct Answer: 1 Global Rationale: When evaluating pupillary response, the unilluminated, or consensual, pupil should also constrict. When this does not occur, it may be indicative of problems associated with cranial nerve III. This is not a normal finding. Increased intracranial pressure is associated with pupils that are unequal and irregularly shaped. This is not evidence that optic nerve damage has occurred. Optic nerve damage can produce changes in the client's visual fields.
The nurse is assessing the client's eyes. Which assessment finding supports the diagnosis of glaucoma? 1. Eyeballs are firm to palpation. 2. Pupils are constricted bilaterally. 3. Central vision is impaired. 4. The client has a history of syphilis.
Correct Answer: 1 . Global Rationale: A client's eyeballs that are firm when palpated may have glaucoma. Dilated, not constricted, pupils are most often associated with glaucoma. Impaired central vision is associated with macular degeneration. Clients who have been infected previously with syphilis may develop a condition called Argyll Robertson pupils. This is when the client's pupils are bilaterally constricted, small, irregular, and nonreactive to light.
The nurse is assessing a client's visual fields by confrontation. Which actions by the nurse indicate appropriate practice? Standard Text: Select all that apply. 1. The nurse asks the client to cover one of her eyes with a card. 2. The nurse uses a penlight to assist with performing the test. 3. The nurse asks the client to sit 20 feet away. 4. The client tells the nurse when she first sees the object. 5. The nurse asks the client to stand 4 feet away.
Correct Answer: 1, 2, 4 Global Rationale: Confrontation to test visual fields is done by asking the client to cover one eye with a card while the nurse covers the eye opposite to the client. The nurse and client sit 2-3 feet away from each other, at eye level. An object such as a pen or penlight is advanced from the periphery to the midline. Both the client and the nurse should be able to see the object at the same time. The client should tell the nurse when she first sees the object in her peripheral vision.
The nurse is assessing a client who is 34 weeks pregnant. Which visual changes are usually normal in this stage in pregnancy and should disappear at some point after delivery? Standard Text: Select all that apply. 1. The client is complaining that her eyes feel very dry. 2. She states that she is experiencing blurry vision. 3. Periorbital edema is noted. 4. Cataracts are noted. 5. She has been unable to wear her contact lenses.
Correct Answer: 1, 2, 5 Global Rationale: The pregnant client may complain of dry eyes. This symptom is usually not significant and disappears after childbirth. The pregnant client may describe visual changes such as blurry vision due to shifting fluid within the eye. Blurriness or distorted vision can occur because of temporary changes in the shape of the eye during the last trimester of pregnancy. Pregnant women often discontinue wearing their contact lenses during their pregnancy as a result of fit and comfort. Eyelid edema is not a common problem associated with pregnancy. Periorbital edema may signal an underlying problem. Cataracts are not commonly associated with pregnancy.
The nurse is performing a focused interview and eye assessment on a client. Which assessment findings indicate the client's is experiencing a vision problem? Standard Text: Select all that apply. 1. The client is frowning and squinting while she is reading the Snellen chart. 2. The client exhibits a symmetrical pupillary light reflex response. 3. As the nurse checks for accommodation, the pupils remain dilated. 4. The client's near vision acuity is 14/14 bilaterally. 5. When the cornea is lightly touched in the right eye, both eyelids close.
Correct Answer: 1, 3 Global Rationale: If the client is frowning or squinting during the test of her ability to see distant objects, this is indicator that the client may be experiencing visual problems. When checking accommodation, the eyes should converge and the pupils should constrict as the eyes focus on the penlight. Symmetrical pupillary responses are normal. The normal result for near vision is 14/14 in each eye. When testing the corneal reflex, touch the eye gently and quickly with a wisp of cotton. The client will react by blinking both eyes. If one or both eyes fail to respond, there could be a problem.
The nurse is examining the eye. The client asks about the specific structures within the eye that are responsible for refraction of light rays. Which structures are involved in this process? Standard Text: Select all that apply. 1. Lens. 2. Macula. 3. Cornea. 4. Iris. 5. Optic disc.
Correct Answer: 1, 3 Global Rationale: The lens is located directly behind the pupil and is used to refract light through the eye. The cornea is a transparent part of the eye and located anteriorly. It allows light to enter the eye and assists with refraction. The macula is located within the retina and does not assist with light refraction. The iris controls the amount of light that enters the eye, but is not associated with refraction. The optic disc is where the optic nerve and retina meet. It is where the vascular network enters the eye. This structure is not associated with refraction.
The nurse is assessing a child previously diagnosed with fetal alcohol syndrome. When conducting a health history interview, which statements by the client's mother are consistent with the child's diagnosis? Standard Text: Select all that apply. 1. "It seems as if one of his eyelids is droopy." 2. "There's a firm little bump on his eyelid but he says it doesn't hurt." 3. "His eyes almost look cloudy." 4. "He has required glasses to see well since he was 2 years old." 5. "His eyelids look they have turned under and he complains that his eyes hurt."
Correct Answer: 1, 3, 4 Global Rationale: A child with fetal alcohol syndrome may experience ptosis. Cataracts are associated with children who have been diagnosed with fetal alcohol syndrome. Structural abnormalities of the eye are associated with fetal alcohol syndrome. These abnormalities may result in reduced visual acuity. Chalazions are firm, non-tender nodules located on the eyelids that are associated with infection. They are not associated with fetal alcohol syndrome. Entropion is when the eyelids invert and the lashes can scratch the cornea. Entropion is not associated with fetal alcohol syndrome.
During an eye examination, the nurse requests that the client read letters located on the Snellen E chart. The client's vision is determined to be 20/200. Which statements regarding this client's vision are accurate? Standard Text: Select all that apply. 1. The client is legally blind. 2. The client is unable to read from a paper at close range. 3. The client is found to be farsighted. 4. The client is myopic. 5. This is common in clients who are over 45 years old.
Correct Answer: 1, 4 Global Rationale: When a client's vision is found to be 20/200, the client is legally blind. Clients who are myopic are unable to see objects in the distance. Presbyopia is the inability to see items at close range. The Snellen E chart assists with determining if the client is able to see items in the distance. Clients who are farsighted are able to see things in the distance. This client is unable to see distant objects. This condition is more common in people who are over 45 years old.
During the assessment of a client's eyes, the nurse suspects the client has entropion. Which assessment data caused the nurse to come to this conclusion? 1. Eversion of the lower eyelid. 2. Inversion of the lid and eyelashes. 3. Swollen, red hair follicles. 4. Firm, non-tender nodule on the eyelid.
Correct Answer: 2 Global Rationale: Entropion is inversion of the lid and lashes caused by a muscle spasm of the eyelid. Ectropion is eversion of the lower eyelid caused by muscle weakness. A stye causes swelling and redness in the affected eye. A stye is a result of a staphylococcal infection of hair follicles on the margin of the lids. A chalazion is a firm, non-tender nodule on the eyelid.
Prior to conducting an eye assessment, which statement by the nurse is appropriate to prepare the client for the examination process? 1. "You can choose which eye to cover during your assessment." 2. "Are you able to read English words?" 3. "Apply pressure to the eye while it is covered during the examination." 4. "You will need to stand 10 feet from the chart for an accurate assessment."
Correct Answer: 2 Global Rationale: It is important to determine if the client is able to read prior to initiating an eye assessment. Clients who cannot read should have their vision assessed using a chart with pictures. The nurse should instruct which eye to cover during the examination process. It is not always appropriate to allow the client to choose. While covering the eye during the examination, the client should be discouraged from applying pressure to the eye. When using the Snellen chart for an eye assessment, the client should stand 20 feet from the chart for an accurate assessment.
The nurse presented a program regarding objectives related to the overall health of eyes that are addressed in Healthy People 2020. Which client statement made by an adult participant in the program indicates an adequate understanding of these objectives? 1. "My 4-year-old doesn't need his vision screened." 2. "I'm going to call my eye doctor and ask that she performs a dilated eye exam." 3. "My mom has been complaining of dry eyes, but I knew it was all in her head." 4. "I didn't know that Asians have the highest risk for developing glaucoma."
Correct Answer: 2 Global Rationale: Preschool-aged children should have their vision screened to detect problems early. Early detection can lead to early treatment. One of the objectives of Healthy People 2020 is to increase the number of people who have dilated eye examinations performed. This is a screening method that can lead to early detection of eye problems. Older adults have a decrease in tear secretions that result in complaints of dry eyes. African Americans have the greatest risk for developing glaucoma when compared to other racial groups.
The nurse is conducting a focused interview with an eye assessment. Which information obtained during the focused interview is the most helpful to the nurse regarding the assessment of the client's eyes? 1. The client graduated from college. 2. The client interacts easily with the nurse. 3. The client is an African American male. 4. The client is 23 years old.
Correct Answer: 2 Global Rationale: The client's ability to communicate is most essential to the interview. The nurse must determine how well the client will be able to participate in the focused interview and follow directions during the physical assessment. It is important to determine the client's educational level. It is important to assess the client's race because this may influence what types of eye conditions the client is at risk for developing. The client's age is important to assess because anatomical and physiologic changes can occur in the eye across the lifespan.
The nurse is assessing the adult client's eyes during a comprehensive health assessment. Which pieces of information should the nurse also gather during the assessment process? Standard Text: Select all that apply. 1. The client's birth weight. 2. The client's parents were born in Spain. 3. The client's annual income is below the poverty level. 4. The client is a welder. 5. The client recently attempted to commit suicide after his wife died in an automobile accident.
Correct Answer: 2, 3, 4, 5 Global Rationale: During a comprehensive health assessment, it is important to gather information about the client's ethnicity and race. Ethnicity may influence how a client performs self-care activities. Hispanics have higher rates of visual impairments than other races. It is important to gather information about the client's socioeconomic status. This may affect how often the client will visit a health care provider for his health care needs and routine screening activities. It is important to gather information about the client's occupation. People who work in some settings are more likely to experience eye injuries. It is important to gather information about the client's emotional well-being. The client's birth weight is not applicable unless the nurse is caring for a pediatric client.
The nurse is teaching a group of nursing students about the cultural implications associated with eye diseases. At the conclusion of the teaching session, which student comment indicates the need for further education? 1. "It is important to assess the African American client for clinical manifestations associated with increased intraocular pressure." 2. "We should assess serum glucose levels in our adult Hispanic clients." 3. "Our diabetic clients should return every 2 years for an assessment of their vision and their retina." 4. "Poorly controlled serum glucose levels can result in retinal changes that affect the client's vision and can even result in blindness."
Correct Answer: 3 Global Rationale: A client who has a personal or family history of diabetes should return each year for a thorough examination of his vision and retina. Diabetic retinopathy is the leading cause of blindness in the United States. African Americans have a higher risk for developing glaucoma. Glaucoma occurs when the flow of fluid around the anterior chamber of the eye is blocked and the client's intraocular pressure increases. Hispanics are more likely to develop type 2 diabetes, which can increase their risk of developing visual changes associated with diabetic retinopathy. Poorly controlled serum glucose levels are associated with diabetes. The client with diabetes can develop diabetic retinopathy. The client with this condition can develop changes in his retina and circulatory system.
The nurse is teaching a middle-aged African American client who was recently diagnosed with glaucoma. Which statement by the client indicates for further education on this diagnosis? 1. "I just thought my pupils were big, I didn't know it could be associated with glaucoma." 2. "So, my headaches may be occurring because of the increased pressure within my eyes." 3. "My race doesn't have anything to do with this diagnosis." 4. "Those halos that I see around lights are associated with glaucoma."
Correct Answer: 3 Global Rationale: African Americans are more likely to develop glaucoma. Glaucoma is a result of restricted fluid flow around the anterior chamber of the eye. The blocked fluid flow results in an increase in the client's intraocular pressure. Dilated pupils can be found in clients with glaucoma. Headaches are associated with glaucoma. Clients with glaucoma may state that they see halos around lights.
The nurse is interviewing the mother of a three-week-old Caucasian infant. Which statement by the mother indicates she requires further education about her newborn's eyes? 1. "It's normal for my baby not to produce tears when she cries." 2. "At this stage, my baby should be able to fixate on a bright light or something that moves." 3. "My baby's eyes are blue and definitely will stay blue." 4. "It was normal for my baby's eyes to be swollen after birth."
Correct Answer: 3 Global Rationale: At this stage, the baby may not be able to produce tears. By the fourth week, the baby will begin to produce tears. At six weeks, the baby will begin to develop binocular vision. At this stage, the baby will fixate on a bright light or a moving object. Light-skinned infants are born with blue eyes. By about the third month of age, the color of the eyes begins to change to a more permanent shade. Before six weeks of age, infants will fixate on a bright or moving object. At birth, many infants have edematous eyelids.
The nurse is performing the cover test and notes inward turning of the client's eye. Which term will the nurse use to document this finding? 1. Exophoria. 2. Strabismus. 3. Esophoria. 4. Mydriasis.
Correct Answer: 3 Global Rationale: Esophoria is when the eye turns inward during the cover test. Exophoria is when the eye turns outward during the cover test. Strabismus is when the axes of the eye cannot be directed at the same object. Mydriasis refers to fixed and dilated pupils.
During the assessment of a client's eyes, the nurse suspects that the client has ptosis. Which assessment data caused the nurse to come to this conclusion? 1. The palpebral conjunctiva is exposed. 2. The iris and cornea are reddened. 3. The eyelid is drooping. 4. The eyelids are swollen and puffy.
Correct Answer: 3 Global Rationale: Ptosis is drooping of the eyelid. Ectropion is eversion of the lower eyelid caused by muscle weakness that produces exposure of the palpebral conjunctiva. Iritis is characterized by redness of the iris and cornea. Periorbital edema refers to swollen, puffy eyelids.
The nurse notices that a client's pupils constrict when reading the consent form for medical treatment. Based on this data, which should the nurse consider as the cause? 1. The room is too dark. 2. The client is able to read. 3. This is a normal response. 4. The client requires glasses for reading.
Correct Answer: 3 Global Rationale: The client's pupils should constrict in response to trying to read what is on the paper. This is a normal finding. When a room is dark, the client's pupils should dilate in response. Pupil constriction occurs as the client focuses on the paper. It does not indicate the client can read. Pupil constriction would not lead the nurse to believe the client needs reading glasses.
The nurse is assessing the client's eye with an ophthalmoscope. The nurse is preparing to focus on the fundus and rotates the lens diopter wheel into the negative numbers. Based on this information, which condition does the client most likely have? 1. Hyperopia. 2. Presbyopia. 3. Myopia. 4. Astigmatism.
Correct Answer: 3 Global Rationale: The diopter is rotated to help the nurse focus on the client's fundus. The diopter is rotated toward the positive numbers when the client is hyperopic, and rotated into the negative numbers when the client is myopic. For any other condition, such as presbyopia or astigmatism, the diopter wheel is rotated until the fundus can be visualized adequately.
The nurse is educating a student on the proper use of an ophthalmoscope for an eye examination. Which statement by the nurse to the student is accurate? 1. "I'm going to examine the client's right eye with my left eye." 2. "I'm going to advance the ophthalmoscope until the instrument touches the client's cornea." 3. "I'm going to begin with the lens set to the 0 diopter." 4. "I can see the red reflex as the light reflects off of the client's lens."
Correct Answer: 3 Global Rationale: The nurse should always begin with the lens set to the 0 diopter. The nurse should prepare to assess the client's eye with an ophthalmoscope by examining the client's right eye with the nurse's right eye. The nurse should advance the ophthalmoscope only until it almost touches the client's eyelashes. The cornea contains many nerve endings and this would be painful for the client. The red reflex is seen as light reflects off of the client's retina, not his lens.
During an eye assessment, a young adult client reports difficulty seeing items within close range. This assessment data is consistent with which item? 1. Aging. 2. Presbyopia. 3. Hyperopia. 4. Astigmatism.
Correct Answer: 3 Global Rationale: Younger clients who are unable to see items well at close range have a condition called hyperopia. This condition is also referred to as farsightedness. Aging can produce changes in the eye but this client is 24 years old. Presbyopia is an age-related condition. The lens loses its ability to accommodate viewing items at close range. Astigmatism occurs when light is refracted over a wide area rather than on a distinct area of the retina.
The nurse notes that a client is unable to control the amount of light that enters the eye. The dysfunction of which structure is the most likely cause of this problem? 1. Cornea. 2. Sclera. 3. Conjunctiva. 4. Iris.
Correct Answer: 4 Global Rationale: The iris responds to the light coming through the cornea by making the pupil larger or smaller, thereby controlling the amount of light that enters the eye. The cornea is the window of the eye. It is the clear, transparent part of the sclera and forms the anterior one sixth of the eye. The sclera supports and protects the structures of the eye. The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye from becoming too dry.
The nurse is assessing the eyes of an older adult client. Which finding is expected by the nurse based on the client's age? 1. The client is easily able to read from a paper held at close range without corrective glasses. 2. There is a noticeable increase in fat within the orbit of the eye. 3. The client states that she feels her tear production has increased over the years. 4. The pupillary light reflex is slower bilaterally.
Correct Answer: 4 Global Rationale: The pupillary light reflex slows with age. The lens of the older client's eye is less elastic and the client's ciliary muscles will become weaker. This results in a decreased ability to focus on objects that are held at close range. There is a decrease in the amount of fat in the orbit of the eye, which produces a drooping appearance of the eye. Older adults experience a decrease in lacrimal secretions.
The nurse taught the client how to self-administer eye drops and the client was performing a return demonstration. During this time, the client inadvertently touched the applicator to their cornea, which caused the client to blink and produce tears. How will the nurse document this occurrence? 1. Abnormal and should be reported to the healthcare provider. 2. Hyperactive. 3. A medication side effect. 4. A normal response.
Correct Answer: 4 Global Rationale: This is a normal response because the cornea is very sensitive. When the cornea is touched, the eyelids blink and tears are produced. The cornea contains many nerve endings and this action would produce a painful sensation for the client. This is not an abnormal response. This would not be noted as a hyperactive response. This is not due to a medication side effect.
During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? a. Presence of tears along the inner canthus b. Blocked nasolacrimal duct in a newborn infant c. Slight swelling over the upper lid and along the bony orbit if the individual has a cold d. Absence of drainage from the puncta when pressing against the inner orbital rim
D. Absence of drainage from the puncta when pressing against the inner orbital rim No swelling, redness, or drainage from the puncta should be observed when it is pressed. Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.
The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? a. Thickness or bulging of the lens b. Posterior chamber as it accommodates increased fluid c. Contraction of the ciliary body in response to the aqueous within the eye d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber
D. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber Intraocular pressure is determined by a balance between the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: a. The eyes converge to focus on the light. b. Light is reflected at the same spot in both eyes. c. The eye focuses the image in the center of the pupil. d. Constriction of both pupils occurs in response to bright light.
D. Constriction of both pupils occurs in response to bright light. The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.
The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? a. Dilation of the pupils b. Consensual light reflex c. Conjugate movement of the eyes d. Convergence of the axes of the eyes
D. Convergence of the axes of the eyes The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.
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.
D. Increased intracranial pressure. 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.
A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: a. Examine the retina to determine the number of floaters. b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal findings, and refer him to an ophthalmologist. d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.
D. Know that floaters are usually insignificant and are caused by condensed vitreous fibers. Floaters are a common sensation with myopia or after middle age and are attributable to condensed vitreous fibers. Floaters or spots are not usually significant, but the acute onset of floaters may occur with retinal detachment.
During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? a. Yellow fatty deposits over the cornea b. Pallor near the outer canthus of the lower lid c. Yellow color of the sclera that extends up to the iris d. Presence of small brown macules on the sclera
D. Presence of small brown macules on the sclera Normally in dark-skinned people, small brown macules may be observed in the sclera.
A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? a. Smooth and clear corneas b. Opacity of the lens behind the cornea c. Bleeding from the areas across the cornea d. Shattered look to the light rays reflecting off the cornea
D. Shattered look to the light rays reflecting off the cornea A corneal abrasion causes irregular ridges in reflected light, which produce a shattered appearance to light rays. No opacities should be observed in the cornea. The other responses are not correct.
A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? a. Refer the patient to an ophthalmologist or optometrist for further evaluation. b. Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.
D. Shorten the distance between the patient and the chart until the letters are seen, and record that distance. If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity.
The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye" and should: a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart. c. Assess the child's visual fields with the confrontation test. d. Test for strabismus by performing the corneal light reflex test.
D. Test for strabismus by performing the corneal light reflex test. Testing for strabismus is done by performing the corneal light reflex test and the cover test. The Snellen eye chart and confrontation test are not used to test for strabismus.
During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: a. Decreased in the older adult. b. Impaired in a patient with cataracts. c. Stimulated by cranial nerves (CNs) I and II. d. Stimulated by CNs III, IV, and VI.
D. stimulated by CNs III, IV, and VI Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI.