Chapter 16 eyes

A nurse is performing an eye assessment of an 81-year-old male client. Which of the following would the nurse document as a normal finding? A) Ectropion B) Episcleritis C) Chalazion D) Exophthalmos

A

A nurse who works at an outpatient ophthalmic clinic has a large number of clients. Which client would be at the highest risk for developing cataracts? A) A 55-year-old female client B) A 40-year-old with arteriosclerosis C) A client who has severe environmental allergies D) A male client who is obese

A

The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? A) Far, then near B) Lateral, then near C) Near, then far D) Lateral, then far

A

After teaching a group of students about the external and internal structures of the eye, the instructor determines that the teaching was successful when the students identify which of the following as external structures? Select all that apply. A) Lacrimal apparatus B) Conjunctiva C) Lens D) Iris E) Sclera F) Caruncle

A,B,F

The nurse is assessing a client whose electronic health record notes a diagnosis of esotropia. When examining this client, the nurse should expect what finding? A) Eye turning outward B) Eye malalignment C) Eye turning inward D) Eye oscillating

C

Which of the following would the nurse expect to assess when examining the eyes of a client who reports a history of severe allergies? A) Generalized redness B) Pinguecula C) Areas of dryness D) Nodular appearance

C

PEERLA

pupils equal, round, reactive to light and accommodation

Which CN test occular muscles?

3,4,6

A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which of the following actions? A) Observing the eye's reaction when a light is shone into the opposite eye B) Shining a light into one eye while covering the other eye with an opaque card C) Moving a finger into the client's peripheral vision field and asking the client to state when he or she sees the finger D) Comparing the difference between the client's dilated pupil and a constricted pupil

A

A nurse has performed the corneal light reflex test during a client's eye examination. During this test, the nurse held a penlight 1 foot from the client's eyes and appraised the client's eye alignment in which of the following ways? A) By comparing the reflection of the light on the client's eye surface B) By comparing the speed of pupillary constriction C) By comparing how quickly the client blinks each eyelid D) By comparing the relative color of the sclerae before and after light exposure

A

A nurse is assessing an adult client's eyes and vision. When performing the cover test, the nurse would cover one of the client's eyes and then do which of the following? A) Ask the client to focus on a distant object, looking for movement in the other eye. B) Ask the client to close the other eye then open that eye quickly. C) Ask the client to follow the nurse's finger with the other eye. D) Ask the client to look directly at a light with the other eye.

A

A nurse is assessing the eyes of a 3-year-old child. Which finding would the nurse document as normal? A) Pseudostrabismus B) Tropia C) Nystagmus D) Exotropia

A

A nurse is observing the red reflex in a client during an eye assessment. During this component of the assessment, the client states, ìI hope you can see it because I have cataracts.î What finding should the nurse expect? A) Black spokes pointing inward B) White arc around the limbus C) Thickened bulbar conjunctiva D) A red spot on the retina

A

A client tells the clinic nurse that she has sought care because she has been experiencing excessive tearing of her eyes. Which assessment should the nurse next perform? A) Inspect the palpebral conjunctiva. B) Assess the nasolacrimal sac. C) Perform the eye positions test. D) Test pupillary reaction to light.

B

A client's history suggests a need to assess eye muscle strength and cranial nerve function. What assessment should the nurse consequently perform? A) Corneal light reflex test B) Eye positions test C) Cover test D) Visual fields test

B

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? A) Recent eye trauma B) Narcotic use C) Macular degeneration D) Recent peripheral nervous system injury

B

A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, ìDo you wear sunglasses during exposure to the sun?î the nurse is addressing a known risk factor for what health problem?A) Presbyopia B) Cataracts C) Nystagmus D) Glaucoma

B

A nurse is completing a comprehensive health history of a 69-year-old woman who is a new client of the clinic. Which of the nurse's interview questions most directly addresses the client's risk for developing cataracts? A) ìDo you exercise regularly?î B) ìHave you ever been tested for diabetes?î C) ìDo you ever take over-the-counter pain medications?î D) ìAt what age did you first start wearing glasses?î

B

A nurse is presenting a class to a local community group about vision and eye health. As part of the presentation, the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation? A) It refers to a client's subjective appraisal of his or her vision. B) It begins with light rays striking the retina. C) It primarily involves the lens of the eye. D) It allows the eyes to focus on near objects.

B

The nurse is using an ophthalmoscope to examine a client's inner eye structures. What action should the nurse perform in order to accurately examine the client's optic disc? A) Slowly approach the client's eye from a 90-degree angle, maintaining a focus on the pupil. B) Position the scope close to the client's eye and look through the pupil at a 15- degree angle. C) From a distance of 3 to 5 cm, examine the pupil from a 45- to 50-degree angle. D) While looking through the ophthalmoscope, approach the client's eye slowly from the side.

B

When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. The nurse would document this as which of the following? A) Physiologic cup B) Optic disc C) Retinal vessels D) Fovea

B

A review of a client's history reveals cranial nerve IV paralysis. Which of the following findings would the nurse expect to assess? A) The eye cannot look to the outside side. B) Ptosis will be evident. C) The eye cannot look down when turned inward. D) The eye will look straight ahead.

C

A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next? A) Attempt to remove the splinter using sterile forceps. B) Irrigate the eye with dilute hydrogen peroxide. C) Arrange for worker to be promptly assessed by an eye specialist. D) Encourage the worker to see an optometrist as soon as possible.

C

A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following? A) Direct reflex B) Optic chiasm C) Consensual response D) Accommodation

C

Peripheral nerve test which cranial nerve?

CN2

A client has sought care because she states that she has begun to see halos around headlights and streetlights when she is out at night. The nurse should recognize the need to refer the client for further assessment related to what health problem? A) Episcleritis B) Strabismus C) Macular degeneration D) Glaucoma

D

A nurse has taught a group of older adults about the high incidence and prevalence of macular degeneration. What health promotion and prevention activity should the nurse encourage these clients to perform? A) Obtain a home version of the Snellen chart and test their vision weekly B) Rinse their eyes with a warmed, normal saline solution three to four times per week C) Maintain a low-sodium diet D) Post an Amsler grid in their home and perform the test on a regular basis

D

A nurse is assessing a client who is suspected to have optic atrophy. Which of the following assessment findings is most consistent with this diagnosis? A) Obscured retinal vessels B) No visible physiologic cup C) Increased appearance of the disc vessels D) A white appearance of the optic disc

D

During a client's eye assessment, the nurse is testing for consensual pupillary constriction. Which technique should the nurse implement? A) Hold a pencil about 12 inches from the tip of the nose. B) Use an ophthalmoscope to inspect the inner eye. C) Shine a light directly into one eye of the client. D) Place a barrier between the client's eyes.

D

During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide? A) ìI'm going to ask you to slowly walk forward until the last line of the chart become clear.î B) ìPlease stand at a comfortable distance from the chart and I'll get you to read each of the letters.î C) ìHold this chart and start to read out the letters after covering one of your eyes.î D) ìCover one of your eyes and then read out the letters on the chart, starting from the top.î

D

A nurse is performing an eye and vision assessment on a client who has an inner ear disorder. This disorder may contribute to what finding during the client's eye positions test?A) Strabismus B) PhoriaC) TropiaD) Nystagmus

D strabimus- crossed phoria- misalignment of the eyes tropia- misaligment of the eyes, always present nystagmus- rapid movement of the eye, side to side

A nurse is conducting an assessment of a client's eyes and vision and has completed the positions test. Following this test, the nurse will be able to document data that address what aspects of eye health? Select all that apply. A) Distant visual acuity B) Near visual acuity C) Accommodation D) Eye muscle strength E) Cranial nerve function

D,E

indirect reflex

constriction of OTHER eye

During a health history, a 62-year-old male client reveals that he occasionally sees spots before his eyes. The nurse interprets this finding as the result of which of the following? A) Increased ocular pressure B) Vitamin A deficiency C) Normal findings for client's age D) Vascular spasm

c

The cover test is used to assess for:

muscle weakness

checking peripheral vision

confrontation test

direct reflex

constriction occurs in the eye exposed to the light