Chapter 16 Prep U

A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition? Hyphema Blepharitis Chalazion Iris nevus

A

The nurse tests the six cardinal directions to test extraocular movement of the eye. True False

A

What is the open space between the eyelids called? The palpebral fissure The limbus The lacrimal apparatus The eyeball

A

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? Ptosis Exophthalmos Ectropion Epicanthus

B

A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon? Direct reaction Consensual reaction Near reaction Accommodation

B

Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)? II (optic) III (oculomotor) IV (trochlear) VI (abducens)

B

A nurse assesses the pupillary reaction to light for a client. Which precaution should the nurse follow to get an accurate result of consensual response? Shine a bright light directly into the eye to be tested Observe the response in the eye focused with light Place an opaque card in between the eyes of the client Instruct the client to close the eye not focused with light

C

Photoreceptors of the eye are located in the eye's ciliary body. lens. retina. Pupil.

C

A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye? "In children, this problem is usually caused by an increase in pressure within the eye." "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

D

A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment? Blunt-force trauma often results in fracture of the orbit High-velocity injuries are typically non-penetrating The client could have optic atrophy This could be a sign of strabismus

A

A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity? Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time Sit the client in front of the examiner, extend one arm, and slowly move one finger upward Tell the client to remove glasses, if present, and read the Snellen card using both eyes Place the client 20 feet from the Snellen chart and record the smallest line the client can read

A

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client? Use of safety equipment Prevention of knee injuries Prevention of head injuries Use of correct foot gear

A

The meibomian glands secrete an oily substance to lubricate the eyes. sweat. hormones. clear liquid tears.

A

The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following? Arcus senilis Presbyopia Ectropion Myopia

A

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed? Presbyopia Cataract formation Loss of convergence Macular degeneration

A

The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents entropion ectropion ptosis Exophthalmos

A

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what? Conjunctiva Limbus Lacrimal apparatus Eyelid

A

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? Medially toward the nose Laterally toward the ear Upward toward the forehead Downward toward the chin

A

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's esotropia. strabismus. phoria. Exotropia.

A

Normal movement of the eye involves what cranial nerves? (Mark all that apply.) II III IV V VI

A, B, C, E

The functional reflex that allows the eyes to focus on near objects is termed pupillary reflex. accommodation. Refraction. indirect reflex.

B

What is a characteristic symptom of Graves hyperthyroidism? Pterygium Exophthalmos Pinguecula Episcleritis

B

Which of the following assessment findings suggests a problem with the client's cranial nerves? A client states that he has recently begun seeing lights flashing in his field of vision. A client's extraocular movements are asymmetrical and she complains of diplopia. Fundoscopic examination reveals intraocular bleeding. A client's lens appears cloudy and she claims that her visual acuity has recently declined.

B

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? Pupils dilate in response to a light shone in the eyes. Eyes do not converge to focus on a shining light. There is no reaction in the opposite pupil to light. Light reflection appears at different spots on both eyes.

C

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? Surgery Daily use of eye drops Corrective lenses No night driving

C

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? She obtains a 20% correct score at 100 feet. She can accurately name 20% of the letters at 20 feet. She can see at 20 feet what a normal person could see at 100 feet. She can see at 100 feet what a normal person could see at 20 feet.

C

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process? Anemia Renal insufficiency Diabetes Retinal detachment

C

The nurse is examining an adult 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 assesses the muscle strength of the eye. assesses the functioning of the cranial nerves innervating the eye muscles. requires the covering of each eye separately. requires the client to focus on an object.

C

The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding? direct light response present in left eye pupils equal and react to accommodation consensual light response present in left eye consensual light response present in right eye

C

When testing the near reaction, an expected finding includes which of the following? Pupillary dilation on near gaze; dilation on distant gaze Pupillary dilation on near gaze; constriction on distant gaze Pupillary constriction on near gaze; dilation on distant gaze Pupillary constriction on near gaze; constriction on distant gaze

C

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? Client did not wear his glasses for this test and therefore it is not accurate. When 50 feet from the chart, the client can see better than a person standing at 20 feet. Client can read the 20/50 line correctly and two other letters on the line above. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

D

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data? Ineffective Individual Coping Disturbed Self Concept Self-Care Deficit Risk for Injury

D

A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for? Retinoblastoma Strabismus Retinitis pigmentosa Glaucoma

D

A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client? Exotropia Esotropia Strabismus Presbyopia

D

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 viral infection. double vision. allergic reactions. lacrimal obstruction.

D

An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing? cataracts glaucoma detached retina macular degeneration

D

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? Client's consensual pupil constricts in response to indirect light. Eyes converge on an object as it is moved towards the nose. Direct light shown into the client's pupils results in constriction. The client and the examiner see the examiner's finger at the same time.

D

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

D

Which technique by the nurse demonstrates proper use of the ophthalmoscope? Uses right eye to examine the client's left eye Moves the scope around so the entire optic disk may be seen Approaches the client directly in front of the pupil Asks the client to fix the gaze upon an object and look straight ahead

D