Sherpath Eyes and Ears

The nurse should ask a patient with a red eye which questions about associated symptoms as part of the history of present illness?

"Do you have pain in or around the eye?" "Do you have any vision loss?"

Which question related to family history should a nurse ask a patient with a red eye?

"Has anyone in your family had glaucoma?"

The nurse should ask a patient who reports halos around lights which questions as part of the past medical history?

"Have you been treated for glaucoma?" "Do you have seasonal allergies?"

Which questions should the nurse ask a patient with vision loss about associated symptoms as part of the history of present illness? A. "Have you experienced a headache?" B. "Have you tried using eye drops?" C. "Do you have any photosensitivity?" D. "Does it feel like there is something in the eye?" E. "How long have you had trouble seeing?"

"Have you experienced a headache?" "Do you have any photosensitivity?" Does it feel like there is something in the eye?"

During the eye assessment, the nurse notes a visual acuity of 20/70 and periorbital swelling. The patient complains of blurred vision and has had recent eye surgery. Which history of present illness information should the nurse document as a part of the eye assessment?

Blurred vision

What findings are expected when assessing the iris and pupils of the eyes?

Both pupils constrict when a light is shone directly into one eye. Both pupils are the same size.

Which finding is expected when both eyes are examined for light reactivity?

Brisk bilateral reactivity

When examining the eyes, which finding is indicative of cataracts?

Cloudiness of the lens in the affected eye

For which features should the nurse inspect during assessment of the sclera?

Color of the sclera Presence of senile hyaline plaque

Which eye reaction is a normal finding when light is briefly shone over the pupil? a. Miosis b. Dilation c. Constriction d. No reactivity

Constriction

Which cranial nerve is responsible for elevation of the eyelid?

Cranial nerve III

When performing the ophthalmoscopic examination, which finding of the optic discs is abnormal?

Cupping of the disc

What is the function of the pupil? a. Dilates and contracts to control the amount of light passing through to the retina b. Produces aqueous humor and contains muscles for accommodation c. Transforms light impulses into electrical impulses d. Serves as the site of central vision in the eye

Dilates and contracts to control the amount of light passing through to the retina

Which family history question should the nurse ask a patient with vision loss? a. "Do you wear glasses or contact lenses?" b. "Does anyone in your family have cataracts?" c. "Have you ever been diagnosed with glaucoma?" d. "Do you also have eye pain with the vision loss?"

Does anyone in your family have cataracts?

For which features should the nurse inspect the orbital area?

Edema Puffiness Sagging tissue

Which eye assessment finding is associated with hyperthyroidism? a. Episcleritis b. Strabismus c. Nystagmus d. Exophthalmos

Exophthalmos

A patient with a history of hypertension complains of impaired vision and eye discomfort. The nurse notes hemorrhages in the eye and increased ocular pressure. Which information related to the eye assessment should the nurse document as objective data?

Eye hemorrhages Increased ocular pressure

Which age-related color change is expected on assessment of the sclera of an older adult?

Yellow

Match the external eye structure with the relevant function. - Distributes tears over the eye surface - Protects from foreign bodies and desiccation - Produces tears that moisten the eye a. conjunctiva b. eyelid c. lacrimal gland

*Distributes tears over the eye surface* Eyelid *Protects from foreign bodies and desiccation* Conjunctiva *Produces tears that moisten the eye* Lacrimal gland

Match the nerve with the relevant function in the eye. - Innervates the lateral rectus muscle - Innervates the superior oblique muscle - Elevates and retracts the eyelid

*Innervates the lateral rectus muscle* Abducens nerve *Innervates the superior oblique muscle* Trochlear nerve *Elevates and retracts the eyelid* Oculomotor nerve

Match the examination with the type of vision it tests.

*Near vision* Rosenbaum pocket screener *Peripheral vision* Confrontation test *Central vision* Snellen chart

Match the internal eye structure with the relevant function. - Supports the internal eye structures - Major part of the refractive power of the eye - Contains pigment that produces eye color - Transforms light impulses into electrical impulses - Allows images from varied distances to be focused on the retina a. cornea b. lens c. retina d. sclera e. iris

*Supports the internal eye structures* Sclera *Major part of the refractive power of the eye* Cornea *Contains pigment that produces eye color* Iris *Allows images from varied distances to be focused on the retina* Lens *Transforms light impulses into electrical impulses* Retina

Which eye finding is normal for a 3-year-old child? a. White reflex b. 20/40 visual acuity c. Different visual acuity in each eye d. Bleeding of retinal blood vessels

20/40 visual acuity

Label the indicated structures of the eye. 1 Outer canthus 2 Lacrimal sac 3 Iris 4 Pupil 5 Conjunctiva

A 1 B 2 C 3 D 4 E 5

Label the indicated structures of the inner eye. 1 Sclera 2 Cornea 3 Iris 4 Lens 5 Retina

A 1 B 2 C 3 D 4 E 5

On inspection of the eyelid, the nurse should assess which features? Select all that apply. - Presence of eyelashes - Fasciculations and tremors - Tenderness of the lacrimal duct - Ability to close the eyelid completely - Flakiness, redness, and swelling of the margin

Fasciculations and tremors Presence of eyelashes Ability to close the eyelid completely Margins for flakiness, redness, and swelling

A patient with a history of hypertension complains of diplopia and halos. The nurse notes eye redness and irritation and a blood pressure of 136/82 mm Hg. Which finding should the nurse document as history of present illness related to the eye assessment? Select all that apply. - Halos - Diplopia - Eye redness - Blood pressure of 136/82 mm Hg - Patient's history of hypertension

Halos Diplopia Eye Redness

Which past medical history questions should the nurse ask a patient with vision loss? Select all that apply. - "Have you had cataracts removed?" - "Does anyone in your family have cataracts?" - "Have you ever been diagnosed with glaucoma?" - "Are you having eye pain?" - "Have you been diagnosed with high blood pressure?"

Have you had cataracts removed? Have you ever been diagnosed with glaucoma? Have you been diagnosed with high blood pressure?

The eye is innervated by which intracranial nerves? - III - IV - VI - XI - XII

III (3) IV (4) VI (6)

When examining the eyes, which finding is indicative of extraocular muscle weakness? a. Nystagmus b. Red reflex c. Pupillary dilation d. Pupillary constriction

Nystagmus

What are the internal layers of the eye? - Outer fibrous layer - Subcutaneous layer - Middle layer - Inner layer - Dermal layer

Outer fibrous layer Middle layer Inner layer

If a patient's vision is less than 20/20 on the Snellen test, which test should be used to determine whether loss of visual acuity is due to a refractive error? a. Lea cards b. Pinhole test c. HOTV eye chart d. Rosenbaum near vision card

Pinhole test

When examining the eyes, which finding describes abnormal findings of the *eyelid*? a. Drusen bodies b. Sclera yellow, dark green, or rust-colored c. Pterygium d. Ptosis

Ptosis

Which eye structure is known as the "white" of the eye? Iris Sclera Cornea Conjunctiva

Sclera

How should the nurse test the clarity of the cornea? a. Shine a light on the cornea. b. Palpate the eyelids gently. c. Swipe the sclera softly with a cotton swab. d. Assess visual acuity using the Snellen chart.

Shine a light on the cornea

Which information should the nurse document as history of present illness related to strabismus? Select all that apply. - Sudden onset of double vision - Eye surgery to correct double vision - Patient reports that eyes cross - Nurse notes that one eye deviates inward - Use of a protective eye device

Sudden onset of double vision Patient reports that eyes cross

The nurse assesses an older adult patient who reports lack of access to food and poor intake over the past month. The nurse notes sunken eyes and loose, wrinkled eyelids. Which information suggestive of poor nutrition should the nurse document as objective data?

Sunken eyes Loose eyelids Wrinkled eyelids

During the eye assessment, the nurse notes discoloration of the sclera and red conjunctiva. The patient reports poor vision and eye pain and wears protective eye devices for work. Which *subjective* information would the nurse document as a part of the *personal/social history* related to the eye examination? a. Eye pain b. Poor vision c. Red conjunctiva d. Discoloration of the sclera e. Use of a protective eye device

Use of a protective eye device

When performing the ophthalmoscopic examination, which finding of the blood vessels is abnormal?

Venules smaller than arterioles