Chapter 13
The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal? 4 mm 6 mm 2 mm 8 mm
4 mm Explanation: Pupils are normally equal in size and range from 3 to 5 mm. Size outside this range are considered abnormal. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 318. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 318
You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what? A left temporal hemianopsia A homonymous hemianopsia A bitemporal hemianopsia A quadrantic defect
A left temporal hemianopsia Explanation: When the client's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 327. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 327
Inspection of a client's eyelids reveals significant lid swelling, moderate redness, but little pain. Which of the following would the nurse suspect? Blepharitis Hordeolum Chalazion Exophthalmos
Chalazion Explanation: A chalazion is an infection of the meibomian gland that produces extreme swelling of the lid, and moderate redness, but minimal pain. Blepharitis is manifested by redness and crusting along the lid margins. Hordeolum is an infection of the hair follicle causing local redness, swelling, and pain. Exophthalmos is a protrusion of the eyeball accompanied by retracted eyelid margins. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 344. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 344
A client asks a nurse if any foods promote eye health. What food would the nurse include as a response? Foods that contain lots of water Low-fat meat Deep-water fish Multigrain foods
Deep-water fish Explanation: Foods that promote eye health include deep-water fish, fruits, and vegetables (e.g., carrots, spinach). Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 321. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 321
A nurse examines a client's retina and finds cotton-wool patches. Which of the following would the nurse suspect? Glaucoma Optic atrophy Diabetes mellitus Papilledema
Diabetes mellitus Explanation: Cotton-wool patches are associated with diabetes mellitus and hypertension. An enlarged physiologic cup would be associated with glaucoma. A swollen optic disc with blurred margins suggests papilledema. A white optic disc and lack of disc vessels suggests optic atrophy. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 321. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 321
A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result? Shined on the forehead Directly on the eye being examined Focused on the bridge of the nose Pointed at a fixed object on the wall
Focused on the bridge of the nose Explanation: When testing the corneal reflex, the nurse should shine the light toward the bridge of the nose. At the same time, the client is instructed to stare straight ahead. This facilitates a parallel image on the cornea. The eye response upon shining the light toward the eye may interfere with the assessment. The light should not be shined toward the forehead or on an object on the wall. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 328. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 328
What is vital in maintaining vision and a healthy outlook for clients? Emotional support Health education Monthly eye exams Physical exercise
Health education Explanation: Nursing education is vital in maintaining vision and a healthy outlook for clients. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 337. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 337
Question 19 of 20 A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Aqueous chamber Vitreous chamber Lacrimal apparatus Sinus
Lacrimal apparatus Explanation: The lacrimal apparatus (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 317. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 317
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? Narcotic use Recent peripheral nervous system injury Recent eye trauma Macular degeneration
Narcotic use Explanation: Pinpoint pupils suggest narcotic use or brain damage. Hyphema would suggest recent eye trauma. Dilated and fixed pupils typically result from central nervous system injury, circulatory collapse, or deep anesthesia. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 347. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 347
On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? Test the pupils for direct and consensual reaction to light Document the findings in the client's record Obtain a referral to the ophthalmologist for a complete eye exam Perform both the distant and near visual acuity tests
Perform both the distant and near visual acuity tests Explanation: The first thing the nurse should do is perform both the distant and near visual acuity exams to assess for loss of far and near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the client's record. If abnormalities are found upon assessment, the client should be referred for a complete eye examination. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice.
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? Cataract formation Presbyopia Loss of convergence Macular degeneration
Presbyopia Explanation: Presbyopia denotes an age-related deficit in close vision. It is less likely that cataracts, macular degeneration, or loss of convergence underlie the colleague's visual changes. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, pp. 336-341. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 336-341
During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect? Cataracts Presbyopia Tropia Myopia
Presbyopia Explanation: Presbyopia is indicated when the client moves an object away from the eyes to focus. It is a common condition in clients over age 45. Myopia is impaired far vision. Cataracts typically are associated with painless blurring, light sensitivity, poor night vision, and a need for a brighter light to read. Tropia refers to a misalignment of the eyes. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 341. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 341
A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? She can see at 100 feet what a normal person could see at 20 feet. 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 20 feet what a normal person could see at 100 feet. Explanation: The denominator of an acuity score represents the line on the chart the client can read. In the example above, the client could read the larger letters corresponding with what a normal person could see at 100 feet. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, pp. 325-226. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 325-226
The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this client's vision? Snellen E Allen Ishihara PERRLA
Snellen E Explanation: The Snellen E chart can be used for people who cannot read or speak English. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 336. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 336
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? The client and the examiner see the examiner's finger at the same time Eyes converge on an object as it is moved towards the nose Client's consensual pupil constricts in response to indirect light 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 Explanation: The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger and a delay in seeing indicates reduced peripheral vision. Client's consensual pupils constrict in response to indirect light as well as direct light shown into the client's pupils resulting in constriction is observed when testing the pupils for reaction to light. Eyes converge on an object as it is moved towards the nose tests for accommodation. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 327. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 327
The nurse tests the six cardinal directions to test extraocular movement of the eye. False True
True Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, pp. 328-239. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 328-239
How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking? Use a Snellen E chart to perform the examination Move an object through the six cardinal positions of gaze Have the client read from a Jaeger reading card Perform the confrontation test
Use a Snellen E chart to perform the examination Explanation: If a client does not speak English, is unable to read, or has a verbal communication problem, the Snellen E chart can be used to test the client's distant visual acuity. With this test, the client is asked to indicate by pointing which way the E is open on the chart. The six cardinal positions of gaze test eye muscle function and cranial nerve function. The Jaeger chart tests near visual acuity. Confrontation test is used to test visual fields for peripheral vision. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 336. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 336
An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to retinal damage. myopia. corneal damage. cataracts.
corneal damage. Explanation: Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, pp. 320-337. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 320-337
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 document the findings in the client's records. ask the client if there is a genetic history of blindness. examine the client for other signs of glaucoma. refer the client for further evaluation.
document the findings in the client's records. Explanation: Validate the eye assessment data that you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 16: Assessing Eyes.
An adult client 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 evaluation of possible glaucoma. increased intracranial pressure. migraine headaches. bacterial infection.
glaucoma. Explanation: A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 320. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 320
The nurse is planning to assess a client's near vision. Which technique should be used? shine a light on the bridge of the nose have the client read newspaper print held 14 inches from the eyes have the client stand 20 feet from a wall chart and read the letters after covering one eye ask the client to move the eyes in the direction of a moving finger
have the client read newspaper print held 14 inches from the eyes Explanation: Near vision is tested by asking the client to read newspaper print held 14 inches from the eyes. Shining a light on the bridge of the nose tests the corneal light reflex. Moving the eyes in the direction of a moving finger tests for extraocular movements. Having the client read letters on a wall chart tests for central and distance vision. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 326. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 326
A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent hemianopsia macular degeneration retinal detachment open-angle glaucoma
macular degeneration Explanation: Macular degeneration causes deterioration in the center of the retina, which leads to a gradual loss of central vision. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, pp. 336-348. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 336-348
Photoreceptors of the eye are located in the eye's lens. retina. ciliary body. pupil.
retina. Explanation: The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends it to the brain. The retina consists of numerous layers of nerve cells, including the cells commonly called rods and cones. These specialized nerve cells are often referred to as "photoreceptors" because they are responsive to light Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 318. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 318
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? "Have you ever been tested for diabetes?" "Do you exercise regularly?" "At what age did you first start wearing glasses?" "Do you ever take over-the-counter pain medications?"
"Have you ever been tested for diabetes?" Explanation: Diabetes is a significant risk factor for cataracts, especially those with an early onset. Exercise, use of pain medications, and visual acuity are not closely correlated with the development of cataracts. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 321. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 321
A 52-year-old client with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse? "Please come into the clinic right away so we can see what is wrong." "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." "I have an opening tomorrow at 2 in the afternoon. Can you come in then?"
"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." Explanation: Floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted clients; no additional follow-up is needed. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 321. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 321
Which of the following assessment findings suggests a problem with the client's cranial nerves? Fundoscopic examination reveals intraocular bleeding. A client's extraocular movements are asymmetrical and she complains of diplopia. A client's lens appears cloudy and she claims that her visual acuity has recently declined. 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. Explanation: Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, pp. 318-325. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 318-325
A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate? Use the E chart rather than the Snellen chart for testing. Have the client keep the glasses on but occlude one eye. Test the client's near visual acuity instead. Ask the client to remove the glasses before testing.
Ask the client to remove the glasses before testing. Explanation: When testing distant visual acuity, the nurse should have the client remove the reading glasses, because they blur distant vision. The client would wear his or her glasses during the test if they were not reading glasses. The nurse would still test the client's distant visual acuity. The E chart would be appropriate if the client could not read or has a handicap that prevents verbal communication. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 325. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 325
Which technique by the nurse demonstrates proper use of the ophthalmoscope? Approaches the client directly in front of the pupil Uses right eye to examine the client's left eye Asks the client to fix the gaze upon an object and look straight ahead Moves the scope around so the entire optic disk may be seen
Asks the client to fix the gaze upon an object and look straight ahead Explanation: After turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye & left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 328. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 328
A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet Client can read the 20/50 line correctly and two other letters on the line above When 50 feet from the chart, the client can see better than a person standing at 20 feet Client did not wear his glasses for this test and therefore it is not accurate
At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet Explanation: The Snellen chart tests distant visual acuity by seeing how far the client can read the letters standing 20 feet from the chart. The top number is how far the client is from the chart and the bottom number refers to the last line the client can read. A reading of 20/50 means the client sees at 20 feet what a person with normal vision can see at 50 feet. The minus number is the number of letters missed on the last line the client can distinguish. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 326. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 326
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
Consensual reaction Explanation: The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 332. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 332
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? Accommodation Consensual response Direct reflex Optic chiasm
Consensual response Explanation: When a light is shone in one eye, that eye will constrict and the opposite (consensual) eye will also constrict. Shining a light in one eye with the resulting constriction of that eye demonstrates the direct reflex. The optic chiasm is the point where the optic nerves from each eyeball cross. Accommodation occurs when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, pp. 332-346. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 332-346
A nurse inspects the eyes of a young child and notices the inward turning of the eyes. What test should the nurse perform to assess whether this finding is normal or abnormal? Confrontation Pupillary reaction to light Corneal light reflex Cover test
Corneal light reflex Explanation: In young children, the pupils will often appear at the inner canthus due to the epicanthic fold. To test the corneal light reflex, the nurse shines a penlight about 12 inches from the face, directing it towards the bridge of the nose. The reflection of light on the cornea should be in the exact same spot on each eye. If not, this is considered abnormal and requires further assessment. The cover test does not test extraocular muscle function. The confrontation test examines peripheral vision. Pupillary reaction to light test constriction of pupil, not alignment. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 328. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 328
The nurse is teaching about the importance of regular eye examinations and should include information about which conditions that place clients at highest risk for blindness? (Select all that apply.) Osteoarthritis Hypertension Hypothyroidism Hyperlipidemia Diabetes
Diabetes Hypertension Explanation: Diabetic retinopathy is the most common cause of blindness in the United States. Hypertensive retinopathy is another high risk factor for blindness over hypothyroidism, hyperlipidemia, and osteoarthritis. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 321. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 321
Why is it important to ask the client regarding discharge or drainage from the eyes? Discharge is associated with a detached retina Discharge is associated with inflterm-35ammation or infection Discharge is associated with presbyopia Discharge is associated with glaucoma
Discharge is associated with inflammation or infection Explanation: Discharge is associated with inflammation or infection. Glaucoma is a disease of the optic nerve that involves loss of retinal ganglion cells. With aging, the ability of the lens to accommodate decreases. Near vision is subsequently impaired, and thus older adults need reading glasses. This is presbyopia. Discharge is not an indication of a detached retina. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 321. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 321
A nurse is inspecting a client's eyelids and eyelashes. Which of the findings would the nurse document as abnormal? Upright lower eyelid White sclera absent above iris Drooping of the upper lid Raised yellow plaques near inner canthus
Drooping of the upper lid Explanation: Drooping of the upper lid is ptosis and may be attributed to oculomotor nerve damage, myasthenia gravis, weakened muscle or tissue, or a congenital disorder. It is an abnormal finding. Raised yellow plaques near the inner canthus are a normal variation associated with increasing age and high lipid levels. An upright lower eyelid and white sclera that is not visible above or below the iris are normal findings. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 330. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 330
What is a characteristic symptom of Graves hyperthyroidism? Exophthalmos Pinguecula Pterygium Episcleritis
Exophthalmos Explanation: In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 345. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 345
What is a characteristic symptom of Graves hyperthyroidism? Pterygium Episcleritis Exophthalmos Pinguecula
Exophthalmos Explanation: In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 345. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 345
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 Ectropion Epicanthus Exophthalmos
Exophthalmos Explanation: In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumor and inflammation in the orbit. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 345. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 345
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record? Exotropia Strabismus Presbyopia Esotropia
Exotropia Explanation: With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 345. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 345
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record? Presbyopia Esotropia Exotropia Strabismus
Exotropia Explanation: With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 345. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 345
Which of the following would a nurse expect to assess in a client with esotropia? Eye oscillating Eye turning outward Eye malalignment Eye turning inward
Eye turning inward Explanation: Esotropia is a term used to describe eyes that turn inward. Exotropia refers to an outward turning of the eyes. Strabismus refers to a constant malalignment of the eyes. Nystagmus refers to oscillating or shaking movement of the eye. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 345. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 345
Which of the following would a nurse expect to assess in a client with esotropia? Eye turning outward Eye oscillating Eye malalignment Eye turning inward
Eye turning inward Explanation: Esotropia is a term used to describe eyes that turn inward. Exotropia refers to an outward turning of the eyes. Strabismus refers to a constant malalignment of the eyes. Nystagmus refers to oscillating or shaking movement of the eye. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 345. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 345
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? Glaucoma Episcleritis Macular degeneration Strabismus
Glaucoma Explanation: Seeing halos around lights is associated with narrow-angle glaucoma. This symptom is not associated with episcleritis, strabismus, or macular degeneration. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 320. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 320
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? 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 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
Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time Explanation: Near vision is tested with a Jaeger card, Snellen card, or comparable card), held 14 inches from the face. Have the client cover one eye with an opaque card before reading from top to bottom. Sitting the client in front of the examiner, extending one arm, and slowly move one finger upward until it is seen by both the client and the examiner is a test for gross peripheral vision. If the client wears glasses, they should be left on for the test. Placing the client 20 feet from the chart and record the smallest line the client can read is the test for distant acuity. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 326. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 326
A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test the near visual acuity using a Jaeger reading card? Instruct the client hold the chart 14 inches from the eyes Place the chart 20 feet away from the client on the wall Place the chart on a table 17 inches away from the client Instruct the client to hold the chart away from the body at arm's length
Instruct the client hold the chart 14 inches from the eyes Explanation: To test the near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arm's length is an arbitrary length depending on the size of the client & is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 326. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 326
During adolescence, what vision change is common? Nearsightedness Amblyopia Presbyopia Color blindness
Nearsightedness Explanation: Vision changes, such as nearsightedness, are common in adolescents. Amblyopia is also known as "lazy eye". This is more common in young children. Presbyopia is the decreased ability for one to focus on near objects and is more common in the adult as they age. Color blindness is a genetic condition and not impacted by the age of the client. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 341. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 341
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? Light reflection appears at different spots on both eyes Nonreaction of the opposite pupil to light Pupils dilate in response to a light shone in the eyes Eyes do not converge to focus on a shining light
Nonreaction of the opposite pupil to light Explanation: When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict. An abnormal response to this test is if wither or both pupils do not constrict in response to light. Pupils do not dilate in response to light shone into them. Convergence of the eyes is called accommodation & occurs when a person moves his focus of vision from a far object to a close object. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 346. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 346
When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. How would the nurse document this finding? Optic disc Retinal vessels Fovea Physiologic cup
Optic disc Explanation: The optic disc is round to oval with sharp, well-defined borders. The physiologic cup appears on the optic disc as slightly depressed and a lighter color than the disc. Arteriole retinal vessels appear bright red, and venules appear darker red and larger, with both progressively narrowing as they move away from the optic disc. The fovea is a small area of the retina that provides acute vision. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 318. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 318
When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following? Physiologic cup Fovea Optic disc Retinal vessels
Optic disc Explanation: The optic disc is round to oval with sharp, well-defined borders. The physiologic cup appears on the optic disc as slightly depressed and a lighter color than the disc. Arteriole retinal vessels appear bright red, and venules appear darker red and larger, with both progressively narrowing as they move away from the optic disc. The fovea is a small area of the retina that provides acute vision. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 335. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 335
During a client's eye assessment, the nurse is testing for consensual pupillary constriction. Which technique should the nurse implement? Use an ophthalmoscope to inspect the inner eye. Place a barrier between the client's eyes. Shine a light directly into one eye of the client. Hold a pencil about 12 inches from the tip of the nose.
Place a barrier between the client's eyes. Explanation: When testing for consensual response, the nurse should place a hand or another barrier to light between the client's eyes to avoid an inaccurate finding. Holding a pencil 12 inches from the tip of the nose is appropriate when testing for accommodation. The nurse should shine a light obliquely onto the eye when testing direct pupillary response. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 322. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 322
When testing the near reaction, an expected finding includes which of the following? Pupillary constriction on near gaze; dilation on distant gaze Pupillary dilation on near gaze; constriction on distant gaze Pupillary constriction on near gaze; constriction on distant gaze Pupillary dilation on near gaze; dilation on distant gaze
Pupillary constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far gaze. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 332. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 332
A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states 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? Risk for Injury Disturbed Self-Concept Self-Care Deficit Ineffective Individual Coping
Risk for Injury Explanation: The only nursing diagnosis that can be confirmed with this data is Risk for Injury. The client is aware of the dangers of driving due to changes in his vision. There is not enough data to support the other diagnosis. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 337. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 337
A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis? Acute iritis Subconjunctival hemorrhage Corneal abrasion Conjunctivitis
Subconjunctival hemorrhage Explanation: A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turns yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rare for a serious condition to cause it, so reassurance is usually the only treatment necessary. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, pp. 330-331. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 330-331
After teaching a group of students about visual fields and visual pathways, the instructor determines that the teaching was successful when the students identify which of the following? The optic nerves from each eyeball cross at the optic chiasma. The visual field of each eye is divided into six quadrants. The visual field of each eye provides a separate, distinct view. The left side of the brain views the right side of the world.
The optic nerves from each eyeball cross at the optic chiasma. Explanation: The optic nerves from each eyeball cross at the optic chiasma. The visual field of each eye is divided into four quadrants. The left side of the brain views the right side of the world due to crossing over of the nerve fibers. The visual fields of each eye overlap. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice.
When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction? Up To the left To the right Down
Up Explanation: The correct technique to use when examining a client's sclera and conjunctiva during an eye examination is to instruct the client to look up. Having the client look down, to the right, or to the left will not provide visualization of the sclera or conjunctiva during the examination. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 330. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 330
How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking? Have the client read from a Jaeger reading card Move an object through the six cardinal positions of gaze Perform the confrontation test Use a Snellen E chart to perform the examination
Use a Snellen E chart to perform the examination Explanation: If a client does not speak English, is unable to read, or has a verbal communication problem, the Snellen E chart can be used to test the client's distant visual acuity. With this test, the client is asked to indicate by pointing which way the E is open on the chart. The six cardinal positions of gaze test eye muscle function and cranial nerve function. The Jaeger chart tests near visual acuity. Confrontation test is used to test visual fields for peripheral vision. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 336. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 336
The functional reflex that allows the eyes to focus on near objects is termed accommodation. indirect reflex. refraction. pupillary reflex.
accommodation. Explanation: Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 332. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 332
The functional reflex that allows the eyes to focus on near objects is termed pupillary reflex. indirect reflex. refraction. accommodation.
accommodation. Explanation: Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 332. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 332
A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis. has a watery, mucoid discharge. usually follows trauma. is not painful. can result from a cough.
has a watery, mucoid discharge. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 330. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 330
A client notices that the newspaper print is not as clear to read as it used to be. What health problem should the nurse consider is occurring with this client? strabismus myopia hyperopia amblyopia
hyperopia Explanation: A change in seeing things close to the eyes is considered hyperopia or farsightedness. Myopia is difficulty with seeing distances or nearsightedness. Amblyopia is considered a lazy eye where one eye is working harder than the other. Strabismus is constant misalignment of the eyes. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 341. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 341
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? glaucoma cataracts detached retina macular degeneration
macular degeneration Explanation: Macular degeneration causes a loss of central vision. Risk factors for macular degeneration are age, smoking history, obesity, family history, and female gender. Cataracts are characterized by cloudiness of the eye lenses. Glaucoma is an increase in intraocular pressure that places pressure on eye structures and affecting vision. A detached retina is the sudden loss of vision in one eye. This health problem may be precipitated by the appearance of blind spots. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 13: Eye Assessment for Advanced and Specialty Practice, p. 319. Chapter 13: Eye Assessment for Advanced and Specialty Practice - Page 319
