NUR 3065 - PrepU Chapter 11
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? Surgery Corrective lenses Daily use of eye drops No night driving
Corrective lenses Explanation: Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition.
The nurse prepares to assess the eyes of a client who is aphasia. Which tool should the nurse use to test distance vision? Newspaper Jaeger test Snellen chart E chart
E chart Explanation: The E chart is used if the client cannot read or has a handicap that prevents verbal communication. This chart is configured just like the Snellen chart by the characters are only Es which face in all directions. The client points to the direction in which the E is facing. The Jaeger test and a newspaper are used to test near vision. The Snellen chart is used by clients who are able to read and state the letter that appears on the different lines of the chart.
What is vital in maintaining vision and a healthy outlook for clients? Physical exercise Health education Monthly eye exams Emotional support
Health education Explanation: Nursing education is vital in maintaining vision and a healthy outlook for clients.
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? "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." "I have an opening tomorrow at 2 in the afternoon. Can you come in then?" "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'." 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.
Which of the following assessment findings suggests a problem with the client's cranial nerves? 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. Fundoscopic examination reveals intraocular bleeding.
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.
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
Arcus senilis Explanation: Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision.
A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding? Ask the client about previous trauma to the eyes Report this to the health care provider Document this finding in the client's record Continue with the examination
Ask the client about previous trauma to the eyes Explanation: Unequal pupil size is termed anisocoria. Often it is a normal finding but it can indicate trauma to the parasympathetic nerve supply to the iris. The nurse should ask the client about previous trauma to the eye to determine whether this is a new finding or new onset. All other options the nurse can do after this is determined.
A client complains of excessive tearing of the eyes. Which assessment would the nurse do next? Inspect the palpebral conjunctiva Perform the eye positions test Assess the nasolacrimal sac Test pupillary reaction to light
Assess the nasolacrimal sac Explanation: Excessive tearing is caused by exposure to irritants or obstruction of the lacrimal apparatus. Therefore the nurse should assess the nasolacrimal sac. Inspecting the palpebral conjunctiva would be done if the client complains of pain or a feeling of something in the eye. The client is not exhibiting signs of problems with muscle strength such as drooping, so performing the eye position test, which assesses eye muscle strength and cranial nerve function, is not necessary. Testing the pupillary reaction to light evaluates pupillary response and function of the oculomotor nerve.
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? Inspect the palpebral conjunctiva. Test pupillary reaction to light. Perform the eye positions test. Assess the nasolacrimal sac.
Assess the nasolacrimal sac. Explanation: Excessive tearing is caused by exposure to irritants or obstruction of the lacrimal apparatus. Therefore the nurse should assess the nasolacrimal sac. Inspecting the palpebral conjunctiva would be done if the client complains of pain or a feeling of something in the eye. The client is not exhibiting signs of problems with muscle strength, such as drooping, so performing the eye position test, which assesses eye muscle strength and cranial nerve function, is not necessary. Testing the pupillary reaction to light evaluates pupillary response and function of the oculomotor nerve.
A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? Client can read the 20/50 line correctly and two other letters on the line above. 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. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.
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.
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 This could be a sign of strabismus The client could have optic atrophy
Blunt-force trauma often results in fracture of the orbit Explanation: High-velocity injuries are typically penetrating. Blunt-force trauma often results in fracture of the orbit. Optic atrophy is atrophy of the optic nerve. Strabismus is the medical term for cross-eye.
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? Consensual response Optic chiasm Accommodation Direct reflex
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.
A nurse is inspecting the bulbar conjunctiva and sclera of a 67-year-old client, and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nursing action at this time? Examine the client's eye for presence of a foreign body Notify the physician of the finding Document the finding and proceed with the examination Ask the client whether he has recently had trouble focusing when reading up close
Document the finding and proceed with the examination Explanation: Yellowish nodules on the bulbar conjunctiva are called pinguecula. These harmless nodules are common in older clients and appear first on the medial side of the iris and then on the lateral side. Therefore, the nurse should document this finding and proceed with the examination. There is no need to notify the physician of the finding. Having trouble focusing when reading up close is a sign of presbyopia, or impaired near vision, which is not associated with the finding of pinguecula. A foreign body or lesion may cause irritation, burning, pain and/or swelling of the upper eyelid but would not cause yellowish nodules.
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? Exophthalmos Epicanthus Ectropion Ptosis
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.
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? Esotropia Presbyopia Strabismus Exotropia
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.
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? Eye malalignment Eye turning outward Eye oscillating 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 an oscillating or a shaking movement of the eye.
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.
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? Strabismus Retinitis pigmentosa Retinoblastoma Glaucoma
Glaucoma Explanation: Glaucoma in a first-degree relative increases the client's risk for the same problem two to three times. Retinoblastoma can be inherited from either parent but does not have increased incidence if a first-degree relative has the disease. Retinitis pigmentosa is also a genetic disease, but a client's risk of the disease is not increased if a first-degree relative is affected. Strabismus is not genetic in nature.
When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following? Optic disc Physiologic cup Fovea 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.
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 Corneal abrasion Subconjunctival hemorrhage 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.
What is the open space between the eyelids called? The lacrimal apparatus The palpebral fissure The limbus The eyeball
The palpebral fissure Explanation: The palpebral fissure is the almond-shaped open space between the eyelids. The limbus is the border of the cornea and the sclera. The eyeball is the round part of the eye within the eyelids and socket. The lacrimal apparatus protects and lubricates the cornea and conjunctiva by producing and draining tears.
How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking? Move an object through the six cardinal positions of gaze Have the client read from a Jaeger reading card Use a Snellen E chart to perform the examination 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.
The functional reflex that allows the eyes to focus on near objects is termed: refraction. indirect reflex. accommodation. 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.
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? pupils equal and react to accommodation consensual light response present in right eye consensual light response present in left eye direct light response present in left eye
consensual light response present in left eye Explanation: The consensual light response occurs when one eye is exposed to light and the pupil of the other eye constricts. Since the light was shined in the right eye, the left pupil constricted. The left eye was not exposed to direct light. There is not enough information to determine if the pupils are equal or reacting to accommodation.
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 myopia. corneal damage. cataracts. retinal damage.
corneal damage. Explanation: Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage.
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: examine the client for other signs of glaucoma. refer the client for further evaluation. document the findings in the client's records. ask the client if there is a genetic history of blindness.
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.
The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents: ectropion exophthalmos ptosis entropion
entropion
A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis: can result from a cough. has a watery, mucoid discharge. is not painful. usually follows trauma.
has a watery, mucoid discharge.
The nurse is planning to assess a client's near vision. Which technique should be used? have the client stand 20 feet from a wall chart and read the letters after covering one eye shine a light on the bridge of the nose 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
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.
