Chapter 14

While examining a patient with an eye infection, the nurse observes red, scaly, greasy flakes on the edge of the eyelids. The nurse asks the patient to describe the discomfort. What description is the patient most likely to provide? "I can see two images of a single object." "I feel like I have sand particles in my eyes." "I have thick, yellow discharge from my eyes." "I feel the movement of spots in front of my eyes."

"I feel like I have sand particles in my eyes."

A nurse is teaching a class on the pathology and physiology of the eye. Which statement by the nurse about eversion of the eyelids during physical examination is accurate? "The patient needs to close both eyes." "The applicator stick should be placed on the lower lid." "The lower lid should be slid up along the bony orbit by the examiner." "The lashes need to be grasped between the examiner's thumb and forefinger."

"The lashes need to be grasped between the examiner's thumb and forefinger."

The nurse observes a health care provider assessing a patient. During the exam, the provider presses against the patient's lacrimal sac and a clear fluid is expelled through the puncta. What can the nurse deduce from this finding? A normal finding that indicates a leakage of aqueous humor A variation from normal that reflects the formation of a hordeolum A variation from normal that may indicate a blocked nasolacrimal duct A normal finding, because the fluid is a lubricating substance stored in the lacrimal sac

A variation from normal that may indicate a blocked nasolacrimal duct

While assessing the eyes of a patient using an ophthalmoscope, the nurse finds that the patient has a scleral crescent. What could cause this finding in the patient? Absence of pigment in the choroid layer Extension of the cup into the disc border Accumulation of pigment in the choroid layer Presence of elevated yellow nodules on the sclera

Absence of pigment in the choroid layer

A patient with a staphylococcus eye infection has seborrheic dermatitis of the eyelid. The patient also reports burning and the sensation of a foreign body in the eye. Which eyelid infection should the nurse look for in the patient? Chalazion Blepharitis Hordeolum Dacryocystitis

Blepharitis

During an assessment, the nurse documents that the patient's preauricular lymph node is swollen and painful. The nurse learns that the patient had a previous history of respiratory infections. Which eye complication should the nurse screen for in this patient? Hyphema Hypopyon Pterygium Conjunctivitis

Conjunctivitis

Which condition may cause miosis in a patient? Damage to the pons Damage to the optic disc Damage to the cerebral cortex Damage to the trochlear nerve IV

Damage to the pons

The nurse performs a cover test to measure a patient's eye muscle strength. Which condition can be assessed with the cover test? Esotropia Esophoria Entropion Enophthalmos

Esophoria

While doing the diagnostic position test, the nurse is still able to see the top portion of the iris while the patient is looking in the downward position. What complication should the nurse watch for in this patient? Nystagmus Hyperthyroidism Cranial nerve dysfunction Extraocular muscle dysfunction

Hyperthyroidism

During the diagnostic positions test, a patient's eye does not move to the down and nasal positions. Which cranial nerve may be affected in the patient? III IV V VI

IV

Which technique does the nurse use to assess the vision of a 7-year-old child? Cover test Ishihara's test Hirschberg test Confrontation test

Ishihara's test

While collecting the subjective data of a patient, the nurse finds that the patient has a previous history of glaucoma. The nurse also finds pilocarpine ophthalmic drops on the patient's prescription list. Which eye abnormality could this patient be at risk for? Miosis Tonic pupil Anisocoria Dacryocystitis

Miosis

What causes binocular diplopia? Dry eyes Cataract Uncorrected refractive error Misalignment of the axes of eyes

Misalignment of the axes of eyes

The nurse is caring for a patient who has been administered deep anesthesia. What visual response would the nurse find in the patient? Miosis Mydriasis Anisocoria Adie's pupil

Mydriasis

The nurse assesses the eye movements of a patient using the diagnostic positions test and finds that the patient is unable to turn his or her eyes in three cardinal positions of gaze—up and nasal, straight nasal, and down and temporal positions. Based on these findings, which cranial nerve paralysis could the patient have? Oculomotor cranial nerve III Trochlear cranial nerve IV Trigeminal cranial nerve V Abducens cranial nerve VI

Oculomotor cranial nerve III

Which are the two cranial nerves (CN) that are responsible for the pupillary light reflex? Optic Oculomotor Abducens Trochlear Trigeminal

Optic Oculomotor

A patient has decreased visual acuity and decreased color vision. The nurse observes a grayish discoloration on the optic disc. Which abnormality will the nurse most likely find in the patient? Papilledema Optic atrophy Narrowed artery Arteriovenous crossing

Optic atrophy

After examining a patient, the nurse documents that the patient has arcus senilis. Which finding in the patient enabled the nurse to reach this conclusion? Presence of thickened and raised corneas Presence of a gray-white arc around the limbus Presence of scattered yellow dots on the retina Presence of yellow plaques on the inner canthus Presence of elevated yellow nodules on the sclera

Presence of thickened and raised corneas Presence of a gray-white arc around the limbus

While collecting data on a patient, the nurse observes bright red blood on the patient's left eyeball. On further examination, the nurse finds a round, bright red 1-mm patch over the lateral aspect of the globe. What condition does the nurse suspect in the patient? Conjunctivitis Corneal abrasion Vitreous hemorrhage Subconjunctival hemorrhage

Subconjunctival hemorrhage

Which finding indicates that a patient has a normal and healthy optic disc? The color of the optic disc is gray. The color of the optic disc is red. The color of the optic disc is black. The color of the optic disc is yellow-orange.

The color of the optic disc is yellow-orange.

Which findings would make the nurse suspect a 1-month-old infant is at risk of vision impairment? The infant is unable to reach for a toy. The infant is unable to fixate its gaze on a toy. The infant is unable to visually follow a bright toy. The infant does not respond visually to a person's face. The infant is unable to visually follow the toy in all directions.

The infant is unable to fixate its gaze on a toy. The infant is unable to visually follow a bright toy.

The nurse is assessing a 1-month-old and documents that the infant has a doll's eye reflex. Which finding led the nurse to reach this conclusion? The infant fixes the eyes towards a bright light for few seconds. The infant's pupils constrict when they are exposed to bright lights. The infant shift the eyes to opposite direction after quick beats of nystagmus. The infant opens the eye when the head is lowered slowly in a supine position.

The infant shift the eyes to opposite direction after quick beats of nystagmus.

A patient tells the nurse, "I got an eye injury while playing baseball." The nurse notices blood in the anterior chamber of the eye. What should the nurse conclude from these findings? The patient has hyphema. The patient has hypopyon. The patient has pterygium. The patient has a corneal abrasion.

The patient has hyphema.

The health care provider uses the red lens and adjusts the diopter setting of the ophthalmoscope while assessing a patient's eyes. Why is this assessment technique performed? The patient has farsightedness. The patient has nearsightedness. The provider is observing the red reflex. The provider is observing the corneal light reflex.

The patient has nearsightedness.

While checking lateral gaze, the nurse notices that the patient's eye rhythmically moves when turned to the lateral position. What can the nurse interpret from this observation? The patient has strabismus. The patient has nystagmus. The patient has glaucoma. The patient has phoria.

The patient has nystagmus.

After an eye-assessment, the health care provider suspects that the patient may have a brain tumor. What sign or symptom would the nurse expect to find in this patient to support the health care provider's suspicion? The patient has optic atrophy. The patient has papilledema. The patient has cataracts. The patient has a corneal abrasion.

The patient has papilledema.

The nurse is assessing a patient using the diagnostic positions test. Based on which finding does the nurse document paralysis of cranial nerve VI? The patient is unable to turn the eye up and nasal. The patient is unable to turn the eye straight nasal. The patient is unable to turn the eye down and nasal. The patient is unable to turn the eye straight temporal.

The patient is unable to turn the eye straight temporal.

While assessing the visual acuity of a patient by means of a Snellen chart, the nurse records the finding of the patient as having 20/100 vision. What does the finding indicate? The vision of the patient is normal. The patient has 20 percent of the normal vision. The patient sees at 20 feet what normal eyes would see at 100 feet. The patient must stand 100 feet from the chart to read it clearly.

The patient sees at 20 feet what normal eyes would see at 100 feet.