EAQ chapter 15

Which statement by a student indicates a need for further teaching about pathophysiology of the eye?

"Glaucoma is a common disease in children."

Which pathophysiology causes a scleral crescent?

Absence of pigment in the choroid layer

A patient having trouble seeing nearby objects is experiencing a dysfunction of which type of reflex?

Accommodation

Which tool involves showing a preschool child seven cards with pictures of familiar objects, kept at a distance of 15 feet?

Allen test

The nurse shines a light straight toward the bridge of the nose of the patient. A bright dot of light appears at the 3 o'clock position in the left eye and the 9 o'clock position in the right eye. How would the nurse document this finding?

Asymmetry in corneal light reflex

The nurse observes that a patient has a swollen and reddened upper eyelid. The nurse learns that the patient recently had infectious mononucleosis. The nurse anticipates which diagnosis?

Dacryoadenitis

Which patient characteristic indicates strabismus?

Deviation in the eye axis

A patient with cachexia as a result of chronic illness will likely have which eye abnormality?

Enophthalmos

The nurse performs a cover test to assess for which condition?

Esophoria

Which action by the student nurse performing a pupillary light reflex test needs correction?

Focusing the light from in front of the patient

Which cranial nerves (CN) are responsible for the pupillary light reflex? Select all that apply.

II III

The patient is unable to turn the eyes in three cardinal positions of gaze—up and nasal, straight nasal, and down and temporal positions. The nurse suspects paralysis of which cranial nerve?

III

A patient tells the nurse, "I feel a throbbing pain in my eyes when I look at bright light." The nurse sees a dull red halo around the iris and cornea of the patient's eye. The nurse suspects which condition?

Iritis

Which technique would the nurse use to assess the color vision of a 7-year-old child?

Ishihara test

Which visual response indicates a patient has not fully metabolized deep anesthesia?

Mydriasis

Which condition(s) may cause periorbital edema in a patient? Select all that apply.

Myxedema Renal failure Congestive heart failure

Which optical assessment supports a brain tumor diagnosis?

Papilledema

The nurse encourages the patient to wear a hat and sunglasses when outside to prevent which condition(s)? Select all that apply.

Pingueculae Basal cell carcinoma

The nurse suspects damage to which structure when miosis is present?

Pons

After assessing the patient, the nurse documents "PERRLA" in the patient's medical record. Which finding supports the nurse's documentation?

Pupils are equal, round, reactive to light and accommodation

The nurse suspects that a 40-year-old patient has age-related macular degeneration after observing yellow deposits under the patient's retina. Difficulty in which area(s) supports the nurse's suspicion? Select all that apply.

Reading Sewing

A patient develops sudden clouding of vision, severe eye pain, and halos around light. Which action by the nurse is appropriate?

Report this to the primary health care provider.

Which term describes scales on the eyebrows?

Seborrhea

A "shadow sign" and an anteriorly pushed iris indicate which eye condition?

Shallow anterior chamber

Which color indicates that a patient has a normal and healthy optic disc?

Yellow-orange

While examining a patient with an eye infection, the nurse observes red, scaly, greasy flakes on the edge of the eyelids and asks the patient to describe the discomfort. Which description is the patient most likely to provide?

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

Which statement about the anatomy and physiology of the eye indicates effective learning?

"The autonomic nervous system (ANS) determines the size of the pupil."

Which statement to the novice nurse is accurate regarding how to perform eyelid eversion?

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

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. Which statement would the nurse use to explain the results to the patient?

"Your eyes are able to see at 20 feet what normal eyes see at 100 feet."

The health care provider presses against the patient's lacrimal sac and a clear fluid is expelled through the puncta. Which would the nurse deduce from this finding?

A variation from normal that may indicate a blocked nasolacrimal duct

An older adult patient reports sudden, intense eye pain and sees halos around lights. On examination, the nurse observes a cloudy cornea and a dilated pupil. Suspicion of which condition would the nurse report to the provider?

Acute glaucoma

The nurse learns a 4-year-old with strabismus has not received proper treatment for this condition. Which complication would the nurse expect to observe?

Amblyopia

The patient with meningitis has small and bilaterally irregular pupils that do not react to light but constrict with accommodation. Which term would the nurse use to document this finding?

Argyll Robertson pupil

A patient complains of a burning and itching sensation of the eyelids. On assessment, the nurse finds that lid margins have thickened and formed a crust. Which condition would the nurse suspect?

Blepharitis

A patient with a staphylococcus eye infection reports burning and the sensation of a foreign body in the eye. The nurse reports suspicion of which eyelid infection to the provider?

Blepharitis

A patient has a beady nodule protruding from the eyelid with freely movable skin overlying it. The nurse uses which term to report the finding to the provider?

Chalazion

The patient with a respiratory infection has a swollen and painful preauricular node. For which eye complication would the nurse assess the patient?

Conjunctivitis

The nurse exposes the patient's right eye to light and notices that both eyes constrict at the same time. Which reflex would the nurse document the presence of in the left eye of the patient?

Consensual light reflex

A patient tells the nurse, "Something is stuck in my eye, and I can't see anything." On examination, no foreign body is seen. The patient also reports tearing and sensitivity to light. Which condition would the nurse suspect?

Corneal abrasion

A patient with an eye infection reports pain, warmth, and redness in the part of the eye closest to the nose. The nurse notices that the patient has purulent discharge when applying pressure on the conjunctival sac. The nurse anticipates which diagnosis?

Dacryocystitis

Epicanthal folds and large spacing between the eyes are consistent with which diagnosis?

Down syndrome

Which sign would the nurse observe in a patient with Horner syndrome?

Drooping eyelid

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. The nurse performs further testing to assess for which condition?

Hyperthyroidism

The patient reports, "I got hit in the eye while playing baseball." The nurse notices blood in the anterior chamber of the eye. Which term would the nurse use to document this finding?

Hyphema

During the diagnostic positions test, a patient's eye does not move to the down and nasal positions. The nurse suspects dysfunction of which cranial nerve?

IV

While reviewing the patient's chart, the nurse notes a history of glaucoma and a prescription for pilocarpine ophthalmic drops. The nurse assesses the patient for which eye abnormality?

Miosis

Which causes binocular diplopia?

Misalignment of the axes of eyes

While checking lateral gaze, the nurse notices that the patient's eye moves rhythmically when turned to the lateral position. Which term would the nurse use to document this assessment?

Nystagmus

A patient with decreased visual acuity and decreased color vision is found to have a grayish discoloration on the optic disc. The nurse attributes these changes to which condition?

Optic atrophy

The nurse finds yellowish elevated nodules on the conjunctiva of the patient's eyes. The nurse learns that the patient works in the wood recycling industry. Which term would the nurse use to document this finding?

Pingueculae

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 nearsightedness.

After reviewing a patient's Hirschberg test results, the health care provider instructs the nurse to perform the cover test. Which is the rationale for doing this test?

The patient presents with an asymmetric light reflex in both eyes.

Which finding indicates the patient with open-angle glaucoma has tunnel vision?

The patient reports a decrease in the peripheral vision.

The nurse learns in report that the patient has arcus senilis. The nurse anticipates which abnormalities? Select all that apply.

Thickened and raised corneas Gray-white arc around the limbus

A 50-year-old patient has raised yellow plaques on the eyelids at the inner canthus. The laboratory reports show the presence of high cholesterol levels. Which term would the nurse use to document this finding?

Xanthelasma

Which statement accurately describes the signs and symptoms of iritis?

A deep red halo is seen around iris and cornea.

The nurse is assessing an older adult patient and notices a white ring along the patient's cornea. The patient states, "I can see things clearly." Which term would the nurse use to document this assessment?

Arcus senilis

Which finding in a 1-month-old infant prompts the nurse to request a referral to an ophthalmologist?

Cannot fixate the gaze on a toy

Which statement is true regarding the occurrence of eye diseases and racial variation?

Cataracts are more common in African Americans than in Hispanics.

Which response stimulates blinking in both eyes?

Corneal reflex

The inability to perform which directional movement in the diagnostic positions test indicates paralysis of cranial nerve VI?

Straight temporal

The nurse finds a round, bright red 1-mm patch over the lateral aspect of the globe of a patient's eye. Which term would the nurse use to document this finding?

Subconjunctival hemorrhage

Which finding prompts the nurse to document the presence of the doll's eyes reflex in a 1-month-old infant?

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