HA Prep U Eyes, chp 16

When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are patients most likely at increased risk for if a first-degree relative has it?

Glaucoma Correct Explanation: Glaucoma in a first-degree relative increases the patient'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 patient's risk of the disease is not increased if a first-degree relative is affected. Strabismus is not genetic. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 233. (less)

A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent

macular degeneration Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 235. (less)

A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye?

"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." Explanation: Conjunctivitis usually has an infectious etiology. Severe pain and vision damage are not common consequences. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 240. (less)

Which vision acuity reading indicates blindness?

20/200 Correct Explanation: The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision. This means that the client being tested can distinguish what a person with normal vision can distinguish from 20 feet away. The top or first number is always 20, indicating the distance from the client to the chart. The bottom or second number refers to the last full line the client could read. The higher the second number, the poorer the vision. 20/40 and 20/100 also denote poor vision. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 236. (less)

Which of the following assessment findings suggests a problem with the client's cranial nerves?

A client's extraocular movements are asymmetrical and she complains of diplopia. Correct 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: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 228. (less)

Which technique by the nurse demonstrates proper use of the ophthalmoscope?

Asks the client to fix the gaze upon an object and look straight ahead Correct 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: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 245. (less)

A client performs the test for distant visual acuity & scores 20/50-2. 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 Correct 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 & 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: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 236. (less)

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

Conjunctiva Correct Explanation: The conjunctiva is a thin mucous membrane that lines the inner eyelid (palpebral conjunctivae) and also covers the sclera (bulbar conjunctivae). The border between the cornea and the sclera is the limbus. The lacrimal apparatus protects and lubricates the cornea and the conjunctiva by producing and draining tears. The eyelid is a loose fold of skin that covers and protects the eye. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 228. (less)

client visits the health care clinic with reports of itchy and watery eyes for three days. The nurse observes a generalized redness to the conjunctiva. The nurse recognizes this as what condition?

Conjunctivitis Correct Explanation: Redness of the conjunctiva is called conjunctivitis and can be due to n allergic reaction, and viral or bacterial infection. Blepharitis is an infection of the eye lid by the staphylococcus bacteria. A hordeolum is also called a stye and is caused by infection in the lower eyelashes. A chalazion is an infected meibomian gland in the lower lid. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 240. (less)

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?

Consensual reaction Correct 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: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 243. (less)

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 Correct 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: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 238, 248. (less)

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?

Have the client hold the Jaeger card 14 inches from the face & read with one eye at a time Correct 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 t op 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 & record the smallest line the client can read is the test for distant acuity. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 237. (less)

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?

Perform both the distant and near visual acuity tests Correct 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: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, pp. 236-237. (less)

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?

Presbyopia Correct Explanation: Prebyopia 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: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 237. (less)

When testing the near reaction, an expected finding includes which of the following?

Pupillary constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far gaze. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 237. (less)

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 Correct 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: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 259. (less)

Which of the following is a symptom of the eye?

Scotomas Explanation: Scotomas are specks in the vision or areas where the client cannot see; therefore, this is a common and concerning symptom of the eye. Tinnitus is a ringing in the ears, dysphagia is difficulty swallowing, and rhinorrhea is a "runny nose." Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 232. (less)

The nurse tests the six cardinal directions to test extraocular movement of the eye.

True Correct Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 238. (less)

What should the nurse instruct a patient regarding contact lenses to prevent injury to the eye? (Select all that apply.)

• Do not share lenses. • Keep the lenses clean. • Wash hands before inserting or removing the lenses. • Discard unused portions of contact solutions at the expiration date. Explanation: The nurse should instruct the patient to not share the lenses, to keep the lenses clean, to wash hands before inserting or removing the lenses, and to discard unused portions of contact solutions at the expiration date. The lenses should be inspected for scratches or damage every year. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 234. (less)

The anatomy and physiology instructor is discussing the eye with the prenursing students. What would the instructor cite as part of the lacrimal apparatus? (Select all that apply.)

• Lacrimal gland • Nasolacrimal duct • Punctum Correct 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. The palpebral fissure is the open space between the eyelids. The limbus is the border between the cornea and the sclera. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Eyes, p. 228. (less)