Health assessment Ch. 11

The nurse is assessing cranial nerves III, IV, and VI. Which instructions should the nurse provide to the client in order to perform this assessment?

"Follow my finger with only your eyes."

A 52-year-old patient 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?

"It is not an uncommon finding in people older than 40 years for this to happen. They are called "floaters""

A patient comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse?

"You will need to see the doctor to have your eye checked."

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.)

-Diabetes -Hypertension

A comprehensive physical examination of the eye includes tests for which of the following? Select all that apply.

-Visual acuity -Eye muscle function -Internal ocular structures -The external eye

Which vision acuity reading indicates blindness?

20/200

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

A client's extra-ocular movements are asymmetrical and she complains of diplopia

6. A nurse who works at an outpatient ophthalmic clinic has a large number of clients. Which client would be at the highest risk for developing cataracts? A) A 55-year-old female client B) A 40-year-old with arteriosclerosis C) A client who has severe environmental allergies D) A male client who is obese

A) A 55-year-old female client

7. A nurse is assessing an adult client's eyes and vision. When performing the cover test, the nurse would cover one of the client's eyes and then do which of the following? A) Ask the client to focus on a distant object, looking for movement in the other eye. B) Ask the client to close the other eye then open that eye quickly. C) Ask the client to follow the nurse's finger with the other eye. D) Ask the client to look directly at a light with the other eye.

A) Ask the client to focus on a distant object, looking for movement in the other eye.

15. A nurse is observing the red reflex in a client during an eye assessment. During this component of the assessment, the client states, I hope you can see it because I have cataracts. What finding should the nurse expect? A) Black spokes pointing inward B) White arc around the limbus C) Thickened bulbar conjunctiva D) A red spot on the retina

A) Black spokes pointing inward

30. A nurse has performed the corneal light reflex test during a client's eye examination. During this test, the nurse held a penlight 1 foot from the client's eyes and appraised the client's eye alignment in which of the following ways? A) By comparing the reflection of the light on the client's eye surface B) By comparing the speed of pupillary constriction C) By comparing how quickly the client blinks each eyelid D) By comparing the relative color of the sclerae before and after light exposure

A) By comparing the reflection of the light on the client's eye surface

10. A nurse is performing an eye assessment of an 81-year-old male client. Which of the following would the nurse document as a normal finding? A) Ectropion B) Episcleritis C) Chalazion D) Exophthalmos

A) Ectropion

4. The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? A) Far, then near B) Lateral, then near C) Near, then far D) Lateral, then far

A) Far, then near

19. After teaching a group of students about the external and internal structures of the eye, the instructor determines that the teaching was successful when the students identify which of the following as external structures? Select all that apply. A) Lacrimal apparatus B) Conjunctiva C) Lens D) Iris E) Sclera F) Caruncle

A) Lacrimal apparatus B) Conjunctiva F) Caruncle

26. A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which of the following actions? A) Observing the eye's reaction when a light is shone into the opposite eye B) Shining a light into one eye while covering the other eye with an opaque card C) Moving a finger into the client's peripheral vision field and asking the client to state when he or she sees the finger D) Comparing the difference between the client's dilated pupil and a constricted pupil

A) Observing the eye's reaction when a light is shone into the opposite eye

13. A nurse is assessing the eyes of a 3-year-old child. Which finding would the nurse document as normal? A) Pseudostrabismus B) Tropia C) Nystagmus D) Exotropia

A) Pseudostrabismus

The nurse practitioner is assessing the eyes of a client with long-standing uncontrolled hypertension. What might the nurse practitioner visualize during an assessment with an ophthalmoscope?

AV nicking

The functional reflex that allows the eyes to focus on near objects is termed

Accommodation

The meibomian glands secrete

An oily substance to lubricate the eyes

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

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.

1. 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? A) Inspect the palpebral conjunctiva. B) Assess the nasolacrimal sac. C) Perform the eye positions test. D) Test pupillary reaction to light.

B) Assess the nasolacrimal sac.

28. A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, Do you wear sunglasses during exposure to the sun? the nurse is addressing a known risk factor for what health problem? A) Presbyopia B) Cataracts C) Nystagmus D) Glaucoma

B) Cataracts

9. A client's history suggests a need to assess eye muscle strength and cranial nerve function. What assessment should the nurse consequently perform? A) Corneal light reflex test B) Eye positions test C) Cover test D) Visual fields test

B) Eye positions test

21. 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? A) Do you exercise regularly? B) Have you ever been tested for diabetes? C) Do you ever take over-the-counter pain medications? D) At what age did you first start wearing glasses?

B) Have you ever been tested for diabetes?

20. A nurse is presenting a class to a local community group about vision and eye health. As part of the presentation, the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation? A) It refers to a client's subjective appraisal of his or her vision. B) It begins with light rays striking the retina. C) It primarily involves the lens of the eye. D) It allows the eyes to focus on near objects.

B) It begins with light rays striking the retina.

16. 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? A) Recent eye trauma B) Narcotic use C) Macular degeneration D) Recent peripheral nervous system injury

B) Narcotic use

2. When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. The nurse would document this as which of the following? A) Physiologic cup B) Optic disc C) Retinal vessels D) Fovea

B) Optic disc

27. The nurse is using an ophthalmoscope to examine a client's inner eye structures. What action should the nurse perform in order to accurately examine the client's optic disc? A) Slowly approach the client's eye from a 90-degree angle, maintaining a focus on the pupil. B) Position the scope close to the client's eye and look through the pupil at a 15- degree angle. C) From a distance of 3 to 5 cm, examine the pupil from a 45- to 50-degree angle. D) While looking through the ophthalmoscope, approach the client's eye slowly from the side.

B) Position the scope close to the client's eye and look through the pupil at a 15- degree angle.

11. Which of the following would the nurse expect to assess when examining the eyes of a client who reports a history of severe allergies? A) Generalized redness B) Pinguecula C) Areas of dryness D) Nodular appearance

C) Areas of dryness

23. A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next? A) Attempt to remove the splinter using sterile forceps. B) Irrigate the eye with dilute hydrogen peroxide. C) Arrange for worker to be promptly assessed by an eye specialist. D) Encourage the worker to see an optometrist as soon as possible.

C) Arrange for worker to be promptly assessed by an eye specialist.

3. 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? A) Direct reflex B) Optic chiasm C) Consensual response D) Accommodation

C) Consensual response

8. 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? A) Eye turning outward B) Eye malalignment C) Eye turning inward D) Eye oscillating

C) Eye turning inward

5. During a health history, a 62-year-old male client reveals that he occasionally sees spots before his eyes. The nurse interprets this finding as the result of which of the following? A) Increased ocular pressure B) Vitamin A deficiency C) Normal findings for client's age D) Vascular spasm

C) Normal findings for client's age

14. A review of a client's history reveals cranial nerve IV paralysis. Which of the following findings would the nurse expect to assess? A) The eye cannot look to the outside side. B) Ptosis will be evident. C) The eye cannot look down when turned inward. D) The eye will look straight ahead.

C) The eye cannot look down when turned inward.

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

Conjunctiva

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

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?

Consensual light response present in left eye

While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse?

Consensual reaction

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

Corneal Damage

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

Corrective lenses

17. A nurse is assessing a client who is suspected to have optic atrophy. Which of the following assessment findings is most consistent with this diagnosis? A) Obscured retinal vessels B) No visible physiologic cup C) Increased appearance of the disc vessels D) A white appearance of the optic disc

D) A white appearance of the optic disc

24. During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide? A) I'm going to ask you to slowly walk forward until the last line of the chart become clear. B) Please stand at a comfortable distance from the chart and I'll get you to read each of the letters. C) Hold this chart and start to read out the letters after covering one of your eyes. D) Cover one of your eyes and then read out the letters on the chart, starting from the top.

D) Cover one of your eyes and then read out the letters on the chart, starting from the top.

25. A nurse is conducting an assessment of a client's eyes and vision and has completed the positions test. Following this test, the nurse will be able to document data that address what aspects of eye health? Select all that apply. A) Distant visual acuity B) Near visual acuity C) Accommodation D) Eye muscle strength E) Cranial nerve function

D) Eye muscle strength E) Cranial nerve function

22. 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? A) Episcleritis B) Strabismus C) Macular degeneration D) Glaucoma

D) Glaucoma

18. A nurse is performing an eye and vision assessment on a client who has an inner ear disorder. This disorder may contribute to what finding during the client's eye positions test? A) Strabismus B) Phoria C) Tropia D) Nystagmus

D) Nystagmus

12. During a client's eye assessment, the nurse is testing for consensual pupillary constriction. Which technique should the nurse implement? A) Hold a pencil about 12 inches from the tip of the nose. B) Use an ophthalmoscope to inspect the inner eye. C) Shine a light directly into one eye of the client. D) Place a barrier between the client's eyes.

D) Place a barrier between the client's eyes.

29. A nurse has taught a group of older adults about the high incidence and prevalence of macular degeneration. What health promotion and prevention activity should the nurse encourage these clients to perform? A) Obtain a home version of the Snellen chart and test their vision weekly B) Rinse their eyes with a warmed, normal saline solution three to four times per week C) Maintain a low-sodium diet D) Post an Amsler grid in their home and perform the test on a regular basis

D) Post an Amsler grid in their home and perform the test on a regular basis

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

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?

Focused on the bridge of the nose

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

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

Glaucoma

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 Jaeger card 14 inches from the face & read with one eye at a time

A patient is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the patient's medical record supports this diagnosis?

Increased intraocular pressure

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

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?

Instruct the client to hold the chart 14 inches from the eyes

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?

Macular degeneration

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

Muscular Degeneration

On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing 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

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

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

Position the client 609.6cm (20ft) away from the chart

A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?

Presbyopia

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

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

Pupillary constriction on near gaze; dilation on distant gaze

The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test

Requires the covering of each eye separately.

Photoreceptors of the eye are located in the eye's

Retina

On visual confrontation testing, a client with a recent stroke cannot see the examiner's fingers on the entire right side with either eye covered. Which of the terms would describe this finding?

Right homonymous hemianopsia

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

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that 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

Which of the following is a symptom of the eye?

Scotomas

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

She can see at 20 feet what a normal person could see at 100 feet

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 patient's vision?

Snellen E

A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?

Stye

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

A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?

The larger the bottom number, the worse the visual acuity

Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination?

Touch the cornea with a wisp of cotton

When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction?While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse?

Up

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

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

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

Use of safety equipment

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

Use safety equipment

You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what?

A left temporal hemianopsia

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

The middle layer of the eye is known as the

Choroid layer

What eye function is the nurse preparing to assess when the patient is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

Distant vision

An elderly client presents to the health care clinic with reports of decreased tearing in both eyes. The nurse observes the presence of ectropion. What is an appropriate action by the nurse?

Document the finding as a normal sign of aging

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's

Esotropia

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

What is a characteristic symptom of Graves hyperthyroidism?

Exopthalamus

The nurse is planning to assess a client's near vision. Which technique should be used?

Have the client read newspaper print held 14 inches from the eyes

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

Lacrimal apparatus

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

True

The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents

entropion