Jarvis Ch. 14: Eyes

A 2-week-old infant can fixate on an object but not follow a light or bright toy. The nurse would: 1. consider this a normal finding. 2. assess the pupillary light reflex for possible blindness. 3. continue with the examination and assess visual fields. 4. expect that a 2-week-old infant should be able to fixate and follow an object.

ANS: 1 By 2 to 4 weeks an infant can fixate on an object. By 1 month, the infant should fixate and follow a bright light or toy.

A patient is unable to read the 20/100 line on the Snellen chart. The nurse would: 1. refer the patient to an ophthalmologist or optometrist for further evaluation. 2. assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. 3. ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. 4. shorten the distance between the patient and the chart and ask him or her to read the smallest line of print possible.

ANS: 1 If vision is poorer than 20/30, refer the person to an ophthalmologist or optometrist.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: 1. she may have macular degeneration. 2. her vision is normal for someone her age. 3. she has the beginning stages of cataract formation. 4. she has increased intraocular pressure or glaucoma.

ANS: 1 Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision.

A patient's vision is recorded as 20/80 in each eye. The nurse recognizes that this finding indicates that: 1. the patient has poor vision. 2. the patient has acute vision. 3. the patient has normal vision. 4. the patient is presbyopic.

ANS: 1 Normal visual acuity is 20/20 in each eye. The larger the denominator, the poorer the vision.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse would: 1. consider this a normal finding. 2. refer the individual for further evaluation. 3. document this as an asymmetric light reflex. 4. perform the confrontation test to validate the findings.

ANS: 1 Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric.

During an ophthalmscopic examination of the eye, the examiner notes areas of exudate that look like "cotton wool" or fluffy gray-white cumulus clouds. This finding indicates which possible problem? 1. Diabetes 2. Hyperthyroidism 3. Glaucoma 4. Hypotension

ANS: 1 Soft exudates or "cotton wool" areas look like fluffy gray-white cumulus clouds, They occur with diabetes, hypertension, subacute bacterial endocarditis, lupus, and papilledema of any cause.

When examining the eye, the nurse is aware that the bulbar conjunctiva: 1. overlies the sclera. 2. covers the iris and pupil. 3. is visible at the inner canthus of the eye. 4. is a thin mucous membrane that lines the lids.

ANS: 1 The bulbar conjunctiva overlies the eyeball with the white sclera showing through.

The nurse is testing a patient's visual accommodation, which refers to: 1. pupillary constriction when looking at a near object. 2. pupillary dilation when looking at a far object. 3. changes in peripheral vision in response to light. 4. involuntary blinking in the presence of bright light.

ANS: 1 The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision.

When the retina is examined, which of the following is considered a normal finding? 1. An optic disc that is a yellow-orange color 2. Optic disc margins that are blurred around the edges 3. The presence of pigmented crescents in the macular area 4. The presence of the macula located on the nasal side of the retina

ANS: 1 The optic disc is located on the nasal side of the retina. It is a creamy yellow-orange to pink color.

Which of the following is an expected normal finding when performing the diagnostic positions test? 1. Convergence of the eyes 2. Parallel movement of both eyes 3. Nystagmus in extreme superior gaze 4. A slight amount of lid lag when moving the eyes from a superior to inferior position

ANS: 2 A normal response for the diagnostic positions test is parallel tracking of the object with both eyes.

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notes the presence of blood in the anterior chamber of the eye. This finding indicates the presence of: 1. hypopyon. 2. hyphema. 3. corneal abrasion. 4. iritis.

ANS: 2 Hyphema is the term for blood in anterior chamber is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma.

The nurse is performing an eye assessment on an 80-year-old patient. Which of the following findings is considered abnormal? 1. A decrease in tear production 2. Unequal pupillary constriction in response to light 3. The presence of arcus senilis seen around the cornea 4. Loss of the outer hair on the eyebrows due to a decrease in hair follicles

ANS: 2 Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric.

The nurse is conducting a visual examination. Which of the following statements regarding visual pathways and visual fields is true? 1. The right side of the brain interprets vision for the right eye. 2. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. 3. Light rays are refracted through the transparent media of the eye before striking the pupil. 4. The light impulses are conducted through the optic nerve to the temporal lobes of the brain.

ANS: 2 The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

Which of the following physiological changes is responsible for presbyopia? 1. Degeneration of the cornea 2. Loss of lens elasticity 3. Decreased adaptation to darkness 4. Decreased distance vision abilities

ANS: 2 The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse recognizes that these results indicate that: 1. at 30 feet the patient can read the entire chart. 2. the patient can read at 20 feet what a person with normal vision can read at 30 feet. 3. the patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. 4. the patient can read from 30 feet what a person with normal vision can read from 20 feet.

ANS: 2 The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

In a patient who has anisocoria, the nurse would expect to observe: 1. dilated pupils. 2. excessive tearing. 3. pupils of unequal size. 4. an uneven curvature of the lens.

ANS: 3 Unequal pupil size is termed anisocoria. It exists normally in 5% of the population but may also be indicative of central nervous system disease.

Which of the following would the nurse expect to find when examining the eyes of a black patient? 1. Increased night vision 2. A dark retinal background 3. Increased photosensitivity 4. Narrowed palpebral fissures

ANS: 2 There is an ethnically based variability in the color of the iris and in retinal pigmen- tation, with darker irides having darker retinas behind them.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include 1. loss of central vision. 2. shadow or diminished vision in one quadrant or one half visual field. 3. loss of peripheral vision. 4. sudden loss of pupillary constriction and accommodation.

ANS: 2 With retinal detachment, the person has shadow or diminished vision in one quadrant or one half visual field.

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse recalls that there are various types of glaucoma, such as open-angle glaucoma and closed-angle glaucoma. Which of the following are characteristics of open-angle glaucoma? Select all that apply. 1. The patient may experience sensitivity to light, nausea, and halos around lights. 2. It is the most common type of glaucoma. 3. Immediate treatment is needed. 4. Vision loss begins with peripheral vision. 5. It causes sudden attacks of increased pressure that causes blurred vision. 6. There are virtually no symptoms

ANS: 2, 4, 6 Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is 1. a chalazion. 2. a hordeolum (stye). 3. dacryocystitis. 4. blepharitis.

ANS: 3 A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin.

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: 1. "Vision is not totally developed until 2 years of age." 2. "Infants develop the ability to focus on an object at around 8 months." 3. "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." 4. "Most infants have uncoordinated eye movements for the first year of life."

ANS: 3 By 3 to 4 months of age, the infant establishes binocularity and can fixate on a single image with both eyes simultaneously.

The nurse notes the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse will: 1. check for the presence of exophthalmos. 2. suspect that the patient has hyperthyroidism. 3. ask the patient if he or she has a history of heart failure. 4. assess for blepharitis because this is often associated with periorbital edema.

ANS: 3 Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism.

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has a ptosis of one eye. How would the nurse check for this? 1. Perform the confrontation test. 2. Assess the individual's near vision. 3. Observe the distance between the palpebral fissures. 4. Perform the corneal light test and look for symmetry of the light reflex.

ANS: 3 Ptosis is drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids.

When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: 1. causes pupillary constriction. 2. adjusts the eye for near vision. 3. elevates the eyelid and dilates the pupil. 4. causes contraction of the ciliary body.

ANS: 3 Stimulation of the sympathetic branch dilates the pupil and elevates the eyelid.

To assess color vision on a male child, the nurse would: 1. check color vision annually until the age of 18 years. 2. ask the child to identify the color of his or her clothing. 3. test for color vision once between the ages of 4 and 8. 4. begin color vision screening at the child's 2-year check-up.

ANS: 3 Test only boys for color vision once between the ages of 4 and 8 years.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How would the nurse proceed? 1. Perform the confrontation test. 2. Ask the patient to read the print on a hand-held Jaeger card. 3. Use the Snellen chart positioned 20 feet away from the patient. 4. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.

ANS: 3 The Snellen alphabet chart is the most commonly used and accurate measure of visual acuity.

When a light is directed across the iris of the eye from the temporal side, the examiner is assessing for: 1. drainage from dacryocystitis. 2. the presence of conjunctivitis over the iris. 3. the presence of shadows, which may indicate glaucoma. 4. a scattered light reflex, which may be indicative of cataracts.

ANS: 3 The presence of shadows in the anterior chamber may be a sign of acute angle- closure glaucoma.

In using the ophthalmoscope to assess a patient's eyes, the nurse notes a red glow in the patient's pupils. On the basis of this finding, the nurse would: 1. suspect that there is an opacity in the lens or cornea. 2. check the light source of the ophthalmoscope to verify that it is functioning. 3. consider this a normal reflection of the ophthalmoscope light off the inner retina. 4. continue with the ophthalmoscopic examination and refer the patient for further evaluation.

ANS: 3 The red glow filling the person's pupil is the red reflex. This is caused by the reflection of the ophthalmoscope light off the inner retina.

When assessing the pupillary light reflex, the nurse should use which technique? 1. Shine a penlight from directly in front of the patient and inspect for pupillary constriction. 2. Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction. 3. Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. 4. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose.

ANS: 3 To test the pupillary light reflex, advance a light in from the side and note the direct and consensual pupillary constriction.

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? 1. Smooth and clear corneas 2. Opacity of the lens behind the cornea 3. Bleeding from the areas across the cornea 4. A shattered look to the light rays reflecting off the cornea

ANS: 4 A corneal abrasion causes irregular ridges in reflected light, producing a shattered look to light rays.

A 52-year-old patient describes the presence of occasional "floaters or spots" moving in front of his eyes. The nurse should: 1. examine the retina to determine the number of floaters. 2. presume the patient has glaucoma and refer him for further testing. 3. consider this an abnormal finding and refer him to an ophthalmologist. 4. know that "floaters" are usually not significant and are caused by condensed vitreous fibers.

ANS: 4 Floaters are a common sensation with myopia or after middle age owing to condensed vitreous fibers. Usually, they are not significant.

In assessing the sclera of a black patient, which of the following would be an expected finding? 1. Yellow fatty deposits over the cornea 2. Pallor near the outer canthus of the lower lid 3. Yellow color of the sclera that extends up to the iris 4. The presence of small brown macules on the sclera

ANS: 4 In dark-skinned people, one normally may see small brown macules in the scle

Intraocular pressure is determined by the: 1. thickness or bulging of the lens. 2. posterior chamber as it accommodates for an increase in fluid. 3. contraction of the ciliary body in response to the aqueous within the eye. 4. amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber.

ANS: 4 Intraocular pressure is determined by a balance between the amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber.

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: 1. decreased in the elderly. 2. impaired in a patient with cataracts. 3. stimulated by cranial nerves I and II. 4. stimulated by cranial nerves III, IV, and VI.

ANS: 4 Movement of the extraocular muscles is stimulated by three cranial nerves: III, IV, and VI.

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: 1. retinal detachment. 2. diabetic retinopathy. 3. acute-angle glaucoma. 4. increased intracranial pressure.

ANS: 4 Papilledema, or choked disk, is caused by increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations.

The nurse is performing an eye-screening clinic at the day care center. When examining a 2-year-old child, the nurse suspects that the child has "lazy eye" and would: 1. examine the external structures of the eye. 2. assess visual acuity with the Snellen eye chart. 3. assess the child's visual fields with the confrontation test. 4. test for strabismus by performing the corneal light reflex test.

ANS: 4 Testing for strabismus is done by performing the corneal light reflex test. The light should be reflected at exactly the same spot in both eyes.

The nurse is assessing a patient's eyes for the accommodation response and would expect to see: 1. dilation of the pupils. 2. a consensual light reflex. 3. conjugate movement of the eyes. 4. convergence of the axes of the eyes.

ANS: 4 The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes.

A patient has a normal pupillary light reflex. The nurse recognizes that this indicates that: 1. the eyes converge to focus on the light. 2. light is reflected at the same spot in both eyes. 3. the eye focuses the image in the center of the pupil. 4. constriction of both pupils occurs in response to bright light.

ANS: 4 The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? 1. The presence of tears along the inner canthus 2. A blocked nasolacrimal duct in a newborn infant 3. A slight swelling over the upper lid and along the bony orbit if the individual has a cold 4. The absence of drainage from the puncta when pressing against the inner orbital rim

ANS: 4 There should be no swelling, redness, or drainage from the puncta.

Which of the following statements regarding the outer layer of the eye is true? 1. The outer layer of the eye is very sensitive to touch. 2. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. 3. The trigeminal (CN V) and the trochlear (CN IV) nerves are stimulated when the outer surface of the eye is stimulated. 4. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

ANS:1 The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch.