Sensory_eyes only_dynamic quizzing_exam4_adult2

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? A. Sugar B. Coffee C. Cotton wisps D. Snellen chart

C. Cotton wisps The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve (CN) V, the nurse should ask the client to clench the teeth.

A nurse is planning to administer diphenhydramine hydrochloride to an older adult client. Which of the following actions should the nurse plan to take prior to administration? A Review the medical record for a history of glaucoma B. Plan to administer the medication 30 min prior to a meal C. Explain that the client will need to restrict his fluid intake once he takes the medication D. Remind the client that his appetite might increase when starting the medication

Correct Answer: A. Review the medical record for a history of glaucoma The nurse should review the client's medical record for a history of glaucoma prior to administration of the medication. Diphenhydramine is contraindicated for clients who have narrow-angle glaucoma because diphenhydramine can dilate the pupils. Clients who have glaucoma are administered medication to constrict the pupils, which improves the circulation of the aqueous humor for absorption.

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? A. Romberg B. Kinesthetic sensation C. 2-point discrimination D. Weber

Correct Answer: A. Romberg A Romberg test evaluates standing balance, first with the client's eyes open and then with them closed. The nurse should remain nearby because the client could fall during this test.

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? A. Confirm that the client performed the procedure correctly. B. Instruct the client to look at the floor while instilling the eye drop. C. Remind the client to avoid using a facial t

D. Instruct the client to apply pressure to the inside corner of the eye -The client should apply gentle pressure over the nasolacrimal duct to prevent the medication from flowing into the nasal passages where systemic absorption could result.

Narrowed or closed angle glaucoma The pressure is built

instantly & pt will experience Severe headache, severe eye pain, blurred vision, and halos.

As the optic nerve damage increases? the visual perception is going to

to decrease

A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following pieces of information should the nurse include? A nurse is providing preoperative teaching for a client who will undergo laser-assistec surgery. Which of the following pieces of information should the nurse include? A. "You might need glasses after the surgery." B. "You may drive home after the procedure." C. "Continue to wear your contact lenses

A. "You might need glasses after the surgery." LASIK is a type of refractive laser eye surgery that ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or undercorrection of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery.

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? A. Confrontation test B. Symmetry of palpebral fissures v C. Corneal light reflex D. Accommodation test

C. Corneal light reflex The corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally. This test will indicate the alignment of the client's eyes as well as any deviation inward or outward. With strabismus, the eyes will not align when the client focuses.

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening? A. Annual Papanicolaou (Pap) testing B. Mammogram every 2 years C. Eye examination every 2 years D. Annual colonoscopy

C. Eye examination every 2 years This is essential not only for monitoring vision but also for checking for glaucoma. The client should have annual eye examinations from the age of 65 onward.

A nurse is caring for a 1-year-old infant who has chronic otitis media. The nurse should identify that which of the following areas is at risk of a delay in development? A. Fine motor skills B. Visual acuity C. Speech patterns D. Hand-to-eye coordination

C. Speech patterns Speech patterns are developed through auditory experiences. Chronic otitis media is a common cause of hearing impairment, which can delay the development of speech.

A nurse is teaching a client who is about to start taking propylthiouracil to treat hyperthyroidism. Which of the following statements should the nurse identify as an indication that the teaching has been effective? A."I will need laboratory tests to check my liver function." B. "I should take this medication once daily." C. "Ifl get a rash, I am probably having an allergic reaction." D. "IfI have difficulty sleeping, it is probably because of this medication."

Correct Answer: A. "I will need laboratory tests to check my liver function." Propylthiouracil is hepatotoxic and can cause severe liver injury. The nurse should instruct the client to report dark urine and yellowing of the eyes, which can indicate an injury to the liver.

A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the r client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a pos indicating which of the following alterations? A. Cerebellar dysfunction B. Occipital lobe dysfunction C. Increased intraocular pressure D. Macular degeneration

Correct Answer: A. Cerebellar dysfunction Cerebellar dysfunction causes a loss of position sense (proprioception), which results in a positive Romberg sign.

A nurse is caring for a client who is taking streptomycin. Which of the following medications increases the client's risk of developing ototoxicity when taken with streptomycin? A. Cefoxitin B. Furosemide C. Naproxen D. Amphotericin B

Correct Answer: B. Furosemide Furosemide, a high-ceiling (loop) diuretic, increases the risk of developing ototoxicity when taken with streptomycin, an aminoglycoside.

A nurse is teaching a client who has myopia about laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following is an adverse effect of LASIK surgery? A. Eyelid twitching B. Photosensitivity C. Intraocular hemorrhage D. Dry eyes

D. Dry eyes LASIK surgery is a procedure that can correct nearsightedness, farsightedness, and astigmatism by changing the shape of the cornea. Adverse effects of LASIK surgery include dryness of the eyes and blurred vision.

Wide angled glaucoma The pressure is built

Gradually & pt will see Patchy spots in their peripheral vision and lose their central vision.

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? A. Gustation B. Stereognosis C. Proprioception D. Kinesthesia

b. Stereognosis Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation.

A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions? A. "I will sleep on the affected side." B. "I will avoid bending over." C. "I will restrict caffeine in my diet." D. "I will take aspirin to relieve my pain."

B. "I will avoid bending over." The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can create intraocular hemorrhage.

A nurse is administering brimonidine eye drops to a client who has glaucoma. Which of the following ocular effects should the nurse expect? A. Decreased intraocular pressure B. Blocked growth of new blood vessels C. Paralysis of accommodation D. Mydriasis

Correct Answer: A. Decreased intraocular pressure -Brimonidine is an alpha-2 adrenergic agonist used for the long-term treatment of open-angle glaucoma. It decreases intracular pressure by reducing aqueous humor production.

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. Drop the eye medication into the lower conjunctival sac B. Apply gentle pressure to the outer opening of the eye for 2 min C. Hold the eyedropper 0.5 cm (0.2 in) from the cornea D. Instruct the client to close the eyes tightly after administration

Correct Answer: A. Drop the eye medication into the lower conjunctival sac The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.

A nurse at an ophthalmology clinic is assessing a client referred by the provider for a potential cataract. Which of the following client reports is consistent with cataracts? A. Halos when looking at lights B. Loss of peripheral vision C. Bright flashes of light and floaters D. Eyestrain and headaches with close work

Correct Answer: A. Halos when looking at lights A cataract is a cloudy or opaque area in the lens of the client's eye. Cataracts in adults usually develop with advancing age and can be hereditary. Cataracts develop slowly and painlessly with a gradual onset of difficulty with vision. Visual problems include difficulty seeing at night, halos around lights or glare sensitivity, and decreased visual acuity even in daylight. Cataracts are accelerated by environmental factors such as cigarette smoke or other toxic substances or in response to metabolic diseases such as diabetes mellitus.

A nurse is providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent the development of amblyopia? A. Patch the unaffected eye B. Administer mydriatic eye drops daily C. Obtain prescription eyeglasses D. Administer antihistamines

Correct Answer: A. Patch the unaffected eye Amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of another problem such as strabismus. With strabismus, muscle weakness allows an eye to wander so that the child cannot focus on an object with both eyes at the same time. This confusion causes the brain to ignore the signals from the weak eye in favor of the strong eye. This will result in central blindness if the child does not receive treatment by 6 years of age. To strengthen the weak eye muscles, the parents should patch the unaffected eye.

A nurse is assessing the visual acuity of a group of school-aged children. Which of the following actions should the nurse take? A. Position each child with their heels at a line that is 6 m (20 ft) away from the Snellen chart B. Allow each child to wear his or her glasses during the exam C. Start the screening by covering each child's right eye D. Begin by having each child read the largest line of letters at the top of the Snellen chart

Correct Answer: B. Allow each child to wear his or her glasses during the exam The nurse should allow each child to wear his or her glasses during a screening for visual acuity.

A nurse is reviewing the medical record of a client who might have hearing loss. Which of the following data from the client's medical record should the nurse identify as a risk factor for hearing loss? A. Frequent use of steroids, B. Chronic use of salicylates C. Intermittent use of antacids D. Habitual use of laxatives

Correct Answer: B. Chronic use of salicylates Chronic use of salicylates such as aspirin can lead to ototoxicity, which can manifest as tinnitus or hearing loss.

A nurse is performing a visual acuity screening for a school-aged child using the Snellen letter chart. Which of the following actions should the nurse take? A. Position the child 5 ft away from the letter chart B. Have the child wear his glasses during the vision screening C. Observe for pupillary constriction while shining a light into the child's eye D. Instruct the child to point in the direction the letters are facing

Correct Answer: B. Have the child wear his glasses during the vision screening The nurse should assess the child's visual acuity while the child is wearing prescribed glasses.

A nurse is assessing a 12-year-old child during a well-child checkup. Which of the following physical findings should the nurse report to the provider? A. 5 cm (2 in) of growth in the past year B. Hyperopia C. Presence of pubic hair

Correct Answer: B. Hyperopia The nurse should report hyperopia in a 12-year-old child to the provider. Hyperopia, or farsightedness, is an unexpected finding after the age of 7.

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? A. Pupils nonreactive to light B. Opacity visible behind the pupil C. White circle around the outside border of the iris D. Increased intraocular pressure

Correct Answer: B. Opacity visible behind the pupil. With a cataract, the lens of the eye becomes thick and opaque with age and appears as opacity behind the pupil when the nurse shines a light on the area.

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should t nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis

Correct Answer: B. Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in premature newborns. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. This condition can reduce vision or result in complete blindness.

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. Instruct the client to blink several times after instilling the medication B. Ask the client to look straight ahead during instillation of the medication C. Apply pressure to the puncta after instilling the medication D. Place each drop of the medication directly onto the client's cornea

Correct Answer: C. Apply pressure to the puncta after instilling the medication The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication.

A nurse is preparing to administer timolol eye drops to a client who has primary open-angle glaucoma (POAG). Prior to administering the medication, the nurse should recognize that which of the following conditions in the client's medical history is a contraindication to receiving this medication? A. Hypertension B. Peripheral vision loss C. Asthma D. Increased intraocular pressure

Correct Answer: C. Asthma The nurse should identify that asthma is a contraindication to receiving timolol. Timolol is a beta-blocker that can cause blocking of the beta2-receptors, causing bronchospasm. A client who has a history of asthma is a candidate for an alternate medication to treat this condition such as betaxolol.

A nurse is caring for a client who is experiencing cycloplegia following the administration of atropine eye drops during an eye examination. Which of the following findings should the nurse expect as a result of cycloplegia? A. Inability to tolerate bright lights B. Pinpoint pupils C. Blurred vision D. Inability to perform an upward gaze

Correct Answer: C. Blurred vision Assessment findings of cycloplegia include blurred vision because focusing for near vision is impaired. This action occurs following the administration of atropine because the paralysis of the ciliary muscle prevents near-vision focus. Accommodation, or looking from far to near and vice-versa, is also temporarily impaired.

A nurse is assessing a client who reports an acute visual disturbance that he describes as a "curtain" pulled over hi: visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders? A. Cataracts B. Angle-closure glaucoma C. Retinal detachment D. Macular degeneration

Correct Answer: C. Retinal detachment The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field.

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? A. Multiple floaters B. Flashes of light in front of the eye C. Severe eye pain D. Double vision

Correct Answer: C. Severe eye pain Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headaches, brow pain, and nausea and vomiting.

A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should indicate to the nurse the client is experiencing digoxin toxicity? A. Suppression of dysrhythmias B. Increased atrioventricular (AV) conduction C. Visual disturbances D. Weight gain

Correct Answer: C. Visual disturbances The nurse should recognize that nausea, vomiting, abdominal discomfort, fatigue, and visual disturbances are common manifestations that can indicate that the client is experiencing digoxin toxicity.

A nurse is assessing a client with rheumatoid arthritis who has been taking high doses of prescribed hydroxychloroquine. Which of the following client statements should indicate to the nurse that the client is experiencing an adverse effect of hydroxychloroquine? A. "I have developed sores in my mouth." B. "I often feel like the room is spinning." C. "I noticed that the whites of my eyes look yellow." D. "I have had a change in my vision recently."

Correct Answer: D. "I have had a change in my vision recently." The nurse should identify that hydroxychloroquine is an antimalarial medication used to treat rheumatoid arthritis. Clients who take hydroxychloroquine in high doses are at risk for developing retinopathy, which can be irreversible and cause blindness.

A nurse is assessing a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2 mEq/L. Which of the following findings should the nurse expect? A. Muscle weakness B. Oliguria C. Vomiting D. Blurry vision

Correct Answer: D. Blurry vision Manifestations of lithium toxicity with levels between 2 and 2.5 mEq/L include blurry vision, ataxia, clonic twitching, severe hypotension, and polyuria.

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? A. Finding the bathroom in the dark B. Driving at night C. Seeing numbers on highway signs D. Reading the newspaper

Correct Answer: D. Reading the newspaper With presbyopia, the lens is unable to change shape to focus on near objects. Presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens.

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? A. 2-point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg test.

Correct Answer: D. Romberg test When using the Romberg test, the nurse instructs the client to stand with the feet together and arms at the sides, first with the eyes open and then with eyes closed. The inability to maintain balance is a positive Romberg test.

A nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Which of the following pieces of information in the client's medical record should the nurse identify as a risk factor for tinnitus? A. Use of hydrochlorothiazide B. Chronic use of acetaminophen C. Allergic external otitis D. Sclerosis of the ossicles

Correct Answer: D. Sclerosis of the ossicles Sclerosis of the ossicles, called otosclerosis, is an overgrowth of the tissue of the bones in the middle ear, which can cause tinnitus and conductive hearing loss. A stapedectomy is a surgical procedure that corrects otosclerosis by removing a portion of the stapes and inserting a prosthesis.

A nurse is teaching a group of healthy older adult clients about health screenings after age 50 years. Which of the following health screenings should the nurse recommend for annual completion? A. Cholesterol B. Colonoscopy C. Diabetes mellitus D. Visual acuity

Correct Answer: D. Visual acuity The nurse should recommend an annual visual acuity screening for all clients over 50 years of age.

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A. Lost vision can improve with eye drops. B. Administer eye drops as needed for vision loss. C. Glasses will be necessary to correct the accompanying presbyopia. D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor.

Correct Answers: D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor. Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated. Laser surgery

A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? A. Glaucoma, B. Retinal detachment C. Macular degeneration D. Cataracts

Correct answer: B retinal detachment A flash of light and a sudden loss of vision are manifestations of retinal detachment. Clients report the event of vision loss as sudden and painless.

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration

Correct answer: B. Glaucoma The nurse should identify that an obstruction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to an increase in intraocular pressure, resulting in damage to the eye.

A nurse is providing teaching to a client with tuberculosis who has prescriptions for rifampin and ethambutol. Which of the following findings is an adverse effect of these medications that the client should report to the provider? A. Red-orange discoloration of urine B. Unexpected weight gain C. Ringing in the ears D. Decreased visual acuity

D. Decreased visual acuity The nurse should identify optic neuritis as an adverse effect of ethambutol. The nurse should instruct the client to monitor for changes in visual acuity or color identification as indications of optic neuritis to report to the provider. This adverse effect necessitates termination of ethambutol therapy because irreversible blindness can result.

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? A. "You can expect your vision to return immediately after the procedure." B. "You should avoid reading for 1 week." C. "You can remove eye shields when you're sleeping." D. "You should not lift objects that weigh more than 25 lb."

b. you should avoid reading for 1 week Correct Answer: B. "You should avoid reading for 1 week." The client should avoid reading and any activity that can cause rapid movement of the eye due to the risk of detachment of the retina.

A nurse is providing teaching to a client who has a new prescription for doxycycline. The nurse should instruct the client to monitor for which of the following adverse effects? A. Photosensitivity B. Constipation C. Ototoxicity D. Blurred vision

photosensitivity An adverse effect of doxycycline, a tetracycline antibiotic, is photosensitivity. This makes skin react abnormally to light, especially ultraviolet radiation or sunlight.Prevention involves avoiding direct exposure to sunlight and ultraviolet light, wearing protective clothing outdoors, and using sunscreen.