Ch. 13 PrepU Practice Questions
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?
"Have you ever been tested for diabetes?" Explanation: Diabetes is a significant risk factor for cataracts, especially those with an early onset. Exercise, use of pain medications, and visual acuity are not closely correlated with the development of cataracts.
The nurse is caring for a healthy adult client with no history of vision problems. The nurse should tell the client that a thorough eye examination is recommended every a) year. b) 3 years. c) 4 years. d) 2 years.
2 years. Explanation: A thorough eye examination is recommended for healthy clients without risk factors every 2 years, for ages 18 through 60; annually for those age 61 and older.
The nurse tests the distant visual acuity of several clients and records the findings. Which finding indicates that the client with the poorest vision? 20/30 20/40 20/50 20/60
20/60 The higher the second number, the poorer the client's vision is. The top number is always 20, indicating the distance from the client to the chart.
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 Explanation: When the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.
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) Assess the nasolacrimal sac. b) Inspect the palpebral conjunctiva. c) Test pupillary reaction to light. d) Perform the eye positions test.
Assess the nasolacrimal sac. Explanation: Excessive tearing is caused by exposure to irritants or obstruction of the lacrimal apparatus. Therefore the nurse should assess the nasolacrimal sac. Inspecting the palpebral conjunctiva would be done if the client complains of pain or a feeling of something in the eye. The client is not exhibiting signs of problems with muscle strength, such as drooping, so performing the eye position test, which assesses eye muscle strength and cranial nerve function, is not necessary. Testing the pupillary reaction to light evaluates pupillary response and function of the oculomotor nerve.
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) cataracts b) presbyopia c) nystagmus d) glaucoma
Cataracts Explanation: Sun exposure is a risk factor for cataracts but is not noted to influence the development of presbyopia, nystagmus, or glaucoma.
A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following? a) Cornea b) Conjunctiva c) Retina d) Sclera
Conjunctiva Explanation: The conjunctiva is a thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion. The palpebral conjunctiva lines the inside of the eyelids, and the bulbar conjunctiva covers most of the anterior eye, merging with the cornea at the limbus. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends them to the brain. The sclera is a dense, protective, white covering that physically supports the internal structures of the eye. The transparent cornea (the "window of the eye") permits the entrance of light, which passes through the lens to the retina.
A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response? a) Deep-water fish b) Multigrain foods c) Low-fat meat d) Foods that contain lots of water
Deep-water fish Explanation: Foods that promote eye health include deep-water fish, fruits, and vegetables
nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process? a) Anemia b) Renal insufficiency c) Retinal detachment d) Diabetes
Diabetes Explanation: Exudates appear as light-colored spots on the retinal background and occur in individuals with diabetes or hypertension. Anemia, renal insufficiency, and retinal detachment do not cause this appearance on the retina.
A nurse is inspecting the bulbar conjunctiva and sclera of a 67-year-old client, and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nursing action at this time? a) Notify the physician of the finding b) Document the finding and proceed with the examination c) Examine the client's eye for presence of a foreign body d) Ask the client whether he has recently had trouble focusing when reading up close
Document the finding and proceed with the examination Explanation: Yellowish nodules on the bulbar conjunctiva are called pinguecula. These harmless nodules are common in older clients and appear first on the medial side of the iris and then on the lateral side. Therefore, the nurse should document this finding and proceed with the examination. There is no need to notify the physician of the finding. Having trouble focusing when reading up close is a sign of presbyopia, or impaired near vision, which is not associated with the finding of pinguecula. A foreign body or lesion may cause irritation, burning, pain and/or swelling of the upper eyelid but would not cause yellowish nodules.
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? a) Immediately cover the eyes with warm saline soaks b) Ask the client about recent use of eye medications c) Check the client for the presence of strabismus d) Document the finding as a normal sign of aging
Document the finding as a normal sign of aging Explanation: Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client.
Which action by the nurse indicates the appropriate use of an ophthalmoscope?
Employ the right eye to examine the client's right eye Explanation: The nurse should employ the right eye to examine the client's right eye; this action of the nurse indicates the correct use of the ophthalmoscope. The nurse should hold the ophthalmoscope with the index finger on the lens wheel. The nurse should ask the client to gaze at an object straight ahead and slightly upward, not downward. The nurse should approach the client from the side, not from the front.
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? a) Strabismus b) Esotropia c) Exotropia d) Presbyopia
Exotropia 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.
Which of the following would a nurse expect to assess in a client with esotropia?
Eye that turns inward Esotropia is a term used to describe eyes that turn inward. Exotropia refers to an outward turning of the eyes. Strabismus refers to a constant malalignment of the eyes. Nystagmus refers to oscillating or shaking movement of the eye
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) Strabismus b) Episcleritis c) Macular degeneration d) Glaucoma
Glaucoma Explanation: Seeing halos around lights is associated with narrow-angle glaucoma. This symptom is not associated with episcleritis, strabismus, or macular degeneration.
What is vital in maintaining vision and a healthy outlook for clients? a) Physical exercise b) Emotional support c) Health education d) Monthly eye exams
Health education Explanation: Nursing education is vital in maintaining vision and a healthy outlook for clients.
A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition? a) Blepharitis b) Iris nevus c) Hyphema d) Chalazion
Hyphema Explanation: Hyphema is blood in the anterior chamber of the eye, usually caused by blunt trauma. Blepharitis is inflammation of the margin of the eyelid. Chalazion is a cyst in the eyelid. Iris nevus is a rare condition affecting one eye. The latter 3 conditions are not commonly attributed to blunt force trauma to the head as hyphema is.
What features would most likely be noted on fundoscopic examination of someone with glaucoma? a) AV nicking b) Cotton wool spots c) Microaneurysms d) Increased cup-to-disc ratio
Increased cup-to-disc ratio Explanation: It is important to screen for glaucoma on fundoscopic examination. The cup and disc are among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension. Microaneurysms are seen in diabetes.
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 primarily involves the lens of the eye. b) It allows the eyes to focus on near objects. c) It begins with light rays striking the retina. d) It refers to a client's subjective appraisal of his or her vision.
It begins with light rays striking the retina. Explanation: Visual perception occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted. The lens does not contribute directly to visual perception. Accommodation is the process that allows the eyes to focus on near objects.
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? a) Vitreous chamber b) Lacrimal apparatus c) Aqueous chamber d) Sinus
Lacrimal apparatus 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.
A client presents to the health care clinic with red, watery eyes and constant tearing. The nurse understands that which of the following is the organ that produces tears? a) Eccrine gland b) Sebaceous gland c) Lacrimal gland d) Meibomian gland
Lacrimal gland Explanation: The lacrimal gland, located in the upper outer corner of the orbital cavity just above the eye, produces tears. The meibomian glands, which are located in the tarsal plates of the upper eyelid, secrete an oily substance that lubricates the eyelid. Eccrine glands produce sweat and are located in the skin all over the body. Sebaceous glands are glands located in the dermis of the skin that open to hair follicles and that secrete an oily substance known as sebum.
The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from? a) Asthenopia b) Myopia c) Hyperopia d) Presbyopia
Myopia Explanation: Myopia is nearsightedness, meaning the client can see objects better up close. Asthenopia is eye strain, and symptoms include fatigue, red eyes, eye pain, blurred vision, and headaches. Hyperopia is farsightedness. Presbyopia commonly occurs naturally due to the aging process; therefore it's rare to observe this condition in young adults
A nurse assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? a) Narcotic use b) Recent eye trauma c) Recent central nervous system injury d) Effects of deep anesthesia
Narcotic use Explanation: Pinpoint pupils suggest narcotic use or brain damage. Hyphema would suggest recent eye trauma. Dilated and fixed pupils typically result from central nervous system injury, circulatory collapse, or deep anesthesia
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) Nystagmus c) Tropia d) Phoria
Nystagmus Explanation: Nystagmus may be associated with an inner ear disorder. Strabismus or tropia would refer to a constant malalignment of the eyes due to a muscle weakness detected with the corneal light reflex test. Phoria describes a drifting of the eyes due to a mild muscle weakness and is detected only with the cover test
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? a) Macular degeneration b) Presbyopia c) Loss of convergence d) Cataract formation
Presbyopia 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.
When testing the near reaction, an expected finding includes which of the following? a) Pupillary dilation on near gaze; constriction on distant gaze b) Pupillary constriction on near gaze; dilation on distant gaze c) Pupillary constriction on near gaze; constriction on distant gaze d) Pupillary dilation on near gaze; dilation on distant gaze
Pupillary constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far gaze.
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 The Snellen E chart can be used for people who cannot read or speak English.
What is the primary purpose of the health history in relation to the eyes? a) To identify changes b) To identify if problems are unilateral or bilateral c) To identify a family history of ocular disease d) To test the acuity of central vision
To identify changes Explanation: The purpose of the health history is to identify changes in the eyes.
A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina? a) Permits the entrance of light to the eye b) Transforms light rays into nerve impulses that are conducted to the brain c) Controls the amount of light entering the eye d) Refracts light rays onto the posterior surface of the eye
Transforms light rays into nerve impulses that are conducted to the brain Explanation: Visual perception occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted. The lens functions to refract (bend) light rays onto the retina. Muscles in the iris adjust to control the pupil's size, which controls the amount of light entering the eye. The cornea permits the entrance of light, which passes through the lens to the retina.
A nurse cares for a client with optic atrophy. The nurse recognizes that an ophthalmoscopic examination of the eye should reveal which characteristic finding in the optic disc? a) Blurred margins b) White-colored c) Orange-colored d) Oval-shaped
White-colored Explanation: A white-colored optic disc is the characteristic finding in optic atrophy due to a lack of disc vessels. This condition is caused by the death of optic nerve fibers. An oval-shaped, orange-colored optic disc that is 1.5 mm wide is normal. Blurred margins indicate papilledema, or swelling.
The conjunctiva of the eye is divided into the palpebral portion and the a) bulbar portion. b) nasolacrimal portion. c) intraocular portion. d) canthus portion.
bulbar portion. The conjunctiva is a thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion. The palpebral conjunctiva lines the inside of the eyelids, and the bulbar conjunctiva covers most of the anterior eye, merging with the cornea at the limbus.
The middle layer of the eye is known as the a) retinal layer. b) choroid layer. c) optic layer. d) scleral layer.
choroid layer. Explanation: The middle layer contains both an anterior portion, which includes the iris and the ciliary body, and a posterior layer, which includes the choroid.
The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and a) change refractory of the lens. b) cleanse the cornea and the lens. c) transmit light rays. d) maintain the retinal vessels.
cleanse the cornea and the lens. Explanation: Aqueous humor helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure.
The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to a) constant misalignment of the eyes. b) muscle weakness. c) congenital cataracts. d) decreased accommodation.
decreased accommodation. Explanation: Presbyopia (impaired near vision) is indicated when the client moves the chart away from the eyes to focus on the print. It is caused by decreased accommodation.
The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should a) document the findings in the client's records. b) examine the client for other signs of glaucoma. c) refer the client for further evaluation. d) ask the client if there is a genetic history of blindness.
document the findings in the client's records. Explanation: Validate the eye assessment data that you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.
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 a) glaucoma. b) bacterial infection. c) increased intracranial pressure. d) migraine headaches.
glaucoma. Explanation: A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent:
macular degeneration
The optic nerves from each eyeball cross at the a) visual cortex. b) optic chiasma. c) vitreous humor. d) optic disc.
optic chiasma. Explanation: At the point where the optic nerves from each eyeball cross—the optic chiasma—the nerve fibers from the nasal quadrant of each retina (from both temporal visual fields) cross over to the opposite side.
Straight movements of the eye are controlled by the a) lacrimal muscles. b) corneal muscles. c) oblique muscles. d) rectus muscles.
rectus muscles. Explanation: The extraocular muscles are the six muscles attached to the outer surface of each eyeball. These muscles control six different directions of eye movement. Four rectus muscles are responsible for straight movement, and two oblique muscles are responsible for diagonal movement.
A client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his right eye. The nurse should a) examine the area of head trauma. b) assess the client for double vision. c) ask the client if he sees "halos." d) refer the client to an ophthalmologist.
refer the client to an ophthalmologist. Explanation: Consistent blind spots may indicate retinal detachment. Any report of a blind spot requires immediate attention and referral to a physician.
Which of the following assessment findings suggests a problem with the client's cranial nerves? a) A client's lens appears cloudy and she claims that her visual acuity has recently declined. b) A client's extraocular movements are asymmetrical and she complains of diplopia. c) Fundoscopic examination reveals intraocular bleeding. d) A client states that he has recently begun seeing lights flashing in his field of vision.
A client's extraocular movements are asymmetrical and she complains of diplopia. 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.
A client performs the test for distant visual acuity and scores 20/50-2. How should the nurse most accurately interpret this finding? a) When 50 feet from the chart, the client can see better than a person standing at 20 feet. b) At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet. c) Client can read the 20/50 line correctly and two other letters on the line above. d) Client did not wear his glasses for this test and therefore it is not accurate.
At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet. 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 and 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.
Choice Multiple question - Select all answer choices that apply. A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment? a) This could be a sign of strabismus b) Blunt-force trauma often results in fracture of the orbit c) High-velocity injuries are typically non-penetrating d) The client could have optiatrophy
Blunt-force trauma often results in fracture of the orbit Explanation: High-velocity injuries ARE typically penetrating. Blunt-force trauma often results in fracture of the orbit. Optiatrophy is atrophy of the optic nerve. Strabismus is the medical term for cross-eyed.
Inspection of a client's eyelids reveals significant lid swelling, moderate redness, but little pain. Which of the following would the nurse suspect? a) Hordeolum b) Blepharitis c) Chalazion d) Exophthalmos
Chalazion Explanation: A chalazion is an infection of the meibomian gland that produces extreme swelling of the lid, and moderate redness, but minimal pain. Blepharitis is manifested by redness and crusting along the lid margins. Hordeolum is an infection of the hair follicle causing local redness, swelling, and pain. Exophthalmos is a protrusion of the eyeball accompanied by retracted eyelid margins.
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) Accommodation c) Optic chiasm d) Consensual response
Consensual response Explanation: When a light is shone in one eye, that eye will constrict and the opposite (consensual) eye will also constrict. Shining a light in one eye with the resulting constriction of that eye demonstrates the direct reflex. The optic chiasm is the point where the optic nerves from each eyeball cross. Accommodation occurs when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict.
A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder? a) Glaucoma b) Cataract c) Diabetes d) Hypertension
Glaucoma Explanation: Seeing rings around lights or halos is associated with narrow angle glaucoma. Diabetes produces change in the retina that can cause blurred vision. Cataracts are caused by clouding of the lens of the eyes. Hypertension affects the blood vessels of the eyes which may not cause any eye symptoms until the damage is severe.
During adolescence, what vision change is common? a) Color blindness b) Amblyopia c) Nearsightedness d) Presbyopia
Nearsightedness Explanation: Vision changes, such as nearsightedness, are common in adolescents. Amblyopia is also known as "lazy eye". This is more common in young children. Presbyopia is the decreased ability for one to focus on near objects and is more common in the adult as they age. Color blindness is a genetic condition and not impacted by the age of the client
A patient in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what? a) 20/100 or less b) 20/400 or less c) 20/300 or less d) 20/200 or less
20/200 or less Explanation: In the United States, a person is usually considered legally blind when vision in the better eye, corrected by glasses, is 20/200 or less.
client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client? a) Viral infection b) Vitamin A deficiency c) Brain tumor d) Allergies
Brain tumor Explanation: Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor. Vitamin A deficiency is a cause of night blindness. Allergies are usually indicated by burning or itching pain in the eye. Viral infection is usually indicated by redness or swelling of the eye.
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 OD= right eye, OS= left eye. Therefore, the client has worse vision in the right eye because the larger the number on the bottom, the worse the visual acuity. A client is considered legally blind when the vision in the better eye with corrective lens is 20/200 or less. Snellen test is to test for distant vision (far) not near vision
Choice Multiple question - Select all answer choices that apply. Equipment used for objective data collection involving the eyes includes which of the following? Select all that apply. a) Ophthalmoscope b) Snellen chart c) Penlight d) Occlusive covers e) Protective mask
• Penlight • Ophthalmoscope • Snellen chart • Occlusive covers Explanation: Common equipment used for eye assessment includes penlight, cotton wisps, cotton-tipped applicators, ophthalmoscope, Snellen chart, Jaeger chart, occlusive covers for individual eye testing, and Ishihara plates (optional for testing color vision). A protective mask would not be needed for objective assessment of the eyes. (
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? a) "In children, this problem is usually caused by an increase in pressure within the eye." b) "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." c) "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." d) "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage."
"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 con
Which of the following statements most accurately describes the maintenance of normal intraocular pressure? a) The eye is a closed system whose contents of aqueous humour provide consistent internal pressure. b) The lacrimal gland produces increased fluid when intraocular pressure is low and ceases production when pressure is high. c) The muscles of the ciliary body adjust the volume of the eye in response to increased or decreased pressure. d) Aqueous humour is continuously circulating through the eye with production equalling drainage.
Aqueous humour is continuously circulating through the eye with production equalling drainage. Explanation: Aqueous humour, produced by the ciliary body, maintains intraocular pressure with production equalling drainage. It is not a closed system, and pressure is not adjusted through muscular control of eye volume
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 oscillating b) Eye turning inward c) Eye turning outward d) Eye malalignment
Eye turning inward Explanation: Esotropia is a term used to describe eyes that turn inward. Exotropia refers to an outward turning of the eyes. Strabismus refers to a constant malalignment of the eyes. Nystagmus refers to an oscillating or a shaking movement of the eye.
A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should a) ask the client to return in 2 weeks for another examination. b) document the results in the client's record. c) ask the client to read a handheld vision chart. d) refer the client to an optometrist.
efer the client to an optometrist. Explanation: Myopia (impaired far vision) is present when the second number in the test result is larger than the first (20/40). The higher the second number, the poorer the vision.
The nurse is using the ophthalmoscope to examine the patient's eyes. The nurse holds the scope a) in the left hand for both eyes b) in the left hand for the right eye and in the right hand for the left eye c) in the right hand for the right eye and in the left hand for the left eye d) in the right hand for both eyes
in the right hand for the right eye and in the left hand for the left eye
A client recently diagnosed with Grave's diseases exhibits protruded eyeballs. Which eye care instruction should the nurse discuss with this client? a) "Wear an eyepatch and use moisturizing eye drops." b) "Wear ultraviolet blocking glasses to slow the development of this condition." c) "Clean the eyes from the outer to inner canthus once a day." d) "Use sympathomimetic eye drops twice daily."
"Wear an eyepatch and use moisturizing eye drops." Explanation: Exopthalmos, or protruding eyeballs, is commonly caused by Grave's disease. Untreated exopthalmos can impair the ability of the eye to close properly and can increased dryness. The client should have regular eye exams and can wear an eyepatch and use moisturizing eye drops for dryness. Eyes should be cleaned from the inner to outer canthus as needed. Wearing UV blocking glasses does not affect the progression of this condition, but does help with cataracts. Sympathomimetic eye drops are used to dilate pupils for eye exams. These drops are not commonly prescribed for exopthalmos.
A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding? a) Continue with the examination b) Document this finding in the client's record c) Ask the client about previous trauma to the eyes d) Report this to the health care provider
Ask the client about previous trauma to the eyes Explanation: Unequal pupil size is termed anisocoria. Often it is a normal finding but it can indicate trauma to the parasympathetic nerve supply to the iris. The nurse should ask the client about previous trauma to the eye to determine whether this is a new finding or new onset. All other options the nurse can do after this is determined.
A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate? a) Have the client keep the glasses on but occlude one eye. b) Use the E chart rather than the Snellen chart for testing. c) Test the client's near visual acuity instead. d) Ask the client to remove the glasses before testing
Ask the client to remove the glasses before testing. Explanation: When testing distant visual acuity, the nurse should have the client remove the reading glasses, because they blur distant vision. The client would wear his or her glasses during the test if they were not reading glasses. The nurse would still test the client's distant visual acuity. The E chart would be appropriate if the client could not read or has a handicap that prevents verbal communication. (
A diabetes educator is teaching a group of adults about the risks to vision that result from poorly controlled blood glucose levels. Which of the following pathophysiologic processes underlies the vision loss associated with diabetes mellitus? a) Increased blood glucose levels cause osmotic changes in the aqueous humour. b) Blood vessels supplying the retina become weak and bleeding occurs. c) Diabetes contributes to increased intraocular pressure. d) Diabetes is associated with recurrent corneal infections and consequent scarring.
Blood vessels supplying the retina become weak and bleeding occurs. Explanation: In diabetic retinopathy, the vessels that feed the retina change and weaken. Eventually, they may become blocked and cause bleeding into the eye, which blocks vision. Diabetes does not directly cause an increase in pressure in the eye, osmotic changes in the aqueous humor or corneal infection.
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 relative color of the sclerae before and after light exposure b) By comparing how quickly the client blinks each eyelid c) By comparing the speed of pupillary constriction d) By comparing the reflection of the light on the client's eye surface
By comparing the reflection of the light on the client's eye surface Explanation: During the corneal light reflex test, the reflection of light on the corneas is assessed and should be in the exact same spot on each eye, indicating parallel alignment. Constriction, color of the sclerae, and blinking are not appraised.
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 how quickly the client blinks each eyelid b) By comparing the reflection of the light on the client's eye surface c) By comparing the relative color of the sclerae before and after light exposure d) By comparing the speed of pupillary constriction
By comparing the reflection of the light on the client's eye surface Explanation: During the corneal light reflex test, the reflection of light on the corneas is assessed and should be in the exact same spot on each eye, indicating parallel alignment. Constriction, color of the sclerae, and blinking are not appraised.
A woman who is 5 months pregnant is being assessed at a routine visit. She has increased pigmentation around the eyes. This is known as what? a) Conjunctivitis b) Pink eye c) Chloasma d) Hyphema
Chloasma Explanation: Chloasma, or increased pigmentation around the eyes, may result from increased progesterone levels in pregnant women. Conjunctivitis is inflammation/infection of the conjunctiva. Hyphema is blood in the anterior chamber. Pink eye is a distracter for this question.
The nurse is preparing to assess a client's visual fields to evaluate her gross peripheral vision. Which test would the nurse perform? a) Cover test b) Confrontation test c) Corneal light reflex test d) Eye position test
Confrontation test Explanation: The confrontation test evaluates peripheral vision. The cover test, corneal light reflex test, and eye position test would be used to evaluate extraocular muscle function.
A nurse inspects the eyes of a young child and notices the inward turning of the eyes. What test should the nurse perform to assess whether this finding is normal or abnormal? a) Cover test b) Confrontation c) Corneal light reflex d) Pupillary reaction to light
Corneal light reflex Explanation: In young children, the pupils will often appear at the inner canthus due to the epicanthic fold. To test the corneal light reflex, the nurse shines a penlight about 12 inches from the face, directing it towards the bridge of the nose. The reflection of light on the cornea should be in the exact same spot on each eye. If not, this is considered abnormal and requires further assessment. The cover test does not test extraocular muscle function. The confrontation test examines peripheral vision. Pupillary reaction to light test constriction of pupil, not alignment.
A nurse performs the cover test to assess for proper alignment of the eyes. When uncovering the previously covered eye, the nurse should observe for which response to indicate a normal finding? a) Uncovered eye turns inward to establish focus b) Covered eye moves to establish focus c) Covered eye remains fixed straight ahead d) Both eyes may turn either downward or upward
Covered eye remains fixed straight ahead Explanation: The covered eye should remain fixed straight ahead upon uncovering the eye. The eye moving to any side to reestablish focus indicates a deviation in alignment of the eyes and muscle weakness. The eyes should not turn toward the object to establish focus. The eyes moving upward or downward are abnormal responses.
A nurse is inspecting a client's eyelids and eyelashes. Which of the findings would the nurse document as abnormal? a) Upright lower eyelid b) Drooping of the upper lid c) Raised yellow plaques near inner canthus d) White sclera absent above iris
Drooping of the upper lid Explanation: Drooping of the upper lid is ptosis and may be attributed to oculomotor nerve damage, myasthenia gravis, weakened muscle or tissue, or a congenital disorder. It is an abnormal finding. Raised yellow plaques near the inner canthus are a normal variation associated with increasing age and high lipid levels. An upright lower eyelid and white sclera that is not visible above or below the iris are normal findings
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? a) Medially toward the nose b) Downward toward the chin c) Upward toward the forehead d) Laterally toward the ear
Medially toward the nose Explanation: Follow the blood vessels as they get wider. Follow the vessels medially toward the nose and look for the round yellowish orange structure which is the optic disc.
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? a) Eyes do not converge to focus on a shining light b) Light reflection appears at different spots on both eyes c) Pupils dilate in response to a light shone in the eyes d) Nonreaction of the opposite pupil to light
Nonreaction of the opposite pupil to light Explanation: When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict. An abnormal response to this test is if wither or both pupils do not constrict in response to light. Pupils do not dilate in response to light shone into them. Convergence of the eyes is called accommodation & occurs when a person moves his focus of vision from a far object to a close object.
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) Shining a light into one eye while covering the other eye with an opaque card b) Observing the eye's reaction when a light is shone into the opposite eye 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
Observing the eye's reaction when a light is shone into the opposite eye Explanation: The nurse assesses consensual response at the same time as direct response by shining a light obliquely into one eye and observing the pupillary reaction in the opposite eye. This does not involve a comparison between maximum and minimum pupil size, however. Neither eye is covered, and peripheral vision is not relevant to this assessment
When testing the pupils for consensual response, how can the nurse increase the accuracy of the test? a) Place a barrier between the eyes b) Ask the client to close the opposite eye c) Approach the client from the side d) Shine the light across the bridge of the nose
Place a barrier between the eyes Explanation: To increase the accuracy of the consensual pupil response, the nurse should place a hand or other barrier between the client's eyes to avoid an inaccurate finding. Approaching form the side or shining the light across the bridge of the nose may cause the consensual pupil to constrict by direct light rather than by indirect light. Closing of one eye will not improve the accuracy of the test
A nurse assesses the pupillary reaction to light for a client who has lost vision in one eye. Which precaution should the nurse follow to get an accurate result of consensual response? a) Observe the response in the eye focused with light b) Shine a bright light directly into the eye to be tested c) Instruct the client to close the eye not focused with light d) Place an opaque card in between the eyes of the client
Place an opaque card in between the eyes of the client Explanation: The nurse should place an opaque card in between the eyes of the client when assessing the client for consensual response to avoid inaccurate results. The light should not be focused directly into the eye to be tested; it should be focused obliquely into one eye, and the response should be checked in the other eye. The client should not be instructed to close the other eye not focused with light because the response is checked in the other eye.
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? a) Exotropia b) Strabismus c) Esotropia d) Presbyopia
Presbyopia Explanation: Presbyopia, which is impaired near vision, is indicated when the client moves a reading chart or other reading material away from the eyes to focus on the print. It is caused by decreased accommodation and is a common condition in clients over 45 years of age. 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
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 a) requires the client to focus on an object. b) assesses the muscle strength of the eye. c) requires the covering of each eye separately. d) assesses the functioning of the cranial nerves innervating the eye muscles.
Requires the covering of each eye separately. Explanation: Perform the positions test, which assesses eye muscle strength and cranial nerve function. Instruct the client to focus on an object you are holding (approximately 12 inches from the client's face). Move the object through the six cardinal positions of gaze in a clockwise direction, and observe the client's eye movements.
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? a) Risk for Injury b) Self-Care Deficit c) Ineffective Individual Coping d) Disturbed Self Concept
Risk for Injury Explanation: The only nursing diagnosis that can be confirmed with these 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 diagnoses.
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? a) Dacryocystitis b) Stye c) Chalazion d) Xanthelasma
Stye Explanation: A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.
A patient has a nursing diagnosis of disturbed visual sensory perception. Which of the following is the most appropriate outcome for this patient's care planning? a) The patient will obtain contact lenses to improve self-concept. b) The patient will remain free from harm resulting from a loss of vision. c) The patient will obtain a Seeing Eye dog. d) The patient will remain independent in own home.
The patient will remain free from harm resulting from a loss of vision. Explanation: The patient with disturbed sensory perception is at risk for physical harm and damage as a result of environmental l imitations imposed by impaired vision.
An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is a) ultraviolet light exposure. b) use of antibiotics. c) obesity. d) lack of vitamin C in the diet.
ultraviolet light exposure. Explanation: Exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lenses of the eyes). Consistent use of sunglasses during exposure minimizes the client's risk.
A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with a) migraine headaches. b) retinal deterioration. c) vitamin A deficiency. d) head trauma.
vitamin A deficiency. Explanation: Night blindness is associated with optic atrophy, glaucoma, and vitamin A deficiency.
Choice Multiple question - Select all answer choices that apply. 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.) a) Hypertension b) Osteoarthritis c) Diabetes d) Hypothyroidism e) Hyperlipidemia
• Hypertension • Diabetes Explanation: Diabetic retinopathy is the most common cause of blindness in the United States. Hypertensive retinopathy is another high risk factor for blindness over hypothyroidism, hyperlipidemia, and osteoarthritis.