chapter 13 eyes

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? "Do you exercise regularly?" "Have you ever been tested for diabetes?"

"Have you ever been tested for diabetes?"

A client is concerned about a bright red area on the sclera. What should the nurse say to the client about this finding? "You need to see an ophthalmologist immediately." "This can mean the pressure in your eye is too high." "You are in the process of having a detached retina." "This can occur with sneezing or coughing and is harmless."

"This can occur with sneezing or coughing and is harmless.

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? "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."

"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

A client recently diagnosed with Grave's diseases exhibits protruded eyeballs. Which eye care instruction should the nurse discuss with this client? "Clean the eyes from the outer to inner canthus once a day." "Wear ultraviolet blocking glasses to slow the development of this condition." "Use sympathomimetic eye drops twice daily." "Wear an eyepatch and use moisturizing eye drops."

"Wear an eyepatch and use moisturizing eye drops."

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? 20/100 or less 20/200 or less

20/200 or less

The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal? 2 mm 4 mm 6 mm 8 mm

4 mm

u 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 A homonymous hemianopsia

A left temporal hemianopsia

A nurse is assessing a client who is suspected to have optic atrophy. What assessment finding is most consistent with this diagnosis? increased appearance of the disc vessels A white appearance of the optic disc

A white appearance of the optic disc

A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next? Irrigate the eye with dilute hydrogen peroxide. Arrange for worker to be promptly assessed by an eye specialist.

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

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? Report this to the health care provider Ask the client about previous trauma to the eyes

Ask the client about previous trauma to the eyes

A nurse is assessing an adult client's eyes and vision. When performing the cover test, what would the nurse do next after covering one of the client's eyes? Ask the client to focus on a distant object, looking for movement in the other eye. Ask the client to close the other eye then open that eye quickly.

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

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? Ask the client to remove the glasses before testing. Have the client keep the glasses on but occlude one eye.

Ask the client to remove the glasses before testing.

Which technique by the nurse demonstrates proper use of the ophthalmoscope? Uses right eye to examine the client's left eye Moves the scope around so the entire optic disk may be seen Approaches the client directly in front of the pupil Asks the client to fix the gaze upon an object and look straight ahead

Asks the client to fix the gaze upon an object and look straight ahead

A client complains of excessive tearing of the eyes. Which assessment would the nurse do next? Assess the nasolacrimal sac Perform the eye positions test

Assess the nasolacrimal sac

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? Blood vessels supplying the retina become weak and bleeding occurs. Diabetes is associated with recurrent corneal infections and consequent scarring.

Blood vessels supplying the retina become weak and bleeding occurs.

A 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? Vitamin A deficiency Brain tumor

Brain tumor

A nurse has performed the corneal light reflex test during a client's eye examination. During this test, the nurse appraised the client's eye alignment in which way? By comparing the reflection of the light on the client's eye surface By comparing the speed of pupillary constriction

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

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? Presbyopia Cataracts

Cataracts

The nurse is preparing to assess a client's visual fields to evaluate her gross peripheral vision. Which test would the nurse perform? Cover test Corneal light reflex test Confrontation test

Confrontation test

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? Retina Sclera Cornea Conjunctiva

Conjunctiva

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

Conjunctiva

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

Conjunctivitis

A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon? Accommodation Consensual reaction Near reaction

Consensual reaction

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? Consensual response Accommodation

Consensual response

A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response? Deep-water fish Low-fat meat

Deep-water fish

A 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? Anemia Renal insufficiency Diabetes Retinal detachment

Diabetes

A nurse is inspecting a client's eyelids and eyelashes. Which of the findings would the nurse document as abnormal? Raised yellow plaques near inner canthus Drooping of the upper lid

Drooping of the upper lid

Which data collected in a health history interview of a client should the nurse document as risk factors for the development of cataracts? Select all that apply. Cigarette smoking Thyroid disease Works in lawn maintenance Eats very few fruits or vegetables Hit on the back of the head with a hammer

Eats very few fruits or vegetables Cigarette smoking Works in lawn maintenance

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? Ptosis Exophthalmos Ectropion

Exophthalmos

What muscles control the eye movement and hold the eye in place in the socket? Extraocular Oculomotor

Extraocular

Which of the following would a nurse expect to assess in a client with esotropia? Eye turning inward Eye oscillating

Eye turning inward

The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? Far, then near Lateral, then near

Far, then near

The muscles of the ciliary body control the thickness of the lens, allowing the eye to: Adjust the pressure inside the eye Focus on near or distant objects

Focus on near or distant objects

A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result? Focused on the bridge of the nose Directly on the eye being examined

Focused on the bridge of the nose

A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder? Diabetes Cataract Glaucoma

Glaucoma

A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity? Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time Sit the client in front of the examiner, extend one arm, and slowly move one finger upward

Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time

What is vital in maintaining vision and a healthy outlook for clients? Health education Monthly eye exams

Health education

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? Blepharitis Hyphema

Hyphema

A nurse is presenting a class to a local community 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? Refers to what a person sees with one eye Involves light rays striking the retina

Involves light rays striking the retina

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. What would the nurse include in the explanation? It refers to a client's subjective appraisal of his or her vision. It begins with light rays striking the retina. It primarily involves the lens of the eye. It allows the eyes to focus on near objects.

It begins with light rays striking the retina.

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

Lacrimal apparatus

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? Medially toward the nose Laterally toward the ear

Medially toward the nose

The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from? Presbyopia Myopia

Myopia

A nurse assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? Recent eye trauma Narcotic use

Narcotic use

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? Recent eye trauma Narcotic use

Narcotic use

During adolDuring adolescence, what vision change is common? Nearsightedness Color blindness

Nearsightedness

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? Nonreaction of the opposite pupil to light Light reflection appears at different spots on both eyes

Nonreaction of the opposite pupil to light

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

Normal findings for client's age

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? Tropia Nystagmus

Nystagmus

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 action? Observing the eye's reaction when a light is shone into the opposite eye Shining a light into one eye while covering the other eye with an opaque card

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

when performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. How would the nurse document this finding? Physiologic cup Optic disc

Optic disc

The nurse is conducting a pupillary examination on a 34-year-old man. Both pupils dilate slightly. Both constrict briskly when the light is placed on the right eye. What is the most likely problem? Optic nerve damage on the right Optic nerve damage on the left

Optic nerve damage on the left

On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? Document the findings in the client's record Perform both the distant and near visual acuity tests Test the pupils for direct and consensual reaction to light

Perform both the distant and near visual acuity tests

a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? Document the findings in the client's record Perform both the distant and near visual acuity tests

Perform both the distant and near visual acuity tests

When testing for consensual pupillary constriction, which technique would be most appropriate? Shine a light directly into one eye of the client Place a barrier between the client's eyes

Place a barrier between the client's eyes

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? Observe the response in the eye focused with light Place an opaque card in between the eyes of the client

Place an opaque card in between the eyes of the client

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? Exotropia Esotropia Strabismus Presbyopia

Presbyopia

During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect? Myopia Presbyopia

Presbyopia

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed? Presbyopia Cataract formation

Presbyopia

When testing the near reaction, an expected finding includes which of the following? Pupillary dilation on near gaze; dilation on distant gaze Pupillary dilation on near gaze; constriction on distant gaze Pupillary constriction on near gaze; dilation on distant gaze Pupillary constriction on near gaze; constriction on distant gaze

Pupillary constriction on near gaze; dilation on distant gaze

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? self-Care Deficit Risk for Injury

Risk for Injury

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 allen test

Snellen E

A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis? Corneal abrasion Subconjunctival hemorrhage

Subconjunctival hemorrhage

A client is being assessed for indications of a possible obstructed nasolacrimal duct in the right eye. Under what circumstances should the nurse avoid compressing the lacrimal sac? The area around the sac is inflamed. The client reports experiencing floaters.

The area around the sac is inflamed.

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? Direct light shown into the client's pupils results in constriction. The client and the examiner see the examiner's finger at the same time.

The client and the examiner see the examiner's finger at the same time.

A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results? Vision is worse in the left eye than the right eye The larger the bottom number, the worse the visual acuity

The larger the bottom number, the worse the visual acuity

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? Vision is worse in the left eye than the right eye. The larger the bottom number, the worse the visual acuity.

The larger the bottom number, the worse the visual acuity.

After teaching a group of students about visual fields and visual pathways, the instructor determines that the teaching was successful when the students identify which of the following? The left side of the brain views the right side of the world. The optic nerves from each eyeball cross at the optic chiasma.

The optic nerves from each eyeball cross at the optic chiasma.

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? Controls the amount of light entering the eye Transforms light rays into nerve impulses that are conducted to the brain

Transforms light rays into nerve impulses that are conducted to the brain

When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction? Up Down

Up

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking? Move an object through the six cardinal positions of gaze Use a Snellen E chart to perform the examination

Use a Snellen E chart to perform the examination

A nurse is examining the eyes of a 7-year-old boy. The boy asks the nurse, "What's inside my eyeball?" The nurse explains that the biggest space inside the eyeball contains a clear, gelatinous substance that light passes through. Which of the following is the technical name for this gelatinous substance? Aqueous humor Vitreous humor Lacrimal humor

Vitreous humor

The nurse should make it a priority to assess which client for papilledema? a 45-year-old suspected of experiencing a subarachnoid hemorrhage an 80-year-old diagnosed with chronic open-angle glaucoma

a 45-year-old suspected of experiencing a subarachnoid hemorrhage

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

accommodation.

The conjunctiva of the eye is divided into the palpebral portion and the canthus portion. intraocular portion. nasolacrimal portion. bulbar portion.

bulbar portion.

The middle layer of the eye is known as the retinal layer. choroid layer.

choroid layer.

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and maintain the retinal vessels. cleanse the cornea and the lens.

cleanse the cornea and the lens.

The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding? direct light response present in left eye pupils equal and react to accommodation consensual light response present in left eye consensual light response present in right eye

consensual light response present in left eye

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 congenital cataracts. decreased accommodation.

decreased accommodation.

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

esotropia.

When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals? slightly darker fovea is just discernible no light reflex is visible fundus is grayish brown with a purplish cast

fundus is grayish brown with a purplish cast

A patient has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis has a watery, mucoid discharge. usually follows trauma. is not painful. can result from a cough.

has a watery, mucoid discharge.

The nurse is planning to assess a client's near vision. Which technique should be used? shine a light on the bridge of the nose have the client read newspaper print held 14 inches from the eyes

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

A client notices that the newspaper print is not as clear to read as it used to be. What health problem should the nurse consider is occurring with this client? myopia hyperopia

hyperopia

The nurse is using the ophthalmoscope to examine the patient's eyes. The nurse holds the scope in the right hand for the right eye and in the left hand for the left eye in the left hand for the right eye and in the right hand for the left eye in the right hand for both eyes in the left hand for both eyes

in the right hand for the right eye and in the left hand for the left eye

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for allergic reactions. lacrimal obstruction.

lacrimal obstruction.

When the client reports a problem associated with the drainage of tears from the left eye, the nurse would focus the eye assessment on which eye structure? lacrimal gland lacrimal puncta

lacrimal puncta

A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent macular degeneration open-angle glaucoma

macular degeneration

An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing? detached retina macular degeneration

macular degeneration

ask the client to return in 2 weeks for another examination. refer the client to an optometrist.

refer the client to an optometrist.

photoreceptors of the eye are located in the eye's ciliary body. lens. retina.

retina.

A 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should tell the client that these often occur with aging. refer the client to an ophthalmologist.

tell the client that these often occur with aging.

A parent is very upset because she is told her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in children. t or f

true

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 lack of vitamin C in the diet. ultraviolet light exposure.

ultraviolet light exposure.