Chapter 15 Physical Assessment

A client is referred to the clinic with complaints of blurred vision. Which initial question to the client is the priority? 1. "Would you please tell me about your vision today?" 2. "Do you experience double vision?" 3. "Have you had any eye pain?" 4. "What kinds of activities do you perform at work?"

1

After a comprehensive eye examination, it is determined that the client requires corrective lenses for myopia. Which explanation by the nurse to the client is the most appropriate? 1. "Your glasses will help you to see objects in the distance." 2. "Your glasses will help you to see objects that are very close to you." 3. "Your glasses will help you to improve your eyes' ability to focus and reduce your blurred vision." 4. "Your age has made it more difficult to read items that are at close range. Your new glasses will help."

1

The nurse is assessing a client's eyes during a comprehensive health assessment. Which assessment finding would require immediate intervention? 1. Acute glaucoma. 2. Blepharitis. 3. Periorbital edema. 4. Anisocoria.

1

The nurse is assessing an African American adult client who is experiencing visual changes. Which question to the client is the priority? 1. "Have you or anyone in your family ever been diagnosed with diabetes?" 2. "Do you wear sunglasses when you are outside?" 3. "Did your mother have a vaginal infection at the time of your delivery?" 4. "Do you see any halos around lights?"

1

The nurse is assessing the client's eyes. Which assessment finding supports the diagnosis of glaucoma? 1. Eyeballs are firm to palpation. 2. Pupils are constricted bilaterally. 3. Central vision is impaired. 4. The client has a history of syphilis.

1

The nurse is assessing the client's pupillary responses. The client is found to have no consensual response. Which conclusion by the nurse is the most appropriate? 1. Cranial nerve III may not be functioning appropriately. 2. This is a normal finding. 3. This is evidence of increased intracranial pressure. 4. This is evidence of optic nerve damage.

1

The nurse is assessing the fundus of the older adult client's eye with an ophthalmoscope. The nurse determines that there is a cyst within the macula. Which client symptom does the nurse anticipate? 1. Impaired central vision. 2. Impaired peripheral vision. 3. Consistently elevated serum glucose levels. 4. Uncontrolled hypertension.

1

The nurse is performing a visual examination on a client due to the client's complaints of black dots appearing in the visual field. Which statement by the nurse is most appropriate in this situation? 1. "The black dots are known as floaters and are usually normal." 2. "We need to refer you to an eye surgeon immediately." 3. "You may have glaucoma." 4. "You may have a cataract."

1

The nurse is assessing a client's visual fields by confrontation. Which actions by the nurse indicate appropriate practice? Standard Text: Select all that apply. 1. The nurse asks the client to cover one of her eyes with a card. 2. The nurse uses a penlight to assist with performing the test. 3. The nurse asks the client to sit 20 feet away. 4. The client tells the nurse when she first sees the object. 5. The nurse asks the client to stand 4 feet away.

1, 2, 4

The nurse is assessing a client who is 34 weeks pregnant. Which visual changes are usually normal in this stage in pregnancy and should disappear at some point after delivery? Standard Text: Select all that apply. 1. The client is complaining that her eyes feel very dry. 2. She states that she is experiencing blurry vision. 3. Periorbital edema is noted. 4. Cataracts are noted. 5. She has been unable to wear her contact lenses.

1, 2, 5

The nurse is examining the eye. The client asks about the specific structures within the eye that are responsible for refraction of light rays. Which structures are involved in this process? Standard Text: Select all that apply. 1. Lens. 2. Macula. 3. Cornea. 4. Iris. 5. Optic disc.

1, 3

The nurse is performing a focused interview and eye assessment on a client. Which assessment findings indicate the client's is experiencing a vision problem? Standard Text: Select all that apply. 1. The client is frowning and squinting while she is reading the Snellen chart. 2. The client exhibits a symmetrical pupillary light reflex response. 3. As the nurse checks for accommodation, the pupils remain dilated. 4. The client's near vision acuity is 14/14 bilaterally. 5. When the cornea is lightly touched in the right eye, both eyelids close.

1, 3

The nurse is assessing a child previously diagnosed with fetal alcohol syndrome. When conducting a health history interview, which statements by the client's mother are consistent with the child's diagnosis? Standard Text: Select all that apply. 1. "It seems as if one of his eyelids is droopy." 2. "There's a firm little bump on his eyelid but he says it doesn't hurt." 3. "His eyes almost look cloudy." 4. "He has required glasses to see well since he was 2 years old." 5. "His eyelids look they have turned under and he complains that his eyes hurt."

1, 3, 4

During an eye examination, the nurse requests that the client read letters located on the Snellen E chart. The client's vision is determined to be 20/200. Which statements regarding this client's vision are accurate? Standard Text: Select all that apply. 1. The client is legally blind. 2. The client is unable to read from a paper at close range. 3. The client is found to be farsighted. 4. The client is myopic. 5. This is common in clients who are over 45 years old.

1, 4

During the assessment of a client's eyes, the nurse suspects the client has entropion. Which assessment data caused the nurse to come to this conclusion? 1. Eversion of the lower eyelid. 2. Inversion of the lid and eyelashes. 3. Swollen, red hair follicles. 4. Firm, non-tender nodule on the eyelid.

2

Prior to conducting an eye assessment, which statement by the nurse is appropriate to prepare the client for the examination process? 1. "You can choose which eye to cover during your assessment." 2. "Are you able to read English words?" 3. "Apply pressure to the eye while it is covered during the examination." 4. "You will need to stand 10 feet from the chart for an accurate assessment."

2

The nurse is conducting a focused interview with an eye assessment. Which information obtained during the focused interview is the most helpful to the nurse regarding the assessment of the client's eyes? 1. The client graduated from college. 2. The client interacts easily with the nurse. 3. The client is an African American male. 4. The client is 23 years old.

2

The nurse presented a program regarding objectives related to the overall health of eyes that are addressed in Healthy People 2020. Which client statement made by an adult participant in the program indicates an adequate understanding of these objectives? 1. "My 4-year-old doesn't need his vision screened." 2. "I'm going to call my eye doctor and ask that she performs a dilated eye exam." 3. "My mom has been complaining of dry eyes, but I knew it was all in her head." 4. "I didn't know that Asians have the highest risk for developing glaucoma."

2

The nurse is assessing the adult client's eyes during a comprehensive health assessment. Which pieces of information should the nurse also gather during the assessment process? Standard Text: Select all that apply. 1. The client's birth weight. 2. The client's parents were born in Spain. 3. The client's annual income is below the poverty level. 4. The client is a welder. 5. The client recently attempted to commit suicide after his wife died in an automobile accident.

2, 3, 4, 5

During an eye assessment, a young adult client reports difficulty seeing items within close range. This assessment data is consistent with which item? 1. Aging. 2. Presbyopia. 3. Hyperopia. 4. Astigmatism.

3

During the assessment of a client's eyes, the nurse suspects that the client has ptosis. Which assessment data caused the nurse to come to this conclusion? 1. The palpebral conjunctiva is exposed. 2. The iris and cornea are reddened. 3. The eyelid is drooping. 4. The eyelids are swollen and puffy.

3

The nurse is assessing the client's eye with an ophthalmoscope. The nurse is preparing to focus on the fundus and rotates the lens diopter wheel into the negative numbers. Based on this information, which condition does the client most likely have? 1. Hyperopia. 2. Presbyopia. 3. Myopia. 4. Astigmatism.

3

The nurse is educating a student on the proper use of an ophthalmoscope for an eye examination. Which statement by the nurse to the student is accurate? 1. "I'm going to examine the client's right eye with my left eye." 2. "I'm going to advance the ophthalmoscope until the instrument touches the client's cornea." 3. "I'm going to begin with the lens set to the 0 diopter." 4. "I can see the red reflex as the light reflects off of the client's lens."

3

The nurse is interviewing the mother of a three-week-old Caucasian infant. Which statement by the mother indicates she requires further education about her newborn's eyes? 1. "It's normal for my baby not to produce tears when she cries." 2. "At this stage, my baby should be able to fixate on a bright light or something that moves." 3. "My baby's eyes are blue and definitely will stay blue." 4. "It was normal for my baby's eyes to be swollen after birth."

3

The nurse is teaching a group of nursing students about the cultural implications associated with eye diseases. At the conclusion of the teaching session, which student comment indicates the need for further education? 1. "It is important to assess the African American client for clinical manifestations associated with increased intraocular pressure." 2. "We should assess serum glucose levels in our adult Hispanic clients." 3. "Our diabetic clients should return every 2 years for an assessment of their vision and their retina." 4. "Poorly controlled serum glucose levels can result in retinal changes that affect the client's vision and can even result in blindness."

3

The nurse is teaching a middle-aged African American client who was recently diagnosed with glaucoma. Which statement by the client indicates for further education on this diagnosis? 1. "I just thought my pupils were big, I didn't know it could be associated with glaucoma." 2. "So, my headaches may be occurring because of the increased pressure within my eyes." 3. "My race doesn't have anything to do with this diagnosis." 4. "Those halos that I see around lights are associated with glaucoma."

3

The nurse notices that a client's pupils constrict when reading the consent form for medical treatment. Based on this data, which should the nurse consider as the cause? 1. The room is too dark. 2. The client is able to read. 3. This is a normal response. 4. The client requires glasses for reading.

3

will the nurse use to document this finding? 1. Exophoria. 2. Strabismus. 3. Esophoria. 4. Mydriasis.

3

The nurse is assessing the eyes of an older adult client. Which finding is expected by the nurse based on the client's age? 1. The client is easily able to read from a paper held at close range without corrective glasses. 2. There is a noticeable increase in fat within the orbit of the eye. 3. The client states that she feels her tear production has increased over the years. 4. The pupillary light reflex is slower bilaterally.

4

The nurse notes that a client is unable to control the amount of light that enters the eye. The dysfunction of which structure is the most likely cause of this problem? 1. Cornea. 2. Sclera. 3. Conjunctiva. 4. Iris.

4

The nurse taught the client how to self-administer eye drops and the client was performing a return demonstration. During this time, the client inadvertently touched the applicator to their cornea, which caused the client to blink and produce tears. How will the nurse document this occurrence? 1. Abnormal and should be reported to the healthcare provider. 2. Hyperactive. 3. A medication side effect. 4. A normal response.

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