Chapter 16: Assessing Eyes

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. A left temporal hemianopsia B. A bitemporal hemianopsia C. A quadrantic defect D. A homonymous hemianopsia

A. A left temporal hemianopsia 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.

The functional reflex that allows the eyes to focus on near objects is termed a) accommodation. b) indirect reflex. c) refraction. d) pupillary reflex.

A. Accomodation Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens

The conjunctiva of the eye is divided into the palpebral portion and the a) bulbar portion. b) intraocular portion. c) nasolacrimal portion. d) canthus portion.

A. 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 optic nerves from each eyeball cross at the.. a) optic chiasma b) vitreous humor c) optic disc d) visual cortex

A. Optic chiasma

A 45-year old client reports occasionally seeing spots in front of their eyes, the nurse should... a) tell the client that these often occur with aging b) refer the client to an ophthalmologist c) re-examine the client in two weeks d) assess the client for signs of diabetes

A. Tell the client that these often occur with aging

Diabetes mellitus increases the risk of developing cataract(s). a. True b. False

A. True

The middle layer of the eye is known as... a) choroid layer b) scleral layer c) retinal layer d) optic layer

A. choroid layer

Consistent blind spots are commonly seen in narrow-angel glaucoma. a. True b. False

B. False

_____ occurs when injury causes red blood cells to collect in the lower half of the anterior chamber. a. Strabisus b. Hyphemia c. Hemianopia d. Hypohyon

B. Hyphemia

A client reports they have been experiencing double vision for the past few days, the nurse refers the client to a physician for possible... a)glaucoma b) increased intracranial pressure c) hypertension d) ophthalmic migraine

B. Increased intracranial pressure

A client presents to the clinic complaining of sudden visual loss in the left eye. What is the nurse's priority action? A. Assess cranial nerve function. B. Notify the healthcare provider immediately. C. Ask the client if protective eyewear was worn. D. Perform the Allen test and report the findings urgently.

B. Notify the healthcare provider immediately. Sudden visual loss is an emergency and should be immediately reported to the healthcare provider.

Drooping of the upper eyelid is called a. exophthalmos b. ptosis c. entropion d. papilledema

B. Ptosis

A client visits the doctor after experiencing head trauma and reports a consistent blind spot in his right eye, the nurse should... a) examine the area of head trauma b) refer the client to an ophthalmologist c) assess the client for double vision d) ask the client if they see "halos"

B. Refer the client to an ophthalmologist

A visual field refers to what a person sees with one eye. a. False b. True

B. True

_____ is a hair follicle infection that causes local redness, swelling, and pain in the eyelid. a. conjunctivitis b. hordeolum c. anisocoria d. episcleritis

B. hordeolum

A client reports her peripheral vision is not what it used to be and has a blind spot in their left eye, the nurse should refer the client for evaluation of... a) glaucoma b) increased intracranial pressure c) bacterial infection d) migraine headaches

B. increased intracranial pressure

A client reports that they have been experiencing gradual vision loss, the nurse should... a) ask about the client's diet b) determine whether there's a history of glaucoma c) check the client's blood pressure d) ask the client if they have any known allergies

C. Check the client's blood pressure

While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse? a) Myopia b) Presbyopia c) Consensual reaction d) Direct reaction

C. Consensal Reaction The consensual reaction is when the pupil constricts in the opposite eye. Myopia is impaired far vision. Presbyopia is impaired near vision often seen in middle-aged and older patients. The direct reaction is when the pupil constricts in the same eye.

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 A. exotropia. B. phoria. C. esotropia. D. strabismus.

C. Esotropia. Esotropia is an inward turn of the eye.

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test the near visual acuity using a Jaeger reading card? A. Place the chart 20 feet away from the client on the wall B. Place the chart on a table 17 inches away from the client C. Instruct the client hold the chart 14 inches from the eyes D. Instruct the client to hold the chart away from the body at arm's length

C. Instruct the client hold the chart 14 inches from the eyes To test the near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arm's length is an arbitrary length depending on the size of the client & is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client

A client reports burning and itching of both eyes, the nurse should assess for... a) a foreign body b) recent trauma c) blind spots d) allergies

D. Allergies

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and... a) transmit light rays b) maintain the retinal vessels c) change refractory of the lens d) cleanse the cornea and the lens

D. Cleanse the cornea and the lens

A client reports a sudden change in her vision, the nurse advises this is associated with... a) diabetes b) the aging process c) hypertension d) head trauma

D. Head trauma

On 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? a) Document the findings in the client's record b) Obtain a referral to the ophthalmologist for a complete eye exam c) Test the pupils for direct and consensual reaction to light d) Perform both the distant and near visual acuity tests

D. Perform both the distant and near visual acuity tests The first thing the nurse should do is perform both the distant and near visual acuity exams to assess for loss of far and near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the client's record. If abnormalities are found upon assessment, the client should be referred for a complete eye examination

A client reports difficulty driving at night, the nurse should explain this is associated with... a) retinal deterioration b) head trauma c) migraine headaches d) vitamin A deficiency

D. Vitamin A deficiency

An adult client reports throbbing aching pain in their right eye, the nurse should assess for... a) recent exposure to irritants b) increased intracranial pressure c) excessive tearing d) a foreign body

D. a foreign body

An adult client reports excessive tearing in their left eye, the nurse should assess for... a) viral infection b) double vision c) allergic reactions d) lacrimal obstructions

D. lacrimal obstruction

Straight movements of the eye are controlled by the... a) lacrimal muscles b) oblique muscles c) corneal muscles d) rectus muscles

D. rectus muscles

The nurse is examining a client's eyes and has explained the positions test. The nurse determines the client needs further instructions when the client says that the positions test... a) assesses the muscle strength of the eye b) assesses the functioning of the cranial nerves innervating the eye muscles c) requires the covering of each eye separately d) requires the client to focus on an object

c) requires the covering of each eye separately

The meibomian glands secrete... a) an oily substance to lubricate the eyes b) sweat c) hormones d) clear liquid tears

A. An oily substance to lubricate the eyes

The tarsal plates of the upper eyelid contain... a) meibomian glands b) sebaceous glands c) tear ducts d) ocular muscles

A. meibomian glands

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to a) retinal damage. b) cataracts. c) corneal damage. d) myopia.

C. Corneal damage Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage

The bony orbit and fat cushion of the eye serves as a _____. a) caruncle b) channel c) protector d) filter

C. Protector

Photoreceptors of the eye are located in the eye's... a) ciliary body b) lens c) retina d) pupil

C. Retina

_____ is a local, noninfectious inflammation fo the sclera. a. Chalazion b. Exophthalmos c. Cataract d. Episcleritis

D. Episcleritis

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's... a) eyelid reflexes b) refractory mechanism c) lacrimal reflexes d) corneal reflexes

D.Corneal reflexes