Jensen Ch. 13

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? a) Focused on the bridge of the nose b) Shined on the forehead c) Pointed at a fixed object on the wall d) Directly on the eye being examined

Focused on the bridge of the nose

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

Perform both the distant and near visual acuity tests

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states 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) Ineffective Individual Coping b) Risk for Injury c) Disturbed Self-Concept d) Self-Care Deficit

Risk for Injury

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? a) Subconjunctival hemorrhage b) Corneal abrasion c) Conjunctivitis d) Acute iritis

Subconjunctival hemorrhage

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? a) The client and the examiner see the examiner's finger at the same time b) Client's consensual pupil constricts in response to indirect light c) Direct light shown into the client's pupils results in constriction d) Eyes converge on an object as it is moved towards the nose

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

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? a) To the left b) Down c) To the right d) Up

Up

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

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 a) phoria. b) exotropia. c) strabismus. d) esotropia.

esotropia.

A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent a) open-angle glaucoma b) hemianopsia c) retinal detachment d) macular degeneration

macular degeneration

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

rectus muscles. 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

During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide? a) "Cover one of your eyes and then read out the letters on the chart, starting from the top." b) "I'm going to ask you to slowly walk forward until the last line of the chart become clear." c) "Hold this chart and start to read out the letters after covering one of your eyes." d) "Please stand at a comfortable distance from the chart and I'll get you to read each of the letters."

"Cover one of your eyes and then read out the letters on the chart, starting from the top."

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 quadrantic defect b) A homonymous hemianopsia c) A left temporal hemianopsia d) A bitemporal hemianopsia

A left temporal hemianopsia

A client complains of excessive tearing of the eyes. Which assessment would the nurse do next? 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

A nurse is observing the red reflex in a client during an eye assessment. During this component of the assessment, the client states, "I hope you can see it because I have cataracts." What finding should the nurse expect? a) Thickened bulbar conjunctiva b) A red spot on the retina c) Black spokes pointing inward d) White arc around the limbus

Black spokes pointing inward

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) Consensual reaction b) Direct reaction c) Myopia d) Presbyopia

Consensual 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.

Which of the following would a nurse expect to assess in a client with esotropia? a) Eye oscillating b) Eye turning outward c) Eye malalignment d) Eye turning inward

Eye turning 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.

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? a) Near, then far b) Lateral, then far c) Far, then near d) Lateral, then near

Far, then near

What is a characteristic symptom of Graves hyperthyroidism? a) Pinguecula b) Pterygium c) Episcleritis d) Exophthalmos

Exophthalmos In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.

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

retina.