Ch. 11 PrepU Practice Questions combined
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.
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
Snellen's test is ____ feet from the chart, Allen's test is ____ feet from the chart
20, 15
Which vision acuity reading indicates blindness?
20/200
A 2-month-old infant is being examined at the pediatrician's office. The mother said she noticed the baby was not making tears in the left eye. What does this finding suggest?
A blocked lacrimal apparatus
Which of the following assessment findings suggests a problem with the client's cranial nerves?
A client's extraocular movements are asymmetrical and she complains of diplopia.
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 complains of excessive tearing of the eyes. Which assessment would the nurse do next?
Assess the nasolacrimal sac
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.
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 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?
Confrontation test
A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following?
Consensual response
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.
Why is it important to ask the patient if he or she is experiencing discharge or drainage from the eyes?
Discharge is associated with inflammation or infection
Which of the following would a nurse expect to assess in a client with esotropia?
Eye turning inward
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 & read with one eye at a time
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 patient is diagnosed with an obstruction of the canal of Schlemm. What will the nurse find when assessing this patient's eyes?
Increased intraocular pressure
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?
Instruct the client hold the chart 14 inches from the eyes
When using hand gel to clean the hands, what must the nurse do before touching a patient's eyes?
Make sure the hands are completely dry
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.
During adolescence, what vision change is common?
Nearsightedness
When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following?
Optic discs
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
condition in which the lens of the eye loses its ability to focus, making it difficult to see objects up close
Presbyopia
When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze; dilation on distant gaze
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.
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?
Risk of 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 The Snellen E chart can be used for people who cannot read or speak English.
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?
The client and the examiner see the examiner's finger at the same time
The nurse is preparing to examine a patient's eyes using an ophthalmoscope. Which technique should the nurse follow when using this equipment?
The nurse should place the ophthalmoscope in the right hand and look through the right eye.
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.
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.
Lazy eye-=
amblyopia
Increases pigmintation around pregnant woman's eyes
cholasma
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.
A patient has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis
has a watery, mucoid discharge
Tunneling in visual field=
macular degeneration
Interior ocular structures are inspected how?
opthalmoscope
OD=
right eye
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.
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 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.
What does the top number in vision test indicate?What does the bottom number indicate?
feet patient away from the chart that the patient stoood, smallest line of letters they could read
External eyes and external ocular structures are examined through what?
inspection and palpation
OS=
left eye
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent
macular degeneration
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.
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 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 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.
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.
The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?
4mm
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 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. (
Which technique by the nurse demonstrates proper use of the ophthalmoscope?
Asks the client to fix the gaze upon an object and look straight ahead
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 client performs the test for distant visual acuity & scores 20/50-2. How should the nurse most accurately interpret this finding?
At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet
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.
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.
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 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?
Chloasma
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.
The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?
Conjunctiva
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 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?
Consensual reaction
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?
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? 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 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
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.
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
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.
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?
Exophthalmos
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?
Exotropia
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
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
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.
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
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 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
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
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?
Perform both the distant and near visual acuity tests
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.
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 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?
Subconjunctival hemorrhage
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
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
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.
True
The nurse tests the six cardinal directions to test extraocular movement of the eye
True