Chapter 13 Prepu
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?"
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?
"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."
A client comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse?
"You will need to see the doctor to have your eye checked."
The nurse is caring for a healthy adult client with no history of vision problems. The nurse should tell the client that a thorough eye examination is recommended every
2 years.
A client 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?
20/200 or less
The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?
4 mm
What do retinal abnormalities include?
Age-related macular degeneration
Which of the following statements most accurately describes the maintenance of normal intraocular pressure?
Aqueous humor is continuously circulating through the eye with production equaling drainage.
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?
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?
Ask the client about previous trauma to the eyes
A nurse obtains a tonometer reading of 23 mm Hg on a client. What is the best response of the nurse?
Ask the client if they have experienced any pain or changes in vision.
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.
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 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?
Brain tumor
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?
Cataracts
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
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?
Corrective lenses
A client asks a nurse if any foods promote eye health. What food would the nurse include as a response?
Deep-water fish
The nurse prepares to assess the eyes of a client who is aphasia. Which tool should the nurse use to test distance vision?
E chart
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
What is a characteristic symptom of Graves's hyperthyroidism?
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
A nurse is conducting an assessment of a client's eyes and vision and has completed the cardinal fields of gaze test. Following this test, the nurse will be able to document data that address what aspect(s) of eye health? Select all that apply.
Eye muscle strength, Cranial nerve function
A client's history suggests a need to assess eye muscle strength and cranial nerve function. What assessment should the nurse consequently perform?
Eye positions test
Which of the following would a nurse expect to assess in a client with esotropia?
Eye turning inward
A client has been found to have abnormal vision. What would be the nurse's next step?
Facilitate a referral to an ophthalmologist.
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
What is vital in maintaining vision and a healthy outlook for clients?
Health education
A client reports an area of distortion when looking at the Amsler chart. What does this finding indicate to the nurse?
Macular degeneration
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?
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?
Myopia
A nurse assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following?
Narcotic use
The nurse asks the client to perform the action pictured. What is the nurse assessing?
Near vision
During adolescence, what vision change is common?
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
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
The nurse performs the action shown when assessing a client's eyes. What is the nurse assessing?
Ocular alignment
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 disc
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?
Presbyopia
When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze; dilation on distant gaze
A client wants to use beta-carotene supplements to reduce the risk of developing cataracts and age-related macular degeneration. For which reason should the nurse counsel the client to avoid using this supplement?
Smokes cigarettes
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 client's vision?
Snellen E
The nurse prepares to assess the eyes of a client who cannot read. Which tool should the nurse use to test distance vision?
Snellen chart
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.
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?
Transforms light rays into nerve impulses that are conducted to the brain
When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?
Up
The nurse should make it a priority to assess which client for papilledema?
a 45-year-old suspected of experiencing a subarachnoid hemorrhage
The conjunctiva of the eye is divided into the palpebral portion and the
bulbar portion
The middle layer of the eye is known as the
choroid layer.
A nurse is performing a focused visual assessment on a client. The nurse assesses the pupillary response with a pen light. Both of the client's pupils immediately constrict when the light is shone into the right pupil. How should the nurse document this finding?
consensual reflexes observed
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
document the findings in the client's records.
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
When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals?
fundus is grayish brown with a purplish cast
The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope
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
lacrimal obstruction.
A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent
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?
macular degeneration
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should
position the client 609.6 cm (20 ft) away from the chart.
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.
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
vitamin A deficiency.
The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead?
white
