Chapter 11: The Eyes

Question 1

The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from?

Answer 1

Myopia

Question 2

What is Myopia?

Answer 2

Myopia is nearsightedness, meaning the client can see objects better up close.

Question 3

What is Asthenopia?

Answer 3

Asthenopia is eye strain, and symptoms include fatigue, red eyes, eye pain, blurred vision, and headaches

Question 4

What is Hyperopia

Answer 4

Hyperopia is farsightedness.

Question 5

What is Presbyopia

Answer 5

Presbyopia commonly occurs naturally due to the aging process; therefore it’s rare to observe this condition in young adults

Question 6

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card

Answer 6

instruct the client to hold the chart 14 inches from the eyes

Question 7

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

Answer 7

Esotropia

Question 8

When using the PERRLA acronym, the nurse is assessing which body parts?

Answer 8

Eyes; PERRLA stands for pupils equal, round, reactive to light, and accomodation

Question 9

The nurse observes an inward turning of the lower lid in a 77 year old client. The nurse documents

Answer 9

entropion

Question 10

A factory worker has presented to the occupational health nurse with a small wood splinter in their 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?

Answer 10

arrange for worker to be promptly assessed by an eye specialist

Question 11

when preforming 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?

Answer 11

extotropia

Question 12

when testing the near reaction, an expected finding includes which of the following

Answer 12

pupillary constriction on near gaze, dilation on distant gaze

Question 13

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

Answer 13

Exophthalmos; buldging of protrusion of one of both eyes

Question 14

what is vital in maintaining vision and a healthy outlook for clients?

Answer 14

Health Education

Question 15

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?

Answer 15

Perform both the distant and near visual acuity tests (Snellen chart)

Question 16

a client is diagnosed with a scotoma. what question is appropriate for the nurse to ask to obtain more data about this condition?

Answer 16

“Are the blind spots constant or intermittent?”

Question 17

what is scotoma

Answer 17

a blind spot or a region of partial or complete blindness within the visual field

Question 18

which of the following is a symptom of the eye?
A. Tinnitus
B. Scotomas
C. Rhinorrhea
D. Dysphagia

Answer 18

Scotomas

Question 19

A client presents to the emergency dept after being hit in the head with a baseball bat during a game. The nurse should assess for which condition?

Answer 19

Hyphema

Question 20

What is Hyphema

Answer 20

pooling of blood inside the anterior chamber

Question 21

the nurse is preparing to assess a client;s visual fields to evaluate their gross peripheral vision. Which test would the nurse perform?

Answer 21

Confrontation test

Question 22

what is the confrontation test?

Answer 22

Tests peripheral vision. Cover one eye and have pt follow finger

Question 23

A nurse is providing discharge teaching on preventative measures that can be used to reduce risk to a client who is at high risk of eye disorders. What should the nurse include in the discharge teaching.

Answer 23

wear sunglasses when you are exposed to sunlight, avoid smoking tobacco, eat a well balanced diet that includes green leafy vegetables, have tonometry annually

Question 24

a 12 year old presents to the clinic with their parent for evaluation of a painful lump in the left eye. It started this morning. the client denies any trauma or injury. there is no visual disturbance. upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. based on this, what is the most likely diagnosis?

Answer 24

Stye

Question 25

a nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets that as which of the following?

Answer 25

consensual response

Question 26

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?

Answer 26

Far, then near

Question 27

What is accomodation

Answer 27

when client moves focus of vision from a distant point to a near object causing pupils to constrict

Question 28

during a health history, a 48 year old client states, "I've noticed that i need to hold my newspaper farther away so that i can read it" which of the following would the nurse suspect?

Answer 28

presbyopia

Question 29

what is presbyopia

Answer 29

when a patient moves an object further away to see the object

Question 30

a client reports feeling like they are slowly losing their central vision. The nurse knows this symptom could represent

Answer 30

macular degeneration

Question 31

what is macular degeneration

Answer 31

Macula deteriorates (central part of retina), which leads to blurry or dark spots

Question 32

when using the ophthalmoscope, which of the following would the nurse do

Answer 32

approach the client at. 15 degree angle to the client's side

Question 33

a client shares that a first-degree relative has an eye problem, but they are not sure what the diagnosis is. what major eye problem will the nurse suggest screening the client for?

Answer 33

glaucoma

Question 34

what test would the nurse perform to test for strabismus?

Answer 34

corneal light reflex

Question 35

when performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. How would the nurse document this finding?

Answer 35

optic disc

Question 36

the nurse tests the distant visual acuity of several clients and records the finding. Which finding indicates that they client with the poorest vision?

Answer 36

20/60 ; the higher the number, the poorer the vision

Question 37

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 indication normal peripheral vision for a client using the confrontation test?

Answer 37

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

Question 38

a client is assigned a visual acuity of 20/100 in the left eye. which is true?

Answer 38

they can see at 20 feet what a normal person could see at 100 feet

Question 39

the nurse is assessing visual fields on a client newly admitted for eye surgery. the client's left eye repeatedly does not see the nurse's fingers until they have crosses the line of gaze. they would document that the client has what?

Answer 39

left temporal hemianopsia

Question 40

photoreceptos of the eye are located in the eye's

Answer 40

retina

Question 41

a client is considered legally blind. the nurse knows that this means that vision in the better eye, corrected by glasses, is what?

Answer 41

20/200 or less

Question 42

normal movement of the eye involves what cranial nerves

Answer 42

CN II, III, IV, VI

Question 43

a review of a client's history reveals cranial nerve IV paralysis. Which of the following would be nurse assess.

Answer 43

the eye cannot look down when turned inward

Question 44

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

Answer 44

document the findings in the client's record

Question 45

a nurse is completing a comprehensive health history of a 69 year old 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

Answer 45

have you ever been tested for diabetes?

Question 46

a nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

Answer 46

diabetes

Question 47

what are the glands that are located o the tarsal plates and open on the lid margins

Answer 47

meibomian glands

Question 48

what is the open space between the eyelids called?

Answer 48

the palpebral fissure

Question 49

A 52 year old client with documented presents to the emergency department because of "spots" floating in their line of vision. what should the nurse respond to the client about the symptoms?

Answer 49

this is a normal change in the eye associated with aging

Question 50

what is the largest chamber of the eye

Answer 50

vitreous chamber

Question 52

a client presents to the clinic reporting *sudden* visual loss in the left eye. what is the nurse's priority action?

Answer 52

notify the health care provider immediately

Question 53

a nurse is inspecting a client's eyelids and eyelashes. which of the findings would the nurse document as abnormal?

Answer 53

drooping of the upper lid

Question 54

during adolescence, what vision change is common?

Answer 54

nearsightedness