Question 1

The nurse is performing an eye assessment on a client.Which finding confirms normal accommodation during visual assessment?&#10;A) Both pupils constrict when a light is shined at one eye.&#10;B) The client blinks in response to a threatening movement.&#10;C) Both pupils constrict when focusing on an object being moved in toward the nose.&#10;D) The client is able to hold an upward gaze without moving the head for 15 seconds.

Accepted Answer

Normal accommodation is seen when the client's eyes converge.The pupils constrict when the client focuses on an object that is being moved from about 18 cm from the client's nose in closer toward the nose.Consensual response occurs when both pupils constrict after a light is shined at one eye.The blink reflex occurs in response to a sudden movement.Extraocular muscle function is tested when the client is asked to hold an upward gaze while keeping the head still.

Question 2

Why is the optic disc considered to be a blind spot?&#10;A) This area does not contain photoreceptors.&#10;B) Light rays are unable to focus on this location.&#10;C) Blood vessels form a meshwork and interfere with vision.&#10;D) This area is heavily pigmented and light rays are absorbed.

Accepted Answer

The optic nerve enters the eyeball at this point and contains no photoreceptors.The other responses are incorrect.

Question 3

Which teaching is essential for a client who is going to have intraocular pressure measurement with a slit lamp?&#10;A) &#34;The test causes temporary blindness.&#34;&#10;B) &#34;The test is quick and a local anesthetic is used.&#34;&#10;C) &#34;The test does cause a little pain, but it is over quickly.&#34;&#10;D) &#34;The test causes some tearing, but no pain.&#34;

Accepted Answer

The IOP test done with a slit lamp must have direct eye contact,which could cause discomfort,so a local anesthetic is used.The test is quick but does not cause temporary blindness.

Question 4

An anxious adult client asks why she needs to have intraocular pressure tested every year.What is the best response from the nurse?&#10;A) &#34;Many changes can occur because of aging.&#34;&#10;B) &#34;If the pressure is too low, you will be blind.&#34;&#10;C) &#34;If the pressure is too high, blood will not flow through the eye.&#34;&#10;D) &#34;Loss of vision can occur if the pressure is too high or too low.&#34;

Accepted Answer

Although all responses are somewhat correct,explaining the outcome of abnormal pressure is to the point and is done at the client's level of understanding,especially if she is anxious about the test.

Question 5

The nurse is evaluating a client's technique for instilling eyedrops.Which behavior indicates that the client needs more teaching?&#10;A) Closing they eye after the drops are in&#10;B) Touching the eye with the tip of the dropper&#10;C) Allowing the drops to spread across the eye surface&#10;D) Getting the drops into the conjunctival pocket

Accepted Answer

Touching the eye with the tip of the dropper contaminates the dropper and the medication.If the client has an infection in the eye that is touched,the dropper cannot even be used on the client's other eye.The other answers indicate correct technique.

Question 6

During assessment of an older adult,which finding does the nurse immediately report to the health care provider?&#10;A) Yellowing or bluing of the sclera&#10;B) Lack of discrimination between green and violet&#10;C) An opaque, bluish-white ring within the outer edge of the cornea&#10;D) Pupil constriction in response to light occurring in 2 seconds

Accepted Answer

In an older client,it is normal for the sclera to turn yellow or blue with aging.It is also common for the older adult to have problems discriminating between the colors of green,blue,and violet.Arcus senilis,an opaque,bluish-white ring on the edge of the cornea,is a common occurrence in the older adult.This does not cause vision loss.Pupil constriction as a reaction to light should occur in less than 1 second.If pupil constriction takes longer,then the reaction is considered sluggish and should be reported to the provider.

Question 7

A client relates that the vision in the left eye is greatly decreased from the day before.What does the nurse do first?&#10;A) Assess current medications.&#10;B) Patch the left eye.&#10;C) Notify the ophthalmologist.&#10;D) Perform an in-depth interview.

Accepted Answer

A client with a sudden or persistent loss of vision needs to undergo a complete history and assessment first to identify the possible cause.Information such as current medications must be available before the ophthalmologist is called.The nurse cannot patch the left eye without completing an interview first.

Question 8

The nurse is assessing a client for the possibility of a lens opacity.Which assessment finding confirms this problem?&#10;A) Increased intraocular pressure&#10;B) Absence of a red reflex&#10;C) Decreased central vision&#10;D) Positive corneal staining

Accepted Answer

The red reflex is elicited with an ophthalmoscope and represents reflection of the ophthalmoscopic light through the lens onto the vascular retina.The absence of a red reflex strongly indicates a lens opacity that does not allow light to penetrate through to the retina.The other answers are not related to a lens opacity.Increased intraocular pressure is measured by tonometry and could indicate glaucoma.Decreased central vision is measured by a Snellen chart and a Jaeger card and indicates decreased visual acuity.Positive corneal staining with topical dye could indicate corneal abrasion.

Question 9

The nurse is assessing the blink reflex in a client who is blind.Which is the best technique to use?&#10;A) Ask the client to blink first with one eye and then with the other.&#10;B) Expel a syringe of air toward the client's eyes.&#10;C) Shine a bright light at the client's pupils one at a time.&#10;D) Suddenly bring a finger toward the client's face.

Accepted Answer

A blind client cannot respond with a blink reflex to visually threatening movements such as bright light or bringing a finger toward the client.Air blowing suddenly at the eye should elicit the blink reflex as a protective response.Asking the client to blink first with one eye and then with the other will not elicit the blink reflex.

Question 10

A client has paralysis of the right medial rectus muscle of the right eye.Which assessment finding assists the nurse in validating this diagnosis?&#10;A) Client is unable to turn the eye in toward the nose.&#10;B) Client is unable to lift the upper eyelid.&#10;C) Client cannot look downward.&#10;D) Client cannot look upward.

Accepted Answer

Contraction of the medial rectus muscle turns the eye toward the nose.The superior oblique muscle pulls the eye downward,and the inferior oblique muscle pulls the eye upward.The ocular muscles do not lift the upper eyelid.

Question 11

A client is scheduled for electroretinography.Which statement indicates that the client understands the teaching about this procedure?&#10;A) &#34;I will wear dark glasses in sunlight to prevent eye pain.&#34;&#10;B) &#34;I am going to drink at least 3 liters of water to flush the dye out of my system.&#34;&#10;C) &#34;I will avoid rubbing my eyes until the anesthetic drops have worn off.&#34;&#10;D) &#34;I will not drive for the first 24 hours after the procedure.&#34;

Accepted Answer

The answer of A client is scheduled for electroretinography.Which statement...

Question 12

A client with presbyopia asks her nurse about corrective lenses.Which is the nurse's best response?&#10;A) &#34;This type of problem cannot be helped with corrective lenses.&#34;&#10;B) &#34;Corrective lenses are needed for both near and distance vision.&#34;&#10;C) &#34;Corrective lenses can be used for reading and close work.&#34;&#10;D) &#34;Corrective lenses are needed for distance only.&#34;

Accepted Answer

The answer of A client with presbyopia asks her nurse...

Question 13

During assessment,the nurse notes that a client's right pupil is 2 mm larger than the left pupil.Which is the nurse's first action?&#10;A) Ask the client how long this condition has been present.&#10;B) Attempt to elicit a red reflex in both eyes.&#10;C) Document the finding as the only action.&#10;D) Identify the medications that the client is taking.

Accepted Answer

The answer of During assessment,the nurse notes that a client's...

Question 14

The nurse is performing vision screenings.Which client is at greatest risk for developing vision problems?&#10;A) Postpartum woman with no complications&#10;B) Young client who has diabetes mellitus&#10;C) Middle-aged adult who takes aspirin daily&#10;D) Older client with chronic dry eye syndrome

Accepted Answer

The answer of The nurse is performing vision screenings.Which client...

Question 15

The nurse is assessing extraocular eye movements (EOMs)in an older adult client and finds that the client is unable to sustain an upward gaze for longer than 2 seconds.What does the nurse do next?&#10;A) Repeat the test while holding the client's head in a fixed position.&#10;B) Perform a cover-uncover eye test.&#10;C) Document the finding and continue assessing.&#10;D) Assess for additional signs of impending brain attack.

Accepted Answer

The answer of The nurse is assessing extraocular eye movements...

Question 16

The nurse performs an assessment of a client's extraocular movement and notes no difficulty.Which additional assessment data assist in confirming this finding?&#10;A) No episodes of double vision&#10;B) Synchronized blinking movements&#10;C) No reports of headaches and dizziness&#10;D) Both pupils constricting equally in response to light

Accepted Answer

The answer of The nurse performs an assessment of a...

Question 17

A client is told that he has 20/10 vision when tested on the Snellen chart.How does the nurse explain this finding to the client?&#10;A) &#34;You can read at 10 feet what others can read at 20 feet.&#34;&#10;B) &#34;You can read at 20 feet what others can read at 10 feet.&#34;&#10;C) &#34;This demonstrates normal vision.&#34;&#10;D) &#34;You are considered legally blind.&#34;

Accepted Answer

The answer of A client is told that he has...

Question 18

The nurse is educating a client about the instillation of eyedrops.Which client statement indicates the need for additional teaching?&#10;A) &#34;Squeezing my eye tightly after I put the drops in may force the drops out of my eye too quickly.&#34;&#10;B) &#34;If the drops are kept in the refrigerator, I will be able to tell when they are in my eye because they will feel cold.&#34;&#10;C) &#34;My sister has the same prescription, so we can use the same bottle of eyedrops.&#34;&#10;D) &#34;I will wash my hands before I use these eyedrops.&#34;

Accepted Answer

The answer of The nurse is educating a client about...

Question 19

The nurse is assessing an older adult client whose irises no longer fully dilate.What is the best intervention for the nurse to suggest?&#10;A) &#34;Wear dark glasses whenever you are outside.&#34;&#10;B) &#34;Use eyedrops on a regular basis to prevent dryness.&#34;&#10;C) &#34;Avoid rubbing your eyes to prevent corneal abrasions.&#34;&#10;D) &#34;Turn up room lights when reading or doing close work.&#34;

Accepted Answer

The answer of The nurse is assessing an older adult...

Question 20

A teenager is admitted to the emergency department with a possible fracture of the left orbit after getting hit in the face with a baseball.All tests are negative and the client is being discharged.Which is important for the nurse to teach the client?

A) "Keep an eye patch on the eye for 48 hours."
B) "Always wear protective equipment to prevent eye damage."
C) "Take aspirin if a headache should occur."
D) "Do not do any heavy lifting for a week."

Accepted Answer

The answer of A teenager is admitted to the emergency...

Question 21

The nurse is assessing a client's eyes.Which is the first step for the nurse in this procedure?&#10;A) Explain the procedure.&#10;B) Wash the hands.&#10;C) Assess for infections.&#10;D) Use the Snellen chart.

Accepted Answer

The answer of The nurse is assessing a client's eyes.Which...

Question 22

The nurse is assessing the eye changes in an older adult.Which changes lead the nurse to consult with the health care provider?&#10;A) Increasing difficulty perceiving greens, blues, and violets&#10;B) Increasing redness in the eyes&#10;C) Acute pain in the eyes&#10;D) Sudden change in acuity&#10;E) Need for additional lighting for reading&#10;F) Have the client wear dark glasses.

Accepted Answer

The answer of The nurse is assessing the eye changes...

Question 23

The nurse is administering ophthalmic drops to a client with an eye infection.Put the following nursing interventions in order,from first to last.(Separate letters by a comma and space as follows: a,b,c,d.)

A) Recheck the five Rs and the expiration date of the drug.
B) Put on gloves.
C) Have the client tilt the head backward.
D) Wash your hands.
E) Pull the lower eyelid downward and instill the medication into the conjunctival sac.
F) Instruct the client to close the eyes gently without squeezing the eyelids together.

Accepted Answer

The answer of The nurse is administering ophthalmic drops to...

Question 24

A client is scheduled for a fluorescein angiography.Place the nurse's activities in order,from highest to lowest priority.(Separate letters by a comma and space as follows: a,b,c,d.)&#10;A) Start an intravenous access.&#10;B) Instill mydriatic eyedrops.&#10;C) Have the consent form signed.&#10;D) Have the client drink fluids.&#10;E) Inject fluorescein dye.&#10;F) Have the client wear dark glasses.

Accepted Answer

The answer of A client is scheduled for a fluorescein...

Question 25

The nurse is triaging clients in the emergency department.Which clients require immediate attention by an ophthalmologist?&#10;A) Older client with an intraocular pressure (IOP) of 15&#10;B) Confused client in need of an ophthalmoscopic examination&#10;C) Young client with dry drainage from one eye&#10;D) Middle-aged client with recent onset of eye pain

Accepted Answer

The answer of The nurse is triaging clients in the...

Deck 48: Assessment of the Eye and Vision