Deck 48: Assessment of the Eye and Vision

Question 1

The nurse is performing an eye assessment on a client.Which finding confirms normal accommodation during visual assessment?

A) Both pupils constrict when a light is shined at one eye.
B) The client blinks in response to a threatening movement.
C) Both pupils constrict when focusing on an object being moved in toward the nose.
D) The client is able to hold an upward gaze without moving the head for 15 seconds.

Answer 1

Both pupils constrict when focusing on an object being moved in toward the nose.

Question 2

Why is the optic disc considered to be a blind spot?

A) This area does not contain photoreceptors.
B) Light rays are unable to focus on this location.
C) Blood vessels form a meshwork and interfere with vision.
D) This area is heavily pigmented and light rays are absorbed.

Answer 2

This area does not contain photoreceptors.

Question 3

Which teaching is essential for a client who is going to have intraocular pressure measurement with a slit lamp?

A) "The test causes temporary blindness."
B) "The test is quick and a local anesthetic is used."
C) "The test does cause a little pain, but it is over quickly."
D) "The test causes some tearing, but no pain."

Answer 3

"The test is quick and a local anesthetic is used."

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?

A) "Many changes can occur because of aging."
B) "If the pressure is too low, you will be blind."
C) "If the pressure is too high, blood will not flow through the eye."
D) "Loss of vision can occur if the pressure is too high or too low."

Question 5

The nurse is evaluating a client's technique for instilling eyedrops.Which behavior indicates that the client needs more teaching?

A) Closing they eye after the drops are in
B) Touching the eye with the tip of the dropper
C) Allowing the drops to spread across the eye surface
D) Getting the drops into the conjunctival pocket

Question 6

During assessment of an older adult,which finding does the nurse immediately report to the health care provider?

A) Yellowing or bluing of the sclera
B) Lack of discrimination between green and violet
C) An opaque, bluish-white ring within the outer edge of the cornea
D) Pupil constriction in response to light occurring in 2 seconds

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?

A) Assess current medications.
B) Patch the left eye.
C) Notify the ophthalmologist.
D) Perform an in-depth interview.

Question 8

The nurse is assessing a client for the possibility of a lens opacity.Which assessment finding confirms this problem?

A) Increased intraocular pressure
B) Absence of a red reflex
C) Decreased central vision
D) Positive corneal staining

Question 9

The nurse is assessing the blink reflex in a client who is blind.Which is the best technique to use?

A) Ask the client to blink first with one eye and then with the other.
B) Expel a syringe of air toward the client's eyes.
C) Shine a bright light at the client's pupils one at a time.
D) Suddenly bring a finger toward the client's face.

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?

A) Client is unable to turn the eye in toward the nose.
B) Client is unable to lift the upper eyelid.
C) Client cannot look downward.
D) Client cannot look upward.

Question 11

A client is scheduled for electroretinography.Which statement indicates that the client understands the teaching about this procedure?

A) "I will wear dark glasses in sunlight to prevent eye pain."
B) "I am going to drink at least 3 liters of water to flush the dye out of my system."
C) "I will avoid rubbing my eyes until the anesthetic drops have worn off."
D) "I will not drive for the first 24 hours after the procedure."

Question 12

A client with presbyopia asks her nurse about corrective lenses.Which is the nurse's best response?

A) "This type of problem cannot be helped with corrective lenses."
B) "Corrective lenses are needed for both near and distance vision."
C) "Corrective lenses can be used for reading and close work."
D) "Corrective lenses are needed for distance only."

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?

A) Ask the client how long this condition has been present.
B) Attempt to elicit a red reflex in both eyes.
C) Document the finding as the only action.
D) Identify the medications that the client is taking.

Question 14

The nurse is performing vision screenings.Which client is at greatest risk for developing vision problems?

A) Postpartum woman with no complications
B) Young client who has diabetes mellitus
C) Middle-aged adult who takes aspirin daily
D) Older client with chronic dry eye syndrome

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?

A) Repeat the test while holding the client's head in a fixed position.
B) Perform a cover-uncover eye test.
C) Document the finding and continue assessing.
D) Assess for additional signs of impending brain attack.

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?

A) No episodes of double vision
B) Synchronized blinking movements
C) No reports of headaches and dizziness
D) Both pupils constricting equally in response to light

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?

A) "You can read at 10 feet what others can read at 20 feet."
B) "You can read at 20 feet what others can read at 10 feet."
C) "This demonstrates normal vision."
D) "You are considered legally blind."

Question 18

The nurse is educating a client about the instillation of eyedrops.Which client statement indicates the need for additional teaching?

A) "Squeezing my eye tightly after I put the drops in may force the drops out of my eye too quickly."
B) "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."
C) "My sister has the same prescription, so we can use the same bottle of eyedrops."
D) "I will wash my hands before I use these eyedrops."

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?

A) "Wear dark glasses whenever you are outside."
B) "Use eyedrops on a regular basis to prevent dryness."
C) "Avoid rubbing your eyes to prevent corneal abrasions."
D) "Turn up room lights when reading or doing close work."

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."

Question 21

The nurse is assessing a client's eyes.Which is the first step for the nurse in this procedure?

A) Explain the procedure.
B) Wash the hands.
C) Assess for infections.
D) Use the Snellen chart.

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?

A) Increasing difficulty perceiving greens, blues, and violets
B) Increasing redness in the eyes
C) Acute pain in the eyes
D) Sudden change in acuity
E) Need for additional lighting for reading
F) Have the client wear dark glasses.

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.

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.)

A) Start an intravenous access.
B) Instill mydriatic eyedrops.
C) Have the consent form signed.
D) Have the client drink fluids.
E) Inject fluorescein dye.
F) Have the client wear dark glasses.

Question 25

The nurse is triaging clients in the emergency department.Which clients require immediate attention by an ophthalmologist?

A) Older client with an intraocular pressure (IOP) of 15
B) Confused client in need of an ophthalmoscopic examination
C) Young client with dry drainage from one eye
D) Middle-aged client with recent onset of eye pain