Chapter 46: Assessment of the Eye and Vision Nursing School Test Banks

Chapter 46: Assessment of the Eye and Vision
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

1. The nurse has given a community group a presentation on eye health. Which statement by a participant indicates a need for more instruction?
a. I always lose my sunglasses, so I dont wear them.
b. I have diabetes and get an annual eye exam.
c. I will not share my contact solution with others.
d. I will wear safety glasses when I mow the lawn.
ANS: A
Clients should be taught to protect their eyes from ultraviolet (UV) exposure by consistently wearing sunglasses when outdoors, when tanning in tanning salons, or when working with UV light. The other statements are correct.

DIF: Remembering/Knowledge REF: 970
KEY: Visual system| health promotion| primary prevention
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Health Promotion and Maintenance

2. The nurse reads on a clients chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis?
a. Bulging eyes
b. Drooping eyelids
c. Sunken-in eyes
d. Yellow sclera
ANS: A
Exophthalmos is bulging eyes. Drooping eyelids is ptosis. Sunken-in eyes is enophthalmos. Yellow sclera indicates jaundice.

DIF: Remembering/Knowledge REF: 972
KEY: Visual system| visual assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A clients chart indicates anisocoria. For what should the nurse assess?
a. Difference in pupil size
b. Draining infection
c. Recent eye trauma
d. Tumor of the eyelid
ANS: A
Anisocoria is a noticeable difference in the size of a persons pupils. This is a normal finding in a small percentage of the population. Infection, trauma, and tumors are not related.

DIF: Remembering/Knowledge REF: 972
KEY: Visual assessment| visual system
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing should the nurse prepare the client?
a. Corneal staining
b. Fluorescein angiography
c. Ophthalmoscopy
d. Tonometry
ANS: A
Corneal staining is used when the possibility of eye trauma exists, including a foreign body. Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

DIF: Remembering/Knowledge REF: 974
KEY: Visual system| visual assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best?
a. Doing this allows time for absorption.
b. I am keeping the drops in the eye.
c. This prevents systemic absorption.
d. I am stopping you from rubbing your eye.
ANS: C
This technique, called punctal occlusion, prevents eyedrops from being absorbed systemically. The other answers are inaccurate.

DIF: Understanding/Comprehension REF: 975
KEY: Visual system| medication administration
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

6. The nurse is administering eyedrops to a client with an infection in the right eye. The drops go in both eyes, and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the right eye. What action by the nurse is best?
a. Inform the provider of the issue.
b. Obtain a new bottle of eyedrops.
c. Rinse the clients right eye thoroughly.
d. Wipe the left eye bottle with alcohol.
ANS: B
The nurse has contaminated the clean bottle by using it on the infected eye. The nurse needs to obtain a new bottle of solution to use on the left eye. The other actions are not appropriate.

DIF: Applying/Application REF: 975
KEY: Visual system| medication administration| infection control
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

7. The nurse enters an examination room to help with an eye examination. The client is directed toward the assessment chart shown below:

What is the provider assessing?
a. Color vision
b. Depth perception
c. Spatial perception
d. Visual acuity
ANS: A
This is an Ishihara chart, which is used for assessing color vision. Depth and spatial perception are not typically assessed in a routine vision assessment. Visual acuity is usually tested with a Snellen chart.

DIF: Remembering/Knowledge REF: 973
KEY: Visual system| visual assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

1. The student learning about vision should remember which facts related to the eyes? (Select all that apply.)
a. Aqueous humor controls intraocular pressure.
b. Cones work in low light conditions.
c. Glaucoma occurs due to increased pressure in the eye.
d. Muscles of the iris control light entering the eye.
e. Rods work in low light conditions.
ANS: A, C, D, E
The inflow and outflow of aqueous humor controls the intraocular pressure. Glaucoma results when the pressure is chronically high. Muscles of the iris relax and constrict to control the amount of light entering the eye. Rods work in low light conditions. Cones work in bright light conditions.

DIF: Remembering/Knowledge REF: 966 KEY: Visual system
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The nursing student studying the eye learns that which cranial nerves control its functions? (Select all that apply.)
a. II
b. III
c. VI
d. XII
e. X
ANS: A, B, C
The cranial nerves involved with eye function include II, III, IV, V, VI, and VII.

DIF: Remembering/Knowledge REF: 968 KEY: Visual system
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. The nursing student learns that age-related changes affect the eyes and vision. Which changes does this include? (Select all that apply.)
a. Decreased eye muscle tone
b. Development of arcus senilis
c. Increase in far point of near vision
d. Decrease in general color perception
e. Increase in point of near vision
ANS: A, B, D, E
Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

DIF: Remembering/Knowledge REF: 969 KEY: Visual system
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

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