Chapter 48: Assessment of the Eye and Vision Nursing School Test Banks

Chapter 48: Assessment of the Eye and Vision

Test Bank

MULTIPLE CHOICE

1. 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.

ANS: A

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

DIF: Cognitive Level: Knowledge/Remembering REF: p. 1040

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. 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

ANS: D

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

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.

ANS: B

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Teaching/Learning

4. The nurse performs an assessment of a clients 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

ANS: A

The voluntary muscles of the orbit rotate the eye and coordinate eye movements to ensure that the retina of each eye receives an image at the same time, so that only a single image is perceived. If the client has reported double vision, this would indicate a problem with this coordination. The other answers are not related to extraocular eye movements.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

5. 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.

ANS: A

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.

DIF: Cognitive Level: Comprehension/Understanding REF: Table 48.1, p.1042

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

6. 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 clients 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.

ANS: C

In the older adult, decreased muscle tone impairs the ability to maintain an upward gaze and to sustain convergence. Therefore, this finding is normal for an older adult client. The nurse would not repeat the test or hold the clients head in a fixed position. The nurse would document the finding and continue to assess. This would not be a cause for concern, nor would it be a symptom of impending brain attack. The cover-uncover test is used for determining the degree of peripheral vision.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

7. 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.

ANS: D

With increasing age, the iris has less ability to dilate and clients have difficulty adapting to a darker environment. Older adult clients may need additional light for reading. Wearing dark glasses will not assist the client, and no indication suggests that the clients eyes are dry. Rubbing the eyes should not cause corneal abrasions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning

8. 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

ANS: B

The hyperglycemia that characterizes diabetes mellitus causes numerous vascular problems in the eye and damages the nerves. Although good control of blood glucose levels delays visual problems, it does not eliminate these problems in the diabetic population. Daily aspirin therapy does not place a client at risk for vision problems. Dry eyes are a common finding with older clients because tear production is decreased, but this does not necessarily interfere with the clients vision. Postpartum women should not be at risk for vision problems.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

9. 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.

ANS: D

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)

10. During assessment, the nurse notes that a clients right pupil is 2 mm larger than the left pupil. Which is the nurses 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.

ANS: A

Although both pupils are normally the same size and a difference in size can indicate various pathologies, approximately 5% of people have a noticeable difference in the size of their pupils. The nurse should first determine whether this condition represents a change or has been present for a long time.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

11. 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 clients eyes.

c.

Shine a bright light at the clients pupils one at a time.

d.

Suddenly bring a finger toward the clients face.

ANS: B

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

12. 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.

ANS: C

Normal accommodation is seen when the clients eyes converge. The pupils constrict when the client focuses on an object that is being moved from about 18 cm from the clients 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.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1046

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

13. 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

ANS: B

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.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1049

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

14. 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.

ANS: C

A local anesthetic agent is used for this procedure because an electrode is placed on the cornea. The client could inadvertently scratch or harm the eye by touching or rubbing it while the anesthetic effect is present. No eye pain should be noted with this procedure, no dye is used, and restricting driving for 24 hours is not necessary.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Teaching/Learning

15. The nurse is evaluating a clients 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

ANS: B

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 clients other eye. The other answers indicate correct technique.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Evaluation)

16. 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.

ANS: C

Eyedrops or eye ointment should never be shared because of the risk of spreading infection. The other answers indicate correct technique.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Evaluation)

17. A client with presbyopia asks her nurse about corrective lenses. Which is the nurses 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.

ANS: C

Presbyopia is caused by stiffening of the lens as a result of water loss as the lens ages. Consequently, the lens does not refract as well and light waves converge behind the retinaa condition similar to farsightedness (hyperopia). The condition makes near vision blurry. Corrective lenses for presbyopia increase light wave refraction and are used for reading or close work. Therefore the other answers are incorrect. Presbyopia can be helped with corrective lenses but only for near vision, not for distance vision.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems)

MSC: Integrated Process: Nursing Process (Implementation)

18. 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.

ANS: B

If all tests are negative, restrictions on heavy lifting are not needed. An eye patch does not have to be worn. Acetaminophen (Tylenol) would be a better choice for a headache because aspirin promotes bleeding. The client and the family should be taught about protective equipment while playing sports (helmet and goggles).

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC: Integrated Process: Teaching/Learning

19. 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.

ANS: D

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

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Teaching/Learning

20. 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.

ANS: B

The 20 is the point at which the client can see from the chart, and the 10 is the point at which a healthy eye can see from the chart. Normal vision is 20/20.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1046

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)

21. The nurse is assessing a clients 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.

ANS: B

Before examining a clients eyes, the examiner should wash his or her hands. This is done to prevent contamination of the eye and structures. The nurse could then proceed to explain any procedure, assess infection, or assess visual acuity using the Snellen chart.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

22. 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

ANS: D

A client with abrupt onset of eye pain should be the priority because of possible underlying pathology causing the symptom. An IOP of 15 is within the normal range (10 to 21); therefore the client does not need to be seen by an eye doctor. If a client is confused, the ophthalmoscopic examination must be rescheduled because it would not be safe to perform the examination at this time. Drainage from an eye indicates possible infection, but this would not be the first client to be seen.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

MULTIPLE RESPONSE

1. The nurse is assessing the eye changes in an older adult. Which changes lead the nurse to consult with the health care provider? (Select all that apply.)

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.

Need to hold newspaper farther away to read

ANS: B, C, D

Increasing redness, acute pain, and sudden changes in acuity represent manifestations that might be indicative of a more serious complication and need the providers evaluation. Delay could cause harm. The other signs are associated with the aging process and do not require immediate evaluation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Implementation)

OTHER

1. 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.

ANS:

d, b, a, c, e, f

Medication checking of the five Rs the first time is always the first step, followed by handwashing and gloving because of the risk for secretions. Rechecking the five Rs right before giving the medication, which is actually the third time that the five Rs are checked, is critical for maintaining safety. The nurse has the client tilt the head back, prepare the eye, give the drug, and have the client gently close the eye.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

2. A client is scheduled for a fluorescein angiography. Place the nurses 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.

ANS:

c, b, a, e, d, f

Before the invasive procedure is started, an informed consent form must be signed. The mydriatic drops are then instilled 1 hour before the procedure. An IV is inserted and the fluorescein dye injected. A series of photographs are taken. After the procedure, the client is instructed to drink plenty of fluids to aid with excretion of the dye through the urine. The client is taught to wear dark glasses to prevent pain caused by the bright light until the mydriatic action of the drops has worn off.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1050

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Implementation)

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