Chapter 13 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 13

Question 1

Type: MCMA

The nurse is assessing a client who is 34 weeks pregnant. Which of the following visual changes are usually normal in this stage in pregnancy and should disappear at some point after delivery?

Standard Text: Select all that apply.

1. The client is complaining that her eyes feel very dry.

2. She states that she is experiencing blurry vision.

3. Periorbital edema is noted.

4. Cataracts are noted.

5. She has been unable to wear her contact lenses.

Correct Answer: 1,2,5

Rationale 1: The client is complaining that her eyes feel very dry. The pregnant client may complain of dry eyes. This symptom is usually not significant and disappears after childbirth.

Rationale 2: She states that she is experiencing blurry vision. The pregnant client may describe visual changes such as blurry vision due to shifting fluid within the eye. Blurriness or distorted vision can occur because of temporary changes in the shape of the eye during the last trimester of pregnancy.

Rationale 3: Periorbital edema is noted. Eyelid edema is not a common problem associated with pregnancy. Periorbital edema may signal an underlying problem.

Rationale 4: Cataracts are noted. Cataracts are not commonly associated with pregnancy.

Rationale 5: She has been unable to wear her contact lenses. Pregnant women often discontinue wearing their contact lenses during their pregnancy as a result of fit and comfort.

Global Rationale: The pregnant client may complain of dry eyes. This symptom is usually not significant and disappears after childbirth. The pregnant client may describe visual changes such as blurry vision due to shifting fluid within the eye. Blurriness or distorted vision can occur because of temporary changes in the shape of the eye during the last trimester of pregnancy. Pregnant women often discontinue wearing their contact lenses during their pregnancy as a result of fit and comfort. Eyelid edema is not a common problem associated with pregnancy. Periorbital edema may signal an underlying problem. Cataracts are not commonly associated with pregnancy.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.

Question 2

Type: MCSA

The nurse noted that the client was unable to control the amount of light that came into her eye. The dysfunction of which of the following structures is the most likely cause of this problem?

1. Cornea

2. Sclera

3. Conjunctiva

4. Iris

Correct Answer: 4

Rationale 1: The cornea is the window of the eye. It is the clear, transparent part of the sclera and forms the anterior one sixth of the eye.

Rationale 2: The sclera supports and protects the structures of the eye.

Rationale 3: The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye from becoming too dry.

Rationale 4: The iris responds to the light coming through the cornea by making the pupil larger or smaller, thereby controlling the amount of light that enters the eye.

Global Rationale: The cornea is the window of the eye. It is the clear, transparent part of the sclera and forms the anterior one sixth of the eye. The sclera supports and protects the structures of the eye. The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye from becoming too dry. The iris responds to the light coming through the cornea by making the pupil larger or smaller, thereby controlling the amount of light that enters the eye.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.

Question 3

Type: MCMA

The nurse is examining the eye. The client asks about the specific structures within the eye that are responsible for refraction of light rays. The nurse accurately states that the following structures are involved in this process:

Standard Text: Select all that apply.

1. Lens

2. Macula

3. Cornea

4. Iris

5. Optic disc

Correct Answer: 1,3

Rationale 1: Lens. The lens is located directly behind the pupil and is used to refract light through the eye.

Rationale 2: Macula. The macula is located within the retina and does not assist with light refraction.

Rationale 3: Cornea. The cornea is a transparent part of the eye and located anteriorly. It allows light to enter the eye and assists with refraction.

Rationale 4: Iris. The iris controls the amount of light that enters the eye, but is not associated with refraction.

Rationale 5: Optic disc. The optic disc is where the optic nerve and retina meet. It is where the vascular network enters the eye. This structure is not associated with refraction.

Global Rationale: The lens is located directly behind the pupil and is used to refract light through the eye. The macula is located within the retina and does not assist with light refraction. The cornea is a transparent part of the eye and located anteriorly. It allows light to enter the eye and assists with refraction. The iris controls the amount of light that enters the eye, but is not associated with refraction. The optic disc is where the optic nerve and retina meet. It is where the vascular network enters the eye. This structure is not associated with refraction.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.

Question 4

Type: MCSA

The nurse taught the client how to self-administer eye drops and the client was performing a return demonstration. During this time, the client inadvertently touched the applicator to their cornea, which caused the client to blink and produce tears. The nurse may document this response as which of the following?

1. Abnormal and should be reported to the healthcare provider

2. Hyperactive

3. A medication side effect

4. A normal response

Correct Answer: 4

Rationale 1: When the cornea is touched, the eyelids blink and tears are produced. The cornea contains many nerve endings and this action would produce a painful sensation for the client. This is not an abnormal response.

Rationale 2: This would not be noted as a hyperactive response.

Rationale 3: This is not due to a medication side effect.

Rationale 4: This is a normal response because the cornea is very sensitive.

Global Rationale: When the cornea is touched, the eyelids blink and tears are produced. The cornea contains many nerve endings and this action would produce a painful sensation for the client. This is not an abnormal response. This would not be noted as a hyperactive response. This is not due to a medication side effect. This is a normal response because the cornea is very sensitive.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.

Question 5

Type: MCHS

The client requests information about where visual information is processed within the brain. Draw an arrow pointing to the location of the occipital lobe.

Screen Shot 2015-09-24 at 12.11.31 PM

Correct Answer:

Rationale : Optic tracts encircle the brain and the impulses are transmitted to the occipital lobe of the brain for interpretation.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.

Question 6

Type: MCMA

The nurse is assessing the clients eyes during a comprehensive health assessment. Which of the following pieces of information should the nurse also gather?

Standard Text: Select all that apply.

1. The client is 62 years old.

2. The clients parents were born in Spain.

3. The clients annual income is below the poverty level.

4. The client is a welder.

5. The client recently attempted to commit suicide after his wife died in an automobile accident.

Correct Answer: 1,2,3,4,5

Rationale 1: The client is 62 years old. During a comprehensive health assessment, it is important to gather objective information such as the clients age.

Rationale 2: The clients parents were born in Spain. During a comprehensive health assessment, it is important to gather information about the clients ethnicity and race. Ethnicity may influence how a client performs self-care activities. Hispanics have higher rates of visual impairments than other races.

Rationale 3: The clients annual income is below the poverty level. During a comprehensive health assessment, it is important to gather information about the clients socioeconomic status. This may affect how often the client will visit a health care provider for his health care needs and routine screening activities.

Rationale 4: The client is a welder. During a comprehensive health assessment, it is important to gather information about the clients occupation. People who work in some settings are more likely to experience eye injuries.

Rationale 5: The client recently attempted to commit suicide after his wife died in an automobile accident. During a comprehensive health assessment, it is important to gather information about the clients emotional well-being.

Global Rationale: During a comprehensive health assessment, it is important to gather objective information such as the clients age. It is also important to gather information about the clients ethnicity and race. Ethnicity may influence how a client performs self-care activities. Hispanics have higher rates of visual impairments than other races. It is important to gather information about the clients socioeconomic status. This may affect how often the client will visit a health care provider for his health care needs and routine screening activities. It is important to gather information about the clients occupation. People who work in some settings are more likely to experience eye injuries. It is important to gather information about the clients emotional well-being.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.

Question 7

Type: MCSA

The nurse is interviewing the mother of a three-week-old Caucasian infant. Which statement by the mother indicates she requires further education about her infants eyes?

1. Its normal for my baby not to produce tears when she cries.

2. At this stage, my baby should be able to fixate on a bright light or something that moves.

3. My babys eyes are blue and definitely will stay blue.

4. It was normal for my babys eyes to be swollen after birth.

Correct Answer: 3

Rationale 1: At this stage, the baby may not be able to produce tears. By the fourth week, the baby will begin to produce tears.

Rationale 2: At six weeks, the baby will begin to develop binocular vision. At this stage, the baby will fixate on a bright light or a moving object.

Rationale 3: Light-skinned infants are born with blue eyes. By about the third month of age, the color of the eyes begins to change to a more permanent shade.

Rationale 4: At birth, many infants have edematous eyelids.

Global Rationale: At this stage, the baby may not be able to produce tears. By the fourth week, the baby will begin to produce tears. At six weeks, the baby will begin to develop binocular vision. At this stage, the baby will fixate on a bright light or a moving object. Light-skinned infants are born with blue eyes. By about the third month of age, the color of the eyes begins to change to a more permanent shade. Before six weeks of age, infants will fixate on a bright or moving object. At birth, many infants have edematous eyelids.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.

Question 8

Type: MCSA

The nurse is assessing the eyes of an 82-year-old client. Which of the following findings are expected by the nurse based on the clients age?

1. The client is easily able to read from a paper held at close range without corrective glasses.

2. There is a noticeable increase in fat within the orbit of the eye.

3. The client states that she feels her tear production has increased over the years.

4. The pupillary light reflex is slower bilaterally.

Correct Answer: 4

Rationale 1: The lens of the older clients eye is less elastic and the clients ciliary muscles will become weaker. This results in a decreased ability to focus on objects that are held at close range.

Rationale 2: There is a decrease in the amount of fat in the orbit of the eye, which produces a drooping appearance of the eye.

Rationale 3: Older adults experience a decrease in lacrimal secretions.

Rationale 4: The pupillary light reflex slows with age.

Global Rationale: The lens of the older clients eye is less elastic and the clients ciliary muscles will become weaker. This results in a decreased ability to focus on objects that are held at close range. There is a decrease in the amount of fat in the orbit of the eye, which produces a drooping appearance of the eye. Older adults experience a decrease in lacrimal secretions. The pupillary light reflex slows with age.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.

Question 9

Type: MCSA

The nurse is performing a visual examination on a client due to the clients complaints of black dots appearing in the visual field. Which of the following statement is the nurses best response to the client?

1. The black dots are known as floaters and are usually normal.

2. We need to refer you to an eye surgeon immediately.

3. You may have glaucoma.

4. You may have a cataract.

Correct Answer: 1

Rationale 1: Black dots or spots are known as floaters. Floaters are considered normal unless they obstruct vision, so they should not be immediately referred to a healthcare provider.

Rationale 2: Floaters are considered normal unless they obstruct vision, so they should not be immediately referred to a healthcare provider.

Rationale 3: Halos around lights are associated with glaucoma.

Rationale 4: Floaters are not seen with cataracts.

Global Rationale: Black dots or spots are known as floaters. Floaters are considered normal unless they obstruct vision, so they should not be immediately referred to a healthcare provider. Halos around lights are associated with glaucoma. Floaters are not seen with cataracts.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.2: Develop questions to be used when completing the focused interview.

Question 10

Type: MCSA

The nurse is completing a focused interview with assessment of the eye. Which of the following is most helpful to the nurse during the focused interview?

1. The client graduated from college.

2. The client interacts easily with the nurse.

3. The client is an African American male.

4. The client is 23 years old.

Correct Answer: 2

Rationale 1: It is important to determine the clients educational level.

Rationale 2: The clients ability to communicate is most essential to the interview. The nurse must determine how well the client will be able to participate in the focused interview and follow directions during the physical assessment.

Rationale 3: It is important to assess the clients race because this may influence what types of eye conditions the client is at risk for developing.

Rationale 4: The clients age is important to assess because anatomical and physiologic changes can occur in the eye across the lifespan.

Global Rationale: The clients ability to communicate is most essential to the interview. The nurse must determine how well the client will be able to participate in the focused interview and follow directions during the physical assessment. It is important to determine the clients educational level. It is important to assess the clients race because this may influence what types of eye conditions the client is at risk for developing. The clients age is important to assess because anatomical and physiologic changes can occur in the eye across the lifespan.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.2: Develop questions to be used when completing the focused interview.

Question 11

Type: MCSA

A client was referred to the clinic with complaints of blurred vision. The initial question for the nurse to ask the client would be which of the following?

1. Would you please tell me about your vision today?

2. Do you experience double vision?

3. Have you had any eye pain?

4. What kinds of activities do you perform at work?

Correct Answer: 1

Rationale 1: The best way to start the focused interview is to begin with open-ended questions that provide the client with an opportunity to describe his own perceptions about his vision.

Rationale 2: Information about double vision is important, but not the best way to start the interview.

Rationale 3: Information about eye pain is important, but not the best way to start the interview.

Rationale 4: Information about work activities is important, but not the best way to start the interview.

Global Rationale: The best way to start the focused interview is to begin with open-ended questions that provide the client with an opportunity to describe his own perceptions about his vision. All of the other questions are appropriate to ask at some point during the focused interview but are not the best way to start the interview. It is important to determine if the client has experienced double vision. Double vision can be caused by muscle or nerve problems and some types of medications. It is important to determine if the client is experiencing eye pain because it can be associated with glaucoma or other eye problems. It is important to determine the clients occupation because some types of occupations put the client at risk for eye injury or eyestrain.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.2: Develop questions to be used when completing the focused interview.

Question 12

Type: MCSA

During an eye assessment, a 24-year-old client reports difficulty seeing items well at close range. The nurse realizes this finding is consistent with:

1. aging.

2. presbyopia.

3. hyperopia.

4. astigmatism.

Correct Answer: 3

Rationale 1: Aging can produce changes in the eye but this client is 24 years old.

Rationale 2: Presbyopia is an age-related condition. The lens loses its ability to accommodate viewing items at close range.

Rationale 3: Younger clients who are unable to see items well at close range have a condition called hyperopia. This condition is also referred to as farsightedness.

Rationale 4: Astigmatism occurs when light is refracted over a wide area rather than on a distinct area of the retina.

Global Rationale: Younger clients who are unable to see items well at close range have a condition called hyperopia. This condition is also referred to as farsightedness. Aging can produce changes in the eye but this client is 24 years old. Presbyopia is an age-related condition. The lens loses its ability to accommodate viewing items at close range. Astigmatism occurs when light is refracted over a wide area rather than on a distinct area of the retina.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.

Question 13

Type: MCSA

The nurse notices that a clients pupils constrict when reading the consent form for medical treatment. This observation would lead the nurse to consider which of the following?

1. The room is too dark.

2. The client is able to read.

3. This is a normal response.

4. The client requires glasses for reading.

Correct Answer: 3

Rationale 1: When a room is dark, the clients pupils should dilate in response.

Rationale 2: Pupil constriction occurs as the client focuses on the paper. It does not indicate the client can read.

Rationale 3: This is a normal finding. The clients pupils should constrict in response to trying to read what is on the paper.

Rationale 4: Pupil constriction would not lead the nurse to believe the client needs reading glasses.

Global Rationale: When a room is dark, the clients pupils should dilate in response. Pupil constriction occurs as the client focuses on the paper. It does not indicate the client can read. This is a normal finding. The clients pupils should constrict in response to trying to read what is on the paper. Pupil constriction would not lead the nurse to believe the client needs reading glasses.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.

Question 14

Type: MCMA

During an eye examination, the nurse requests that the client read letters located on the Snellen E chart. The clients vision is determined to be 20/200. Which of the following is true regarding these findings?

Standard Text: Select all that apply.

1. The client is legally blind.

2. The client is unable to read from a paper at close range.

3. The client is found to be farsighted.

4. The client is myopic.

5. This is common in clients who are over 45 years old.

Correct Answer: 1,4

Rationale 1: The client is legally blind. When a clients vision is found to be 20/200, the client is legally blind.

Rationale 2: The client is unable to read from a paper at close range. The Snellen E chart assists with determining if the client is able to see items in the distance.

Rationale 3: The client is found to be farsighted. Clients who are farsighted are able to see things in the distance. This client is unable to see distant objects.

Rationale 4: The client is myopic. Clients who are myopic are unable to see objects in the distance.

Rationale 5: This is common in clients who are over 45 years old. Presbyopia is the inability to see items at close range. This condition is more common in people who are over 45 years old.

Global Rationale: When a clients vision is found to be 20/200, the client is legally blind. The Snellen E chart assists with determining if the client is able to see items in the distance. Clients who are farsighted are able to see things in the distance. This client is unable to see distant objects.
Clients who are myopic are unable to see objects in the distance. Presbyopia is the inability to see items at close range. This condition is more common in people who are over 45 years old.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.

Question 15

Type: MCSA

The nurse is assessing a clients visual fields by confrontation. Which of the following nursing actions indicates that the nurse requires further education regarding this test?

1. The nurse asks the client to cover one of her eyes with a card.

2. The nurse uses a penlight to assist with performing the test.

3. The nurse asks the client to sit 20 feet away.

4. The client tells the nurse when she first sees the object.

Correct Answer: 3

Rationale 1: Confrontation to test visual fields is done by asking the client to cover one eye with a cover while the nurse covers the eye opposite to the client.

Rationale 2: The nurse and client sit 23 feet away from each other, at eye level. An object such as a pen or penlight is advanced from the periphery to the midline. Both the client and the nurse should be able to see the object at the same time.

Rationale 3: The nurse and client should sit only 23 feet away from each other.

Rationale 4: The client should tell the nurse when she first sees the object in her peripheral vision.

Global Rationale: Confrontation to test visual fields is done by asking the client to cover one eye with a cover while the nurse covers the eye opposite to the client. The nurse and client sit 23 feet away from each other, at eye level. An object such as a pen or penlight is advanced from the periphery to the midline. Both the client and the nurse should be able to see the object at the same time. The nurse and client should sit only 23 feet away from each other. The client should tell the nurse when she first sees the object in her peripheral vision.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.

Question 16

Type: HOTSPOT

The nurse is assessing the clients corneal reflex. Draw an arrow pointing to the area of the eye that the nurse should test for the presence of this reflex.

Screen Shot 2015-09-24 at 12.12.34 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The nurse should use a lateral approach and gently touch the clients cornea on the outer aspect.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.

Question 17

Type: MCSA

The nurse is assessing the clients eye with an ophthalmoscope. The nurse is preparing to focus on the fundus and rotates the lens diopter wheel into the negative numbers. Based on this information, which of the following conditions does the client most likely have?

1. Hyperopia

2. Presbyopia

3. Myopia

4. Astigmatism

Correct Answer: 3

Rationale 1: The diopter is rotated toward the positive numbers when the client is hyperopic.

Rationale 2: For presbyopia the diopter wheel is rotated until the fundus can be visualized adequately.

Rationale 3: The diopter wheel is rotated into the negative numbers when the client is myopic.

Rationale 4: For astigmatism the diopter wheel is rotated until the fundus can be visualized adequately.

Global Rationale: The diopter is rotated to help the nurse focus on the clients fundus. The diopter is rotated toward the positive numbers when the client is hyperopic. The diopter wheel is rotated into the negative numbers when the client is myopic. For any other condition such as presbyopia or astigmatism, the diopter wheel is rotated until the fundus can be visualized adequately.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.4: Explain the use of the ophthalmoscope.

Question 18

Type: HOTSPOT

The nurse is assessing the clients retina. Draw an arrow pointing toward the location of the optic disc.

Screen Shot 2015-09-24 at 12.13.22 PM

Standard Text: Select the correct area on the image.

Screen Shot 2015-09-24 at 12.14.11 PM

Correct Answer:

Rationale : The optic disc can be identified by following the path of the blood vessels. As they grow larger, they lead to the optic disc which is located on the nasal side of the retina. The optic disc normally looks like a round or oval yellow-orange depression with a distinct margin. This is the site where the optic nerve and blood vessels exit from the eye.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.4: Explain the use of the ophthalmoscope.

Question 19

Type: MCSA

The nurse is assessing the fundus of the elderly clients eye with an ophthalmoscope. The nurse determines that there is a cyst within the macula. Which of the following client symptoms may be associated with this finding?

1. Impaired central vision

2. Impaired peripheral vision

3. Consistently elevated serum glucose levels

4. Uncontrolled hypertension

Correct Answer: 1

Rationale 1: Degeneration of the macula can be related to cysts located in this area. It is more common in older adults and results in impaired central vision.

Rationale 2: Impaired peripheral vision can be related to problems with the rods that are located in the retina.

Rationale 3: Elevated serum glucose levels may be associated with diabetic retinopathy.

Rationale 4: Uncontrolled hypertension can be associated with hypertensive retinopathy.

Global Rationale: Degeneration of the macula can be related to cysts located in this area. It is more common in older adults and results in impaired central vision. Impaired peripheral vision can be related to problems with the rods that are located in the retina. Elevated serum glucose levels may be associated with diabetic retinopathy. Uncontrolled hypertension can be associated with hypertensive retinopathy.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.4: Explain the use of the ophthalmoscope

Question 20

Type: MCSA

The nurse is preparing to assess the clients eye with an ophthalmoscope while a student nurse is observing. Which of the following statements by the nurse to the student nurse is accurate regarding this portion of the assessment?

1. Im going to examine the clients right eye with my left eye.

2. Im going to advance the ophthalmoscope until the instrument touches the clients cornea.

3. Im going to begin with the lens set to the 0 diopter.

4. I can see the red reflex as the light reflects off of the clients lens.

Correct Answer: 3

Rationale 1: The nurse should prepare to assess the clients eye with an ophthalmoscope by examining the clients right eye with the nurses right eye.

Rationale 2: The nurse should advance the ophthalmoscope only until it almost touches the clients eyelashes. The cornea contains many nerve endings and this would be painful for the client.

Rationale 3: The nurse should always begin with the lens set to the 0 diopter.

Rationale 4: The red reflex is seen as light reflects off of the clients retina, not his lens.

Global Rationale: The nurse should always begin with the lens set to the 0 diopter. The nurse should prepare to assess the clients eye with an ophthalmoscope by examining the clients right eye with the nurses right eye. The nurse should advance the ophthalmoscope only until it almost touches the clients eyelashes. The cornea contains many nerve endings and this would be painful for the client. The red reflex is seen as light reflects off of the clients retina, not his lens.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.4: Explain the use of the ophthalmoscope.

Question 21

Type: MCSA

The nurse is assessing a clients eyes during a comprehensive health assessment. The nurse knows that the client who demonstrates clinical manifestations of which of the following conditions will require immediate intervention?

1. Acute glaucoma

2. Blepharitis

3. Periorbital edema

4. Anisocoria

Correct Answer: 1

Rationale 1: Acute glaucoma results from a sudden increase in intraocular pressure caused by a blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate interventions to prevent further eye damage.

Rationale 2: Blepharitis is when the eyelid becomes inflamed. The eye burns, itches, and tears but does not require an immediate intervention.

Rationale 3: Periorbital edema is when the eyelid becomes puffy and swollen. It can be related to crying, infection, or systemic problems. It does not require an immediate intervention.

Rationale 4: Anisocoria refers to unequal pupil size, which may be a normal finding or it may indicate that the client has a central nervous system disease.

Global Rationale: Acute glaucoma results from a sudden increase in intraocular pressure caused by a blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate interventions to prevent further eye damage. Blepharitis is when the eyelid becomes inflamed. The eye burns, itches, and tears but does not require an immediate intervention. Periorbital edema is when the eyelid becomes puffy and swollen. It can be related to crying, infection, or systemic problems. It does not require an immediate intervention. Anisocoria refers to unequal pupil size, which may be a normal finding or it may indicate that the client has a central nervous system disease.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.

Question 22

Type: MCSA

The nurse is performing the cover test and notes inward turning of the eye. Which of the following ways will the nurse accurately document this finding?

1. Exophoria

2. Strabismus

3. Esophoria

4. Mydriasis

Correct Answer: 3

Rationale 1: Exophoria is when the eye turns outward during the cover test.

Rationale 2: Strabismus is when the axes of the eye cannot be directed at the same object.

Rationale 3: Esophoria is when the eye turns inward during the cover test.

Rationale 4: Mydriasis refers to fixed and dilated pupils.

Global Rationale: Exophoria is when the eye turns outward during the cover test. Strabismus is when the axes of the eye cannot be directed at the same object. Esophoria is when the eye turns inward during the cover test. Mydriasis refers to fixed and dilated pupils.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.

Question 23

Type: MCSA

A client is found to need corrective lenses for myopia. Which of the following explanations would the nurse provide to this client?

1. Your glasses will help you to see objects in the distance.

2. Your glasses will help you to see objects that are very close to you.

3. Your glasses will help you to improve your eyes ability to focus and reduce your blurred vision.

4. Your age has made it more difficult to read items that are at close range. Your new glasses will help.

Correct Answer: 1

Rationale 1: Myopia is the inability to see objects in the distance.

Rationale 2: Hyperopia is the inability to see objects at close range.

Rationale 3: Astigmatism causes blurred or double vision when the eyes attempt to focus.

Rationale 4: Presbyopia causes the client to experience difficulty focusing on items that are at close range. Presbyopia affects people who are over 45 years old.

Global Rationale: Myopia is the inability to see objects in the distance. Hyperopia is the inability to see objects at close range. Astigmatism causes blurred or double vision when the eyes attempt to focus. Presbyopia causes the client to experience difficulty focusing on items that are at close range. Presbyopia affects people who are over 45 years old.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.

Question 24

Type: MCSA

The nurse is assessing the clients pupillary responses. The client is found to have no consensual response. The finding indicates which of the following to the nurse?

1. Cranial nerve III may not be functioning appropriately.

2. This is a normal finding.

3. This is evidence of increased intracranial pressure.

4. This is evidence of optic nerve damage.

Correct Answer: 1

Rationale 1: When evaluating pupillary response, the unilluminated, or consensual, pupil should also constrict. When this does not occur, it may be indicative of problems associated with cranial nerve III.

Rationale 2: This is not a normal finding.

Rationale 3: Increased intracranial pressure is associated with pupils that are unequal and irregularly shaped.

Rationale 4: This is not evidence that optic nerve damage has occurred. Optic nerve damage can produce changes in the clients visual fields.

Global Rationale: When evaluating pupillary response, the unilluminated, or consensual, pupil should also constrict. When this does not occur, it may be indicative of problems associated with cranial nerve III. This is not a normal finding. Increased intracranial pressure is associated with pupils that are unequal and irregularly shaped. This is not evidence that optic nerve damage has occurred. Optic nerve damage can produce changes in the clients visual fields.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.

Question 25

Type: MCSA

During the assessment of a clients eyes, the nurse suspects the client has entropian. Which of the following did the nurse most likely find while assessing this client?

1. Eversion of the lower eyelid

2. Inversion of the lid and eyelashes

3. Swollen, red hair follicles

4. Firm, nontender nodule on the eyelid

Correct Answer: 2

Rationale 1: Ectropian is eversion of the lower eyelid caused by muscle weakness.

Rationale 2: Entropian is inversion of the lid and lashes caused by a muscle spasm of the eyelid.

Rationale 3: A stye causes swelling and redness in the affected eye. A stye is a result of a staphylococcal infection of hair follicles on the margin of the lids.

Rationale 4: A chalazion is a firm, nontender nodule on the eyelid.

Global Rationale: Entropian is inversion of the lid and lashes caused by a muscle spasm of the eyelid. Ectropian is eversion of the lower eyelid caused by muscle weakness. A stye causes swelling and redness in the affected eye. A stye is a result of a staphylococcal infection of hair follicles on the margin of the lids. A chalazion is a firm, nontender nodule on the eyelid.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.

Question 26

Type: MCSA

During the assessment of a clients eyes, the nurse suspects that the client has ptosis. Which of the following did the nurse most likely find?

1. The palpebral conjunctiva is exposed.

2. The iris and cornea are reddened.

3. The eyelid is drooping.

4. The eyelids are swollen and puffy.

Correct Answer: 3

Rationale 1: Ectropian is eversion of the lower eyelid caused by muscle weakness that produces exposure of the palpebral conjunctiva.

Rationale 2: Iritis is characterized by redness of the iris and cornea.

Rationale 3: Ptosis is drooping of the eyelid.

Rationale 4: Periorbital edema refers to swollen, puffy eyelids.

Global Rationale: Ptosis is drooping of the eyelid. Ectropian is eversion of the lower eyelid caused by muscle weakness that produces exposure of the palpebral conjunctiva. Iritis is characterized by redness of the iris and cornea. Periorbital edema refers to swollen, puffy eyelids.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.

Question 27

Type: MCSA

The nurse is assessing an adult African American client who is experiencing visual changes. Which of the following questions would be the most important to ask this client?

1. Have you or anyone in your family ever been diagnosed with diabetes?

2. Do you wear sunglasses when you are outside?

3. Did your mother have a vaginal infection at the time of your delivery?

4. Do you see any halos around lights?

Correct Answer: 1

Rationale 1: Diabetic retinopathy is the leading cause of blindness in the United States. It is important for the nurse to determine if the client has a personal or family history of diabetes. Type 2 diabetes occurs more frequently in African Americans, Asian Americans, Hispanic Americans, and Native Americans than in Caucasian clients. This will assist the nurse to determine if the client may be suffering visual changes as a result of diabetic retinopathy.

Rationale 2: The nurse can ask about the clients behaviors to determine his risk of developing problems associated with ultraviolet radiation.

Rationale 3: When the nurse is assessing an infant, the nurse should inquire about whether the mother of the infant had a vaginal infection at the time of delivery because this can result in eye infections in the newborn.

Rationale 4: Clients who see halos around lights may be suffering from glaucoma and increased intraocular pressure.

Global Rationale: Diabetic retinopathy is the leading cause of blindness in the United States. It is important for the nurse to determine if the client has a personal or family history of diabetes. Type 2 diabetes occurs more frequently in African Americans, Asian Americans, Hispanic Americans, and Native Americans than in Caucasian clients. This will assist the nurse to determine if the client may be suffering visual changes as a result of diabetic retinopathy. The nurse can ask about the clients behaviors to determine his risk of developing problems associated with ultraviolet radiation. When the nurse is assessing an infant, the nurse should inquire about whether the mother of the infant had a vaginal infection at the time of delivery because this can result in eye infections in the newborn. Clients who see halos around lights may be suffering from glaucoma and increased intraocular pressure.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the eye.

Question 28

Type: MCMA

The nurse is assessing a child previously diagnosed with fetal alcohol syndrome. Which of the following statements by the clients adoptive mother are consistent with the childs diagnosis?

Standard Text: Select all that apply.

1. It seems as if one of his eyelids is droopy.

2. Theres a firm little bump on his eyelid but he says it doesnt hurt.

3. His eyes almost look cloudy.

4. He has required glasses to see well since he was 2 years old.

5. His eyelids look they have turned under and he complains that his eyes hurt.

Correct Answer: 1,3,4

Rationale 1: It seems as if one of his eyelids is droopy. A child with fetal alcohol syndrome may experience ptosis.

Rationale 2: Theres a firm little bump on his eyelid but he says it doesnt hurt. Chalazions are firm, nontender nodules located on the eyelids that are associated with infection. They are not associated with fetal alcohol syndrome.

Rationale 3: His eyes almost look cloudy. Cataracts are associated with children who have been diagnosed with fetal alcohol syndrome.

Rationale 4: He has required glasses to see well since he was 2 years old. Structural abnormalities of the eye are associated with fetal alcohol syndrome. These abnormalities may result in reduced visual acuity.

Rationale 5: His eyelids look like they have turned under and he complains that his eyes hurt. Entropion is when the eyelids invert and the lashes can scratch the cornea. Entropion is not associated with fetal alcohol syndrome.

Global Rationale: A child with fetal alcohol syndrome may experience ptosis. Chalazions are firm, nontender nodules located on the eyelids that are associated with infection. They are not associated with fetal alcohol syndrome. Cataracts are associated with children who have been diagnosed with fetal alcohol syndrome. Structural abnormalities of the eye are associated with fetal alcohol syndrome. These abnormalities may result in reduced visual acuity. Entropion is when the eyelids invert and the lashes can scratch the cornea. Entropion is not associated with fetal alcohol syndrome.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the eye.

Question 29

Type: MCSA

The nurse is preparing to discuss the cultural implications associated with eye diseases with a small group of nursing students. Which of the following statement indicates that the nurse requires further education about this subject?

1. It is important to assess the African American client for clinical manifestations associated with increased intraocular pressure.

2. We should assess serum glucose levels in our adult Hispanic clients.

3. Our diabetic clients should return every 2 years for an assessment of their vision and their retina.

4. Poorly controlled serum glucose levels can result in retinal changes that affect the clients vision and can even result in blindness.

Correct Answer: 3

Rationale 1: African Americans have a higher risk for developing glaucoma. Glaucoma occurs when the flow of fluid around the anterior chamber of the eye is blocked and the clients intraocular pressure increases.

Rationale 2: Hispanics are more likely to develop type 2 diabetes which can increase their risk of developing visual changes associated with diabetic retinopathy.

Rationale 3: A client who has a personal or family history of diabetes should return each year for a thorough examination of his vision and retina. Diabetic retinopathy is the leading cause of blindness in the United States.

Rationale 4: Poorly controlled serum glucose levels are associated with diabetes. The client with diabetes can develop diabetic retinopathy. The client with this condition can develop changes in his retina and circulatory system.

Global Rationale: African Americans have a higher risk for developing glaucoma. Glaucoma occurs when the flow of fluid around the anterior chamber of the eye is blocked and the clients intraocular pressure increases. Hispanics are more likely to develop type 2 diabetes, which can increase their risk of developing visual changes associated with diabetic retinopathy. A client who has a personal or family history of diabetes should return each year for a thorough examination of his vision and retina. Diabetic retinopathy is the leading cause of blindness in the United States. Poorly controlled serum glucose levels are associated with diabetes. The client with diabetes can develop diabetic retinopathy. The client with this condition can develop changes in his retina and circulatory system.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the eye.

Question 30

Type: MCSA

The nurse presented a program regarding objectives related to the overall health of eyes that are addressed in Healthy People 2020. Which of the following statements made by an adult participant in the program indicates an adequate understanding of these objectives?

1. My 4-year-old doesnt need his vision screened.

2. Im going to call my eye doctor and ask that she performs a dilated eye exam.

3. My mom has been complaining of dry eyes, but I knew it was all in her head.

4. I didnt know that Asians have the highest risk for developing glaucoma.

Correct Answer: 2

Rationale 1: Preschooler-aged children should have their vision screened to detect problems early. Early detection can lead to early treatment.

Rationale 2: One of the objectives of Healthy People 2020 is to increase the number of people who have dilated eye examinations performed. This is a screening method that can lead to early detection of eye problems.

Rationale 3: Older adults have a decrease in tear secretions that result in complaints of dry eyes.

Rationale 4: African Americans have the greatest risk for developing glaucoma when compared to other racial groups.

Global Rationale: Preschooler-aged children should have their vision screened to detect problems early. Early detection can lead to early treatment. One of the objectives of Healthy People 2020 is to increase the number of people who have dilated eye examinations performed. This is a screening method that can lead to early detection of eye problems. Older adults have a decrease in tear secretions that result in complaints of dry eyes. African Americans have the greatest risk for developing glaucoma when compared to other racial groups.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.7: Discuss the objectives related to overall health of the eyes and vision as presented in Healthy People 2020.

Question 31

Type: MCMA

The nurse is performing a focused interview and eye assessment on a client. The nurse suspects that the client is experiencing problems associated with her vision based on which of the following pieces of data?

Standard Text: Select all that apply.

1. The client is frowning and squinting while she is reading the Snellen chart.

2. The client exhibits a symmetrical pupillary light reflex response.

3. As the nurse checks for accommodation, the pupils remain dilated.

4. The clients near vision acuity is 14/14 bilaterally.

5. When the cornea is lightly touched in the right eye, both eyelids close.

Correct Answer: 1,3

Rationale 1: The client is frowning and squinting while she is reading the Snellen chart. If the client is frowning or squinting during the test of their ability to see distant objects, this is indicator that the client may be experiencing visual problems.

Rationale 2: The client exhibits a symmetrical pupillary light reflex response. Symmetrical pupillary responses are normal.

Rationale 3: As the nurse checks for accommodation, the pupils remain dilated. When checking accommodation, the eyes should converge and the pupils should constrict as the eyes focus on the penlight.

Rationale 4: The clients near vision acuity is 14/14 bilaterally. The normal result for near vision is 14/14 in each eye.

Rationale 5: When the cornea is lightly touched in the right eye, both eyelids close. When testing the corneal reflex, touch the eye gently and quickly with a wisp of cotton. The client will react by blinking both eyes. If one or both eyes fail to respond, there could be a problem.

Global Rationale: If the client is frowning or squinting during the test of her ability to see distant objects, this is indicator that the client may be experiencing visual problems. Symmetrical pupillary responses are normal. When checking accommodation, the eyes should converge and the pupils should constrict as the eyes focus on the penlight. The normal result for near vision is 14/14 in each eye. When testing the corneal reflex, touch the eye gently and quickly with a wisp of cotton. The client will react by blinking both eyes. If one or both eyes fail to respond, there could be a problem.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 13.8: Apply critical thinking in selected simulations related to physical assessment of the eye.

Question 32

Type: MCSA

The African American middle-aged client has been diagnosed with glaucoma. Which of the following statements by the client indicate that further education is required?

1. I just thought my pupils were big, I didnt know it could be associated with glaucoma.

2. So, my headaches may be occurring because of the increased pressure within my eyes.

3. My race doesnt have anything to do with this diagnosis.

4. Those halos that I see around lights are associated with glaucoma.

Correct Answer: 3

Rationale 1: Glaucoma is a result of restricted fluid flow around the anterior chamber of the eye. The blocked fluid flow results in an increase in the clients intraocular pressure. Dilated pupils can be found in clients with glaucoma.

Rationale 2: Headaches are associated with glaucoma.

Rationale 3: African-Americans are more likely to develop glaucoma.

Rationale 4: Clients with glaucoma may state that they see halos around lights.

Global Rationale: Glaucoma is a result of restricted fluid flow around the anterior chamber of the eye. The blocked fluid flow results in an increase in the clients intraocular pressure. Dilated pupils can be found in clients with glaucoma. Headaches are associated with glaucoma. African-Americans are more likely to develop glaucoma. Clients with glaucoma may state that they see halos around lights.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.8: Apply critical thinking in selected simulations related to physical assessment of the eye.

Question 33

Type: MCSA

The nurse is assessing the clients eyes. Which of the following findings is most consistent with glaucoma?

1. Eyeballs are firm to palpation.

2. Pupils are constricted bilaterally.

3. Central vision is impaired.

4. The client has a history of syphilis.

Correct Answer: 1

Rationale 1: A clients eyeballs that are firm when palpated may have glaucoma.

Rationale 2: Dilated, not constricted, pupils are most often associated with glaucoma.

Rationale 3: Impaired central vision is associated with macular degeneration.

Rationale 4: Clients who have been infected previously with syphilis may develop a condition called Argyll Robertson pupils. This is when the clients pupils are bilaterally constricted, small, irregular, and nonreactive to light.

Global Rationale: A clients eyeballs that are firm when palpated may have glaucoma. Dilated, not constricted, pupils are most often associated with glaucoma. Impaired central vision is associated with macular degeneration. Clients who have been infected previously with syphilis may develop a condition called Argyll Robertson pupils. This is when the clients pupils are bilaterally constricted, small, irregular, and nonreactive to light.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.8: Apply critical thinking in selected simulations related to physical assessment of the eye.

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