Chapter 14: Eyes My Nursing Test Banks

Chapter 14: Eyes

Jarvis: Physical Examination & Health Assessment, 7th Edition

MULTIPLE CHOICE

1. When examining the eye, the nurse notices that the patients eyelid margins approximate completely. The nurse recognizes that this assessment finding:

a.

Is expected.

b.

May indicate a problem with extraocular muscles.

c.

May result in problems with tearing.

d.

Indicates increased intraocular pressure.

ANS: A

The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 281

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

2. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

a.

Decreased in the older adult.

b.

Impaired in a patient with cataracts.

c.

Stimulated by cranial nerves (CNs) I and II.

d.

Stimulated by CNs III, IV, and VI.

ANS: D

Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 283

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

3. The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?

a.

The outer layer of the eye is very sensitive to touch.

b.

The outer layer of the eye is darkly pigmented to prevent light from reflecting internally.

c.

The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated.

d.

The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

ANS: A

The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 283

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

4. When examining a patients eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

a.

Causes pupillary constriction.

b.

Adjusts the eye for near vision.

c.

Elevates the eyelid and dilates the pupil.

d.

Causes contraction of the ciliary body.

ANS: C

Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 283

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

5. The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

a.

Thickness or bulging of the lens

b.

Posterior chamber as it accommodates increased fluid

c.

Contraction of the ciliary body in response to the aqueous within the eye

d.

Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

ANS: D

Intraocular pressure is determined by a balance between the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 284

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

6. The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

a.

The right side of the brain interprets the vision for the right eye.

b.

The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

c.

Light rays are refracted through the transparent media of the eye before striking the pupil.

d.

Light impulses are conducted through the optic nerve to the temporal lobes of the brain.

ANS: B

The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 284

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

7. The nurse is testing a patients visual accommodation, which refers to which action?

a.

Pupillary constriction when looking at a near object

b.

Pupillary dilation when looking at a far object

c.

Changes in peripheral vision in response to light

d.

Involuntary blinking in the presence of bright light

ANS: A

The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 296

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

8. A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:

a.

The eyes converge to focus on the light.

b.

Light is reflected at the same spot in both eyes.

c.

The eye focuses the image in the center of the pupil.

d.

Constriction of both pupils occurs in response to bright light.

ANS: D

The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 296

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

9. A mother asks when her newborn infants eyesight will be developed. The nurse should reply:

a.

Vision is not totally developed until 2 years of age.

b.

Infants develop the ability to focus on an object at approximately 8 months of age.

c.

By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object.

d.

Most infants have uncoordinated eye movements for the first year of life.

ANS: C

Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate simultaneously on a single image with both eyes.

DIF: Cognitive Level: Applying (Application) REF: p. 302

MSC: Client Needs: Health Promotion and Maintenance

10. The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia?

a.

Degeneration of the cornea

b.

Loss of lens elasticity

c.

Decreased adaptation to darkness

d.

Decreased distance vision abilities

ANS: B

The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 286

MSC: Client Needs: Health Promotion and Maintenance

11. Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

a.

Increased night vision

b.

Dark retinal background

c.

Increased photosensitivity

d.

Narrowed palpebral fissures

ANS: B

An ethnically based variability in the color of the iris and in retinal pigmentation exists, with darker irides having darker retinas behind them.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 286

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

12. A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should:

a.

Examine the retina to determine the number of floaters.

b.

Presume the patient has glaucoma and refer him for further testing.

c.

Consider these to be abnormal findings, and refer him to an ophthalmologist.

d.

Know that floaters are usually insignificant and are caused by condensed vitreous fibers.

ANS: D

Floaters are a common sensation with myopia or after middle age and are attributable to condensed vitreous fibers. Floaters or spots are not usually significant, but the acute onset of floaters may occur with retinal detachment.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 287

MSC: Client Needs: Health Promotion and Maintenance

13. The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

a.

Perform the confrontation test.

b.

Ask the patient to read the print on a handheld Jaeger card.

c.

Use the Snellen chart positioned 20 feet away from the patient.

d.

Determine the patients ability to read newsprint at a distance of 12 to 14 inches.

ANS: C

The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 289

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

14. A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

a.

At 30 feet the patient can read the entire chart.

b.

The patient can read at 20 feet what a person with normal vision can read at 30 feet.

c.

The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.

d.

The patient can read from 30 feet what a person with normal vision can read from 20 feet.

ANS: B

The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

DIF: Cognitive Level: Applying (Application) REF: p. 290

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

15. A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?

a.

Refer the patient to an ophthalmologist or optometrist for further evaluation.

b.

Assess whether the patient can count the nurses fingers when they are placed in front of his or her eyes.

c.

Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again.

d.

Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

ANS: D

If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., 10/200). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 290

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

16. A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:

a.

Has poor vision.

b.

Has acute vision.

c.

Has normal vision.

d.

Is presbyopic.

ANS: A

Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision.

DIF: Cognitive Level: Applying (Application) REF: p. 290

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

17. When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 oclock in each eye. The nurse should:

a.

Consider this a normal finding.

b.

Refer the individual for further evaluation.

c.

Document this finding as an asymmetric light reflex.

d.

Perform the confrontation test to validate the findings.

ANS: A

Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 292

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

18. The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

a.

Convergence of the eyes

b.

Parallel movement of both eyes

c.

Nystagmus in extreme superior gaze

d.

Slight amount of lid lag when moving the eyes from a superior to an inferior position

ANS: B

A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of the CN that innervates it.

DIF: Cognitive Level: Applying (Application) REF: p. 292

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

19. During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding?

a.

Yellow fatty deposits over the cornea

b.

Pallor near the outer canthus of the lower lid

c.

Yellow color of the sclera that extends up to the iris

d.

Presence of small brown macules on the sclera

ANS: D

Normally in dark-skinned people, small brown macules may be observed in the sclera.

DIF: Cognitive Level: Applying (Application) REF: p. 294

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

20. A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this?

a.

Perform the confrontation test.

b.

Assess the individuals near vision.

c.

Observe the distance between the palpebral fissures.

d.

Perform the corneal light test, and look for symmetry of the light reflex.

ANS: C

Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 294

MSC: Client Needs: Health Promotion and Maintenance

21. During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?

a.

Presence of tears along the inner canthus

b.

Blocked nasolacrimal duct in a newborn infant

c.

Slight swelling over the upper lid and along the bony orbit if the individual has a cold

d.

Absence of drainage from the puncta when pressing against the inner orbital rim

ANS: D

No swelling, redness, or drainage from the puncta should be observed when it is pressed. Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.

DIF: Cognitive Level: Applying (Application) REF: p. 295

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

22. When assessing the pupillary light reflex, the nurse should use which technique?

a.

Shine a penlight from directly in front of the patient, and inspect for pupillary constriction.

b.

Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction.

c.

Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.

d.

Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

ANS: C

To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

DIF: Cognitive Level: Applying (Application) REF: p. 296

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

23. The nurse is assessing a patients eyes for the accommodation response and would expect to see which normal finding?

a.

Dilation of the pupils

b.

Consensual light reflex

c.

Conjugate movement of the eyes

d.

Convergence of the axes of the eyes

ANS: D

The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.

DIF: Cognitive Level: Applying (Application) REF: p. 296

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

24. In using the ophthalmoscope to assess a patients eyes, the nurse notices a red glow in the patients pupils. On the basis of this finding, the nurse would:

a.

Suspect that an opacity is present in the lens or cornea.

b.

Check the light source of the ophthalmoscope to verify that it is functioning.

c.

Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina.

d.

Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.

ANS: C

The red glow filling the persons pupil is the red reflex and is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 298

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

25. The nurse is examining a patients retina with an ophthalmoscope. Which finding is considered normal?

a.

Optic disc that is a yellow-orange color

b.

Optic disc margins that are blurred around the edges

c.

Presence of pigmented crescents in the macular area

d.

Presence of the macula located on the nasal side of the retina

ANS: A

The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the accumulation of pigment in the choroid.

DIF: Cognitive Level: Applying (Application) REF: p. 300

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

26. A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

a.

Consider this a normal finding.

b.

Assess the pupillary light reflex for possible blindness.

c.

Continue with the examination, and assess visual fields.

d.

Expect that a 2-week-old infant should be able to fixate and follow an object.

ANS: A

By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 302

MSC: Client Needs: Health Promotion and Maintenance

27. The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:

a.

Check color vision annually until the age of 18 years.

b.

Ask the child to identify the color of his or her clothing.

c.

Test for color vision once between the ages of 4 and 8 years.

d.

Begin color vision screening at the childs 2-year checkup.

ANS: C

Test boys only once for color vision between the ages of 4 and 8 years. Color vision is not tested in girls because it is rare in girls. Testing is performed with the Ishihara test, which is a series of polychromatic cards.

DIF: Cognitive Level: Applying (Application) REF: p. 304

MSC: Client Needs: Health Promotion and Maintenance

28. The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a lazy eye and should:

a.

Examine the external structures of the eye.

b.

Assess visual acuity with the Snellen eye chart.

c.

Assess the childs visual fields with the confrontation test.

d.

Test for strabismus by performing the corneal light reflex test.

ANS: D

Testing for strabismus is done by performing the corneal light reflex test and the cover test. The Snellen eye chart and confrontation test are not used to test for strabismus.

DIF: Cognitive Level: Applying (Application) REF: p. 304

MSC: Client Needs: Health Promotion and Maintenance

29. The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

a.

Decrease in tear production

b.

Unequal pupillary constriction in response to light

c.

Presence of arcus senilis observed around the cornea

d.

Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles

ANS: B

Pupils are small in the older adult, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 308

MSC: Client Needs: Health Promotion and Maintenance

30. The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:

a.

Check for the presence of exophthalmos.

b.

Suspect that the patient has hyperthyroidism.

c.

Ask the patient if he or she has a history of heart failure.

d.

Assess for blepharitis, which is often associated with periorbital edema.

ANS: C

Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 313

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

31. When a light is directed across the iris of a patients eye from the temporal side, the nurse is assessing for:

a.

Drainage from dacryocystitis.

b.

Presence of conjunctivitis over the iris.

c.

Presence of shadows, which may indicate glaucoma.

d.

Scattered light reflex, which may be indicative of cataracts.

ANS: C

The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This method is not correct for the assessment of dacryocystitis, conjunctivitis, or cataracts.

DIF: Cognitive Level: Applying (Application) REF: p. 321

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

32. In a patient who has anisocoria, the nurse would expect to observe:

a.

Dilated pupils.

b.

Excessive tearing.

c.

Pupils of unequal size.

d.

Uneven curvature of the lens.

ANS: C

Unequal pupil size is termed anisocoria. It normally exists in 5% of the population but may also be indicative of central nervous system disease.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 296

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

33. A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he cant see well from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

a.

Loss of central vision.

b.

Shadow or diminished vision in one quadrant or one half of the visual field.

c.

Loss of peripheral vision.

d.

Sudden loss of pupillary constriction and accommodation.

ANS: B

With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 318

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

34. A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a:

a.

Chalazion.

b.

Hordeolum (stye).

c.

Dacryocystitis.

d.

Blepharitis.

ANS: B

A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling. Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids (see Table 14-3).

DIF: Cognitive Level: Applying (Application) REF: p. 315

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

35. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have:

a.

Macular degeneration.

b.

Vision that is normal for someone her age.

c.

The beginning stages of cataract formation.

d.

Increased intraocular pressure or glaucoma.

ANS: A

Macular degeneration is the most common cause of blindness. It is characterized by the loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not consistent with vision that is considered normal at any age.

DIF: Cognitive Level: Applying (Application) REF: p. 286

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

36. A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion?

a.

Smooth and clear corneas

b.

Opacity of the lens behind the cornea

c.

Bleeding from the areas across the cornea

d.

Shattered look to the light rays reflecting off the cornea

ANS: D

A corneal abrasion causes irregular ridges in reflected light, which produce a shattered appearance to light rays. No opacities should be observed in the cornea. The other responses are not correct.

DIF: Cognitive Level: Applying (Application) REF: p. 296

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

37. An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:

a.

Retinal detachment.

b.

Diabetic retinopathy.

c.

Acute-angle glaucoma.

d.

Increased intracranial pressure.

ANS: D

Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.

DIF: Cognitive Level: Applying (Application) REF: p. 322

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

38. During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:

a.

Hypopyon.

b.

Hyphema.

c.

Corneal abrasion.

d.

Pterygium.

ANS: B

Hyphema is the term for blood in the anterior chamber and is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. (See Table 14-7 for descriptions of the other terms.)

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 321

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

39. During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling dry and itchy. Which action by the nurse is correct?

a.

Assessing the eye for a possible foreign body

b.

Documenting the finding as ptosis

c.

Assessing for other signs of ectropion

d.

Contacting the prescriber; these are signs of basal cell carcinoma

ANS: C

The condition described is known as ectropion, and it occurs in older adults and is attributable to atrophy of the elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot effectively siphon tears; excessive tearing results. Ptosis is a drooping of the upper eyelid. These signs do not suggest the presence of a foreign body in the eye or basal cell carcinoma.

DIF: Cognitive Level: Applying (Application) REF: p. 314

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE

1. During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma?Select all that apply.

a.

Patient may experience sensitivity to light, nausea, and halos around lights.

b.

Patient experiences tunnel vision in the late stages.

c.

Immediate treatment is needed.

d.

Vision loss begins with peripheral vision.

e.

Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision.

f.

Virtually no symptoms are exhibited.

ANS: B, D, F

Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are exhibited. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 309

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

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