Chapter 14: Eyes Jarvis: Physical Examination & Health Assessment, 7th Edition
M!"#P!E CH$#CE
1. When examining the eye, the nurse notices that the patient’s eyelid margins approximate
completely. completely. The nurse recognizes that this assessment finding: a. Is expected. b. May indicate a problem ith extraocular muscles. c. May result in problems ith tearing. d. Indicates increased intraocular pressure. !"#: !
The palpebral fissure is the elliptical open space beteen the eyelids, and, hen closed, the lid margins approximate completely, hich is a normal finding. $I%: &ogniti'e (e (e'el: )n )nderstanding *& *&omprehension+ -%: p. / /1 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation . $uring ocular examinations, the nurse eeps in mind that mo'ement of the extraocular
muscles is: a. $ecreased in the older adult. b. Impaired in a patient ith cataracts. c. #timulated by cranial ner'es *&"s+ I and II. d. #timulated by &"s III, I2, and 2I. !"#: $
Mo'ement of the extraocular muscles is stimulated by three &"s: III, I2, I2, and 2I. $I%: &ogniti'e (e'el: emembering *3noledge+ -%: p. /4 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 4. The nurse is performing an external eye examination. Which statement regarding the outer
layer of the eye is true5 true5 a. The outer layer of the eye is 'ery sensiti'e to touch. b. The outer layer of the eye is darly pigmented to pre'ent light from reflecting internally. c. The trigeminal ner'e *&" 2+ and the trochlear ner'e *&" I2+ are stimulated hen the outer surface of the eye is stimulated. d. The 'isual recepti'e layer of the eye in hich light a'es are changed into ner'e impulses is located in the outer layer of the eye. !"#: !
The cornea and the sclera mae up the outer layer of the eye. The cornea is 'ery sensiti'e to touch. The middle layer, the choroid, has dar pigmentation to p re'ent light from reflecting internally. internally. The trigeminal ner'e *&" 2+ and the facial ner'e *&" 2II+ are stimulated hen the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is here light a'es are changed into ner'e impulses.
$I%: &ogniti'e (e (e'el: )n )nderstanding *& *&omprehension+ -%: p. / /4 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 6. When examining a patient’s eyes, the nurse recalls that stimulation of the sympathetic branch
of the autonomic ner'ous system: a. &auses pupillary constriction. b. !d7usts the eye for near 'ision. c. -le'ates the eyelid and dilates the pupil. d. &auses contraction of the ciliary body. !"#: &
#timulation of the sympathetic branch of the au tonomic ner'ous system dilates the pupil and ele'ates the eyelid. 0arasympathetic ner'ous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near 'ision. The ciliary body controls the thicness of the lens. $I%: &ogniti'e (e (e'el: )n )nderstanding *& *&omprehension+ -%: p. / /4 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 8. The nurse is re'ieing causes of increased intraocular pressure. Which of these fac tors
determines intraocular pressure5 a. Thicness or bulging of the lens b. 0osterior chamber as it accommodates increased fluid c. &ontraction of the ciliary body in response to the a9ueous ithin the eye d. !mount of a9ueous produced and resistance to its outflo at the angle of the anterior chamber !"#: $
Intraocular pressure is determined by a balance beteen the amount of a9ueous produced and the resistance to its outflo at the angle of the anterior chamber. The other responses are incorrect. $I%: &ogniti'e (e'el: emembering *3noledge+ -%: p. /6 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation . The nurse is conducting a 'isual examination. Which of these statements regarding 'isual
pathays and 'isual fields is true5 true5 a. The right side of the brain interprets the 'ision for the right eye. b. The image formed on the retina is upside don and re'ersed from its actual appearance in the outside orld. c. (ight rays are refracted through the transparent media of the eye before striing the pupil. d. (ight impulses are conducted through the optic ner'e to the temporal lobes of the brain. !"#: ;
The image formed on the retina is upside don and re'ersed from its actual a ppearance in the outside orld. The light rays are refracted through the transparent media of the eye before striing the retina, and the ner'e impulses are co nducted through the optic ner'e tract to the 'isual cortex of the occipital lobe of the brain. The left side of the brain interprets 'ision for the right eye. $I%: &ogniti'e (e'el: emembering *3noledge+ -%: p. /6 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation <. The nurse is testing a patient’s 'isual accommodation, hich refers to hich action5 a. 0upillary constriction hen looing at a near ob7ect b. 0upillary dilation hen looing at a far ob7ect c. &hanges in peripheral 'ision in response to light d. In'oluntary blining in the presence of bright light !"#: !
The muscle fibers of the iris contract the pupil in bright light and accommodate for near 'ision, hich also results in pupil constriction. The other responses are not correct. $I%: &ogniti'e (e'el: emembering *3noledge+ -%: p. = M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation /. ! patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates
that: a. The eyes con'erge to focus on the light. b. (ight is reflected at the same spot in both eyes. c. The eye focuses the image in the center of the pupil. d. &onstriction of both pupils occurs in response to bright light. !"#: $
The pupillary light reflex is the normal constriction of the p upils hen bright light shines on the retina. The other responses are not correct. $I%: &ogniti'e (e (e'el: )n )nderstanding *& *&omprehension+ -%: p. = = M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation =. ! mother ass hen her neborn infant’s eyesight ill be de'eloped. The nurse should reply: a. >2ision >2ision is not totally de'eloped until years of age.? b. >Infants de'elop the ability to focus on an ob7ect at approximately / months of
age.? c. >;y approximately 4 months of age, infants de'elop more coordinated eye mo'ements and can fixate on an ob7ect.? d. >Most infants ha'e uncoordinated eye mo'ements for the first year of life.? !"#: &
-ye mo'ements may be poorly coordinated at birth, but by 4 to 6 months of age, the infant should establish binocularity and should be able to fixate simultaneously on a single image ith both eyes.
$I%: &ogniti'e (e'el: !pplying *!pplication+ M#&: &lient &lient "eeds: Aealth Aealth 0romotion 0romotion and Maintenanc Maintenancee
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1@. The nurse is re'ieing in ageBrelated changes in the eye for a class. Which of these
physiologic changes is responsible for presbyopia5 a. $egeneration of the cornea b. (oss of lens elasticity c. $ecreased adaptation to darness d. $ecreased distance 'ision abilities !"#: ;
The lens loses elasticity and decreases its ability to change shape to accommodate for near 'ision. This condition is called presbyopia called presbyopia.. $I%: &ogniti'e (e (e'el: )n )nderstanding *& *&omprehension+ M#&: &lient &lient "eeds: Aealth Aealth 0romotion 0romotion and Maintenanc Maintenancee
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11. Which of these assessment findings ould the nurse expect to see hen examining the eyes of
a blac patient5 a. Increased night 'ision b. $ar retinal bacground c. Increased photosensiti'ity d. "arroed palpebral fissures !"#: ;
!n ethnically based 'ariability in the color o f the iris and in retinal pigmentation exists, ith darer irides ha'ing darer retinas behind them. $I%: &ogniti'e (e (e'el: )n )nderstanding *& *&omprehension+ -%: p. / / M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are 1. ! 8ByearBold 8ByearBold patient describes the presence of occasional floaters occasional floaters or or spots spots mo'ing mo'ing in front of
his eyes. The nurse should: a. -xamine the retina to determine the number of floaters. b. 0resume the patient has glaucoma and refer him for further testing. c. &onsider these to be abnormal findings, and refer him to an ophthalmologist. d. 3no that floaters are usually insignificant and are caused by condensed 'itreous fibers. !"#: $
%loaters are a common sensation ith myopia or after middle age and are attributable to condensed 'itreous fibers. %loaters or spots are not usually significant, but the acute onset of floaters may occur ith retinal detachment. $I%: &ogniti'e (e'el: !nalyzing *!nalysis+ M#&: &lient &lient "eeds: Aealth Aealth 0romotion 0romotion and Maintenanc Maintenancee
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14. The nurse is preparing to assess the 'isual acuity of a 1ByearBold patient. Ao should the
nurse proceed5
a. b. c. d.
0erform the confrontation test. !s the patient to read the print on a handheld Caeger card. )se the #nellen chart positioned @ feet aay from the patient. $etermine the patient’s ability ability to read nesprint at a distance of 1 to 16 inches. inch es.
!"#: &
The #nellen alphabet chart is the most commonly used and most accurate measure of o f 'isual acuity. acuity. The confrontation test is a gross measure of peripheral 'ision. The Caeger c ard or nespaper tests are used to test near 'ision. $I%: &ogniti'e (e'el: !nalyzing *!nalysis+ -%: p. /= M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are 16. ! patient’s 'ision is recorded as @D4@ hen the #nellen eye chart is used. The nurse interprets
these results to indicate that: a. !t 4@ feet the patient can read the entire chart. b. The patient can read at @ feet hat a person ith normal 'ision can read at 4@ feet. c. The patient can read the chart from @ feet in the left eye and 4@ feet in the right eye. d. The patient can read from 4@ feet hat a person ith normal 'ision ' ision can read from @ feet. !"#: ;
The top number indicates the distance d istance the person is standing from the chartE the de nominator gi'es the distance at hich a normal eye can see. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. =@ M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 18. ! patient is unable to read e'en the largest letters on the #nellen chart. The nu rse should tae
hich action next5 a. efer the patient to an ophthalmologist or optometrist op tometrist for further e'aluation. b. !ssess hether the patient can count the nurse’s nurse’s fingers hen they are placed in front of his or her eyes. c. !s the patient to put on his or her reading glasses and attempt to read the #nellen chart again. d. #horten the distance beteen the patient and the chart until the letters are seen, and record that distance. !"#: $
If the person is unable to see e'en the largest letters hen standing @ 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., >1@D@@?+. If 'isual acuity is e'en loer, then the nurse should assess hether the person can count fingers hen they are spread in front of the eyes or can distinguish light perception from a penlight. If 'ision is poorer than @D4@, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the 'isual acuity. $I%:
&ogniti'e (e'el: !nalyzing *!nalysis+
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M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 1. ! patient’s patient’s 'ision is recorded as @D/@ in each ea ch eye. The nurse interprets this finding to mean
that the patient: a. Aas poor 'ision. b. Aas acute 'ision. c. Aas normal 'ision. d. Is presbyopic. !"#: !
"ormal 'isual acuity is @D@ in each eyeE the larger the denominator, denominator, the poorer the 'ision. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. =@ M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 1<. When performing the corneal light reflex assessment, the nurse notes that the light is reflected
at o’cloc in each eye. The nurse should: a. &onsider this a normal finding. b. efer the indi'idual for further e'aluation. c. $ocument this finding as an asymmetric light reflex. d. 0erform the confrontation test to 'alidate the findings. !"#: !
eflection 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 co' er test. $I%: &ogniti'e (e'el: !nalyzing *!nalysis+ -%: p. = M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are 1/. The nurse is performing the diagnostic positions test. "ormal findings ould be hich of
these results5 a. &on'ergence of the eyes b. 0arallel mo'ement of both eyes c. "ystagmus in extreme superior gaze d. #light amount of lid lag hen mo'ing the eyes from a superior to an inferior position !"#: ;
! normal response for the diagnostic positions test is parallel tracing of the ob7ect ith both eyes. -ye mo'ement that is not parallel indicates a eaness of an extraocular muscle or dysfunction of the &" that inner'ates it. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. = M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are 1=. $uring an assessment of the sclera of a blac patient, the nurse ould consider hich of these
an expected finding5 a. Fello fatty deposits o'er o 'er the cornea b. 0allor near the outer canthus of the loer lid c. Fello color of the sclera that extends up to the iris
d. 0resence of small bron macules on the sclera !"#: $
"ormally in darBsinned people, small bron macules may be obser'ed in the sclera. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. =6 M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are
@ByearBold man is at the clinic for an eye examination. The nurse suspects that he h as @. ! @ByearBold ptosis of one eye. Ao should the nurse chec for this5 a. 0erform the confrontation test. b. !ssess the indi'idual’s near 'ision. c. Gbser'e the distance beteen the palpebral fissures. d. 0erform the corneal light test, and loo for symmetry of the light reflex. !"#: &
0tosis is a drooping of the upper eyelid eye lid that ould be apparent by obser'ing the distance beteen the upper and loer eyelids. The confrontation test measures peripheral 'ision. Measuring near 'ision or the corneal light test do es not chec for ptosis. $I%: &ogniti'e (e'el: !nalyzing *!nalysis+ M#&: &lient &lient "eeds: Aealth Aealth 0romotion 0romotion and Maintenanc Maintenancee
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1. $uring an examination of the eye, the nurse ould expect hat normal finding hen
assessing the lacrimal apparatus5 a. 0resence of tears along the inner canthus b. ;loced nasolacrimal duct in a neborn infant c. #light selling o'er the upper lid and along the bony orbit if the indi'idual has a cold d. !bsence of drainage from the puncta pun cta hen pressing against the inner orbital rim !"#: $
"o selling, redness, or drainage from the puncta should be obser'ed hen it is pressed. egurgitation of fluid from the puncta, hen pressed, indicates duct blocage. The lacrimal glands are not functional at birth. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. =8 M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are . When assessing the pupillary light reflex, the nurse should use hich techni9ue5 a. #hine a penlight from directly in front of the patient, and inspect for pupillary
constriction. b. !s the patient to follo the penlight in eight directions, and obser'e for bilateral pupil constriction. c. #hine a light across the pupil from the side, and obser'e for direct and consensual c onsensual pupillary constriction. d. !s the patient to focus on a distant ob7ect. Then as the patient to follo the penlight to approximately < cm from the nose. !"#: &
To test the pupillary light reflex, the nurse should a d'ance a light in from the side and note the direct and consensual pupillary constriction. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. = M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are 4. The nurse is assessing a patient’s eyes for the accommodation response and ould expect to
see hich normal finding5 a. $ilation of the pupils b. &onsensual light reflex c. &on7ugate mo'ement of the eyes d. &on'ergence of the axes of the eyes !"#: $
The accommodation reaction includes pupillary constriction and con'ergence of the axes of the eyes. The other responses are not correct. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. = M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are 6. In using the ophthalmoscope to assess a patient’s eyes, the nurse notices a red glo in the
patient’s patient’s pupils. Gn the basis of this finding, the nurse ould: a. #uspect that an opacity is present in the lens or cornea. b. &hec the light source of the ophthalmoscope to 'erify that it is functioning. c. &onsider the red glo a normal reflection of the ophthalmoscope light off the inner retina. d. &ontinue ith the ophthalmoscopic examination, and refer the patient for further e'aluation. !"#: &
The red glo filling the person’s 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. $I%: &ogniti'e (e'el: !nalyzing *!nalysis+ -%: p. =/ M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are 8. The nurse is examining a patient’s retina ith an ophthalmoscope. Which finding is
considered normal5 a. Gptic disc that is a yelloBorange color b. Gptic disc margins that are blurred around the edges c. 0resence of pigmented crescents in the macular area d. 0resence of the macula located on the nasal side of the retina !"#: !
The optic disc is located on the nasal side of the retina. Its color is a creamy yelloBorange to a pin, and the edges are distinct and sharply demarcated, no t blurred. ! pigmented crescent is blac and is due to the accumulation of pigment in the choroid. $I%:
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M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are . ! BeeBold infant can fixate on an ob7ect but cannot follo a light or bright toy. The nurse
ould: a. &onsider this a normal finding. b. !ssess the pupillary light reflex for possible blindness. c. &ontinue ith the examination, and assess 'isual fields. d. -xpect that a BeeBold infant should be able to fixate and follo an ob7ect. !"#: !
;y to 6 ees an infant can fixate on an ob7ect. ;y the age of 1 month, the infant should fixate and follo a bright light or toy. $I%: &ogniti'e (e'el: !nalyzing *!nalysis+ M#&: &lient &lient "eeds: Aealth Aealth 0romotion 0romotion and Maintenanc Maintenancee
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<. The nurse is assessing color 'ision of a male child. Which statement is correct5 The nurse
should: a. &hec color 'ision annually until the age of 1/ years. b. !s the child to identify the color of his or her clothing. c. Test for color 'ision once beteen the ages of 6 and / years. d. ;egin color 'ision screening at the child’s Byear checup. !"#: &
Test boys only once for color 'ision beteen the ages of 6 and / years. &olor 'ision is not tested in girls because it is rare in girls. Testing Testing is performed ith the Ishihara test, hich is a series of polychromatic cards. $I%: &ogniti'e (e'el: !pplying *!pplication+ M#&: &lient &lient "eeds: Aealth Aealth 0romotion 0romotion and Maintenanc Maintenancee
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/. The nurse is performing an eyeBscreening clinic at a daycare center. When examining a B
yearBold child, the nurse suspects that the child has a >lazy eye? and should: a. -xamine the external structures of the eye. b. !ssess 'isual acuity ith the #nellen eye chart. c. !ssess the child’s 'isual fields ith the confrontation test. d. Test for strabismus by performing the corneal light reflex test. !"#: $
Testing for strabismus is done by performing the corneal light reflex test and the co'er test. The #nellen eye chart and a nd confrontation test are not used to test for strabismus. $I%: &ogniti'e (e'el: !pplying *!pplication+ M#&: &lient &lient "eeds: Aealth Aealth 0romotion 0romotion and Maintenanc Maintenancee
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=. The nurse is performing an eye assessment on an /@ByearBold patient. Which of these findings
is considered abnormal5 a. $ecrease in tear production b. )ne9ual pupillary constriction in response to light c. 0resence of arcus senilis obser'ed around the cornea
d. (oss of the outer hair on the eyebros attributable to a decrease in hair follicles !"#: ;
0upils are small in the older adult, and the pupillary light reflex may be sloed, but b ut pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons. $I%: &ogniti'e (e (e'el: )n )nderstanding *& *&omprehension+ M#&: &lient &lient "eeds: Aealth Aealth 0romotion 0romotion and Maintenanc Maintenancee
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4@. The nurse notices the presence of o f periorbital edema hen performing an eye assessment on a
<@ByearBold patient. The nurse should: a. &hec for the presence of exophthalmos. b. #uspect that the patient has hyperthyroidism. c. !s the patient if he or she has a history of heart failure. d. !ssess for blepharitis, hich is often associated ith periorbital edema. !"#: &
0eriorbital edema occurs ith local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. 0eriorbital edema is no t associated ith blepharitis. $I%: &ogniti'e (e'el: !nalyzing *!nalysis+ -%: p. 414 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 41. When a light is directed across the iris of a patient’s patient’s eye from the temporal side, the nurse nu rse is
assessing for: a. $rainage from dacryocystitis. b. 0resence of con7uncti'itis o'er the iris. c. 0resence of shados, hich may indicate glaucoma. d. #cattered light reflex, hich may be indicati'e of cataracts. !"#: &
The presence of shados in the anterior chamber may be a sign of acute angleBclosure glaucoma. The normal iris is flat and creates no shados. This method is n ot correct for the assessment of dacryocystitis, con7uncti'itis, or cataracts. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. 41 M#&: &lient "eeds: "eeds: #afe and -ffecti'e &are &are -n'ironment: -n'ironment: Management of &are 4. In a patient ho has anisocoria, the nurse ould expect to obser'e: a. $ilated pupils. b. -xcessi'e tearing. c. 0upils of une9ual size. d. )ne'en cur'ature of the lens. !"#: &
)ne9ual pupil size is termed anisocoria. anisocoria. It normally exists in 8H of the population but may also be indicati'e of central ner'ous system disease.
$I%: &ogniti'e (e (e'el: )n )nderstanding *& *&omprehension+ -%: p. = = M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 44. ! patient comes to the emergency department after a boxing match, an d his left eye is sollen
almost shut. Ae has bruises on his face and an d nec. Ae says he is orried because he >can’t see ell? from his left eye. The physician suspects retinal damage. The nurse recogn izes that signs of retinal detachment include: a. (oss of central 'ision. b. #hado or diminished 'ision in one 9uadrant or one half of the 'isual field. c. (oss of peripheral 'ision. d. #udden loss of pupillary constriction and accommodation. !"#: ;
With retinal detachment, the person has shados or diminished 'ision in one 9uad rant or one half of the 'isual field. The other responses are not signs o f retinal detachment. $I%: &ogniti'e (e'el: !nalyzing *!nalysis+ -%: p. 41/ M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 46. ! patient comes into the clinic complaining of pain in her right eye. Gn examination, the
nurse sees a pustule at the lid margin that is painful to touch, red, and sollen. The nurse recognizes that this is a: a. &halazion. b. Aordeolum *stye+. c. $acryocystitis. d. ;lepharitis. !"#: ;
! hordeolum, or stye, is a painful, red, and sollen pustule at the lid margin. ! chalazion is a nodule protruding on the lid, toard the inside, and is nontender, firm, ith discrete selling. $acryocystitis is an inflammation of the lacrimal sac. ;lepharitis is inflammation of the eyelids *see Table 16B4+. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. 418 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 48. ! /ByearBold /ByearBold oman is in the eye clinic for a checup. #he tells the nurse that she has been
ha'ing trouble reading the paper, seing, and e'en seeing the faces of her grandchildren. Gn examination, the nurse notes that she has some loss of central 'ision but her peripheral 'ision is normal. These findings suggest that she may ha'e: a. Macular degeneration. b. 2ision 2ision that is normal for someone her age. ag e. c. The beginning stages of cataract formation. d. Increased intraocular pressure or glaucoma. !"#: !
Macular degeneration is the most common cause cau se of blindness. It is characterized by the loss of central 'ision. &ataracts ould sho lens opacity. &hronic openBangle glaucoma, the most common type of glaucoma, in'ol'es in'ol' es a gradual loss of peripheral 'ision. These findings are not consistent ith 'ision that is considered normal at any age. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. / M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 4. ! patient comes into the emergency department after an accident ac cident at or. ! machine ble
dust into his eyes, and he as not earing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings ou ld suggest that he has suffered a corneal abrasion5 a. #mooth and clear corneas b. Gpacity of the lens behind the cornea c. ;leeding from the areas across the cornea d. #hattered loo to the light rays reflecting off the cornea !"#: $
! corneal abrasion causes irregular ridges in reflected light, hich produce a shattered appearance to light rays. "o opacities should be obser'ed in the cornea. corne a. The other responses are not correct. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. = M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 4<. !n ophthalmic examination re'eals papilledema. The nurse is aare that this finding
indicates: a. etinal detachment. b. $iabetic retinopathy. retinopathy. c. !cuteBangle glaucoma. d. Increased intracranial pressure. !"#: $
0apilledema, or choed dis, is a serious sign of increased intracranial pressure, hich is caused by a spaceBoccupying spaceBoccupy ing mass such as a brain tumor or hematoma. h ematoma. This pressure causes 'enous stasis in the globe, shoing redness, congestion, and ele'ation of the optic disc, blurred margins, hemorrhages, and absent 'enous pulsations. 0apilledema is not associated associated ith the conditions in the other responses. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. 4 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 4/. $uring a physical education class, a student is hit in the eye ith 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. Aypopyon. b. Ayphema. c. &orneal abrasion. d. 0terygium.
!"#: ;
Hyphema is 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 ma7or intraocular trauma. *#ee Table 16B< for descriptions of the other terms.+ $I%: &ogniti'e (e'el: !nalyzing *!nalysis+ -%: p. 41 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation 4=. $uring an assessment, the nurse notices that an older adult patient has tears rolling don his
face from his left eye. &loser examination shos that the loer lid is loose and rolling outard. The patient complains of his eye feeling >dry and itchy.? Which action by the nurse is correct 5 a. !ssessing the eye for a possible foreign body b. $ocumenting the finding as ptosis c. !ssessing for other signs of ectropion d. &ontacting the prescriberE these are signs of basal cell carcinoma !"#: &
The condition described is non as ectropion, ectropion, and it occurs in older adults and is attributable to atrophy of the elastic and fibrous tissues. The loer lid does not approximate to the eyeball, and, as a result, the puncta cannot effecti'ely siphon tearsE excessi'e tearing results. 0tosis is a drooping of the upper eyelid. eye lid. These signs do not suggest the presence of a foreign body in the eye or basal cell carcinoma. $I%: &ogniti'e (e'el: !pplying *!pplication+ -%: p. 416 M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation
M!"#P!E %EP$'E
1. $uring an examination, a patient states that she as diagnosed ith openBangle glaucoma
years ago. The nurse assesses for characteristics of openBangle glaucoma. Which of these are characteristics of openBangle glaucoma5 Select all that apply. apply. a. 0atient may experience sensiti'ity to light, nausea, and halos around lights. b. 0atient experiences tunnel 'ision in the late stages. c. Immediate treatment is needed. d. 2ision 2ision loss begins ith peripheral 'ision. e. GpenBangle glaucoma causes sudden attacs of increased pressure that cause blurred 'ision. f. 2irtually 2irtually no symptoms are exhibited. !"#: ;, $, $, %
GpenBangle glaucoma is the most common type of glaucomaE 'irtually no symptoms are exhibited. 2ision 2ision loss begins ith the peripheral 'ision, hich often goes unnoticed because indi'iduals learn to compensate intuiti'ely by turning their heads. The other characteristics are those of closedBangle glaucoma. $I%: &ogniti'e (e (e'el: )n )nderstanding *& *&omprehension+ -%: p. 4@ 4@= M#&: &lient "eeds: "eeds: 0hysiologic 0hysiologic Integrity: Integrity: 0hysiologic 0hysiologic !daptation