CH 15 Eyes

Question 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.

Answer 1

a. Is expected.

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

Question 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.

Answer 2

d. Stimulated by CNs III, IV, and VI.

Question 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.

Answer 3

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

Question 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.

Answer 4

c. Elevates the eyelid and dilates the pupil.

Question 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

Answer 5

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

Question 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.

Answer 6

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

Question 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

Answer 7

a. Pupillary constriction when looking at a near object

Question 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.

Answer 8

d. Constriction of both pupils occurs in response to bright light.

Question 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.

Answer 9

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

Question 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

Answer 10

b. Loss of lens elasticity

Question 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

Answer 11

b. Dark retinal background

Question 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.

Answer 12

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

Question 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.

Answer 13

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

Question 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.

Answer 14

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

Question 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.

Answer 15

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

Question 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.

Answer 16

a. Has poor vision.

Question 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.

Answer 17

a. Consider this a normal finding.

Question 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

Answer 18

b. Parallel movement of both eyes

Question 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

Answer 19

d. Presence of small brown macules on the sclera

Question 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.

Answer 20

c. Observe the distance between the palpebral fissures.

Question 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

Answer 21

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

Question 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.

Answer 22

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

Question 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

Answer 23

d. Convergence of the axes of the eyes

Question 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.

Answer 24

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

Question 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

Answer 25

a. Optic disc that is a yellow-orange color

Question 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.

Answer 26

a. Consider this a normal finding.

Question 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.

Answer 27

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

Question 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.

Answer 28

d. Test for strabismus by performing the corneal light reflex test.

Question 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

Answer 29

b. Unequal pupillary constriction in response to light

Question 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.

Answer 30

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

Question 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.

Answer 31

c. Presence of shadows, which may indicate glaucoma.

Question 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.

Answer 32

c. Pupils of unequal size.

Question 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.

Answer 33

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

Question 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.

Answer 34

b. Hordeolum (stye).

Question 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.

Answer 35

a. Macular degeneration.

Question 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

Answer 36

d. Shattered look to the light rays reflecting off the cornea

Question 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

Answer 37

d. Increased intracranial pressure

Question 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.

Answer 38

b. Hyphema.

Question 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

Answer 39

c. Assessing for other signs of ectropion

Question 40

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.

Answer 40

b. Patient experiences tunnel vision in the late stages.
d. Vision loss begins with peripheral vision.
f. Virtually no symptoms are exhibited.