Exam (elaborations)
Ch 48_ Assessment of the Eye and Vision, NCLEX Prac
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- EXAM 1- FETAL HEART MONITORING
Ch 48_ Assessment of the Eye and Vision, NCLEX Prac
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Ch 48: Assessment of the Eye and Vision,NCLEX Prac
Why is the optic disc considered to be a blind spot?
a. This area does not contain photoreceptors.
b. Light rays are unable to focus on this location.
c. Blood vessels form a meshwork and interfere with vision.
d. This area is heavily pigmented and light rays are absorbed. - ANS-ANS: A
The optic nerve enters the eyeball at this point and contains no photoreceptors. The
other responses are incorrect.
During assessment of an older adult, which finding does the nurse immediately report to
the health care provider?
a. Yellowing or bluing of the sclera
b. Lack of discrimination between green and violet
c. An opaque, bluish-white ring within the outer edge of the cornea
d. Pupil constriction in response to light occurring in 2 seconds - ANS-ANS: D
In an older client, it is normal for the sclera to turn yellow or blue with aging. It is also
common for the older adult to have problems discriminating between the colors of
green, blue, and violet. Arcus senilis, an opaque, bluish-white ring on the edge of the
cornea, is a common occurrence in the older adult. This does not cause vision loss.
Pupil constriction as a reaction to light should occur in less than 1 second. If pupil
constriction takes longer, then the reaction is considered sluggish and should be
reported to the provider.
Which teaching is essential for a client who is going to have intraocular pressure
measurement with a slit lamp?
a. "The test causes temporary blindness."
b. "The test is quick and a local anesthetic is used."
c. "The test does cause a little pain, but it is over quickly."
d. "The test causes some tearing, but no pain." - ANS-ANS: B
The IOP test done with a slit lamp must have direct eye contact, which could cause
discomfort, so a local anesthetic is used. The test is quick but does not cause temporary
blindness.
The nurse performs an assessment of a client's extraocular movement and notes no
difficulty. Which additional assessment data assist in confirming this finding?
a. No episodes of double vision
, b. Synchronized blinking movements
c. No reports of headaches and dizziness
d. Both pupils constricting equally in response to light - ANS-ANS: A
The voluntary muscles of the orbit rotate the eye and coordinate eye movements to
ensure that the retina of each eye receives an image at the same time, so that only a
single image is perceived. If the client has reported double vision, this would indicate a
problem with this coordination. The other answers are not related to extraocular eye
movements.
A client has paralysis of the right medial rectus muscle of the right eye. Which
assessment finding assists the nurse in validating this diagnosis?
a. Client is unable to turn the eye in toward the nose.
b. Client is unable to lift the upper eyelid.
c. Client cannot look downward.
d. Client cannot look upward. - ANS-ANS: A
Contraction of the medial rectus muscle turns the eye toward the nose. The superior
oblique muscle pulls the eye downward, and the inferior oblique muscle pulls the eye
upward. The ocular muscles do not lift the upper eyelid.
The nurse is assessing extraocular eye movements (EOMs) in an older adult client and
finds that the client is unable to sustain an upward gaze for longer than 2 seconds.
What does the nurse do next?
a. Repeat the test while holding the client's head in a fixed position.
b. Perform a cover-uncover eye test.
c. Document the finding and continue assessing.
d. Assess for additional signs of impending brain attack. - ANS-ANS: C
In the older adult, decreased muscle tone impairs the ability to maintain an upward gaze
and to sustain convergence. Therefore, this finding is normal for an older adult client.
The nurse would not repeat the test or hold the client's head in a fixed position. The
nurse would document the finding and continue to assess. This would not be a cause
for concern, nor would it be a symptom of impending brain attack. The cover-uncover
test is used for determining the degree of peripheral vision.
The nurse is assessing an older adult client whose irises no longer fully dilate. What is
the best intervention for the nurse to suggest?
a. "Wear dark glasses whenever you are outside."
b. "Use eyedrops on a regular basis to prevent dryness."
c. "Avoid rubbing your eyes to prevent corneal abrasions."
d. "Turn up room lights when reading or doing close work." - ANS-ANS: D
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