Chapter 71
1. The function of the lens of the eye is accommodation. This allows the individual to:
1. See objects at close and at far range.
2. See at night.
3. Prevent too much light from entering the eye.
4. Distinguish color.
Answer: See objects at close and at far range.
Rationale:
The lens is the focusing structure of accommodation that allows seeing objects at close and at
far range. Night vision and color vision are a function of rods and cone receptors in the retina.
The pupil controls the amount of light entering the eye.
2. An examination of a client indicates there is limited central vision. This would indicate a
problem with the:
1. Macula.
2. Lens.
3. Sclera.
4. Extraocular muscles.
Answer: Macula.
Rationale:
The center of the retina, called the macula, is where the greatest numbers of cone receptors
are located for central and color vision. The sclera is the outer protective layer of the eyeball
that helps maintain its shape. The lens is the focusing structure of accommodation. The
extraocular muscles move the eyeball.
3. A client complains that sometimes there appears to be gnats in his field of vision. The
nurse realizes the client is talking about:
1. Floaters.
2. Conjunctivitis.
3. Nystagmus.
4. Strabismus.
Answer: Floaters.
Rationale:
The vitreous gel is made up mainly of water with a collagen framework. The collagen
network can be aggregated by vitreous collapse due to aging and form opacities, which cast
shadows on the retina. These shadows are referred to as floaters. The client often describes
this as seeing gnats or a fine filament floating in the line of sight. Conjunctivitis is an
inflammation of the conjunctiva. The main symptom is a discharge from the eyes. Nystagmus
is an involuntary tremor or jerky movement of the eyeball. Strabismus is a functional
misalignment of the extraocular muscles that causes the eyes not to focus together.
4. During an initial examination of the eye, the intraocular pressure should be measured. The
nurse would use a _______________ to determine to pressure.
1. Tonometer
2. Ophthalmoscope
3. Pen light
4. Snellen acuity chart
Answer: Tonometer
Rationale:
A tonometer is used to measure the intraocular pressure. An ophthalmoscope is used to view
the fundus of the eye by viewing through the pupil. A pen light is used for external
examination of the eye. The Snellen acuity chart is used to measure visual acuity.
5. During an assessment of the eye, the optic nerve can be evaluated by:
1. Direct ophthalmoscope examination.
2. Using dilation eyedrops.
3. Shining a pen light into the eye.
4. A tonometer.
Answer: Direct ophthalmoscope examination.
Rationale:
Direct ophthalmoscope examination is used to check the fundus of the eye, viewing through
the pupil. The optic nerve can be visualized and should be checked for color, shape, and
vessels. Dilation eyedrops are used for many diagnostic tests, but are not required to see the
optic nerve with an ophthalmoscope. The optic nerve cannot be seen by shining a pen light
into the eye. A tonometer is used to measure intraocular pressure.
6. A visual field test is performed on a client to test peripheral visual acuity. The nurse finds
that the client’s angle of recognition of the test object is decreased in two of the four
quadrants. The appropriate response of the nurse should be to:
1. Refer for further testing.
2. Document it is a normal test result.
3. Repeat the test.
4. Repeat the test with the client’s glasses on.
Answer: Refer for further testing.
Rationale:
If any visual field defects are noted, the client should be sent for sophisticated visual field
testing. The degree of angle recognition must approximate normal degrees for all four
quadrants to be documented as normal results. The test does not need to be repeated if
administered correctly. The client’s glasses should be off because the glasses frame may
interfere with the field of vision.
7. A client has been diagnosed with primary glaucoma. Primary glaucoma refers to form of
glaucoma that:
1. Has no relation to other ocular conditions.
2. Is the result of another preexisting ocular condition.
3. Is caused by a congenital anomaly.
4. Is not as serious as other forms of glaucoma.
Answer: Has no relation to other ocular conditions.
Rationale:
Primary glaucoma infers that it has no relation to other ocular conditions, and secondary
glaucoma is the result of another preexisting ocular condition. A congenital anomaly is a
cause of secondary glaucoma. Glaucoma is always serious and can cause blindness because
the increased intraocular pressure can cause optic nerve changes.
8. The nurse performed a cover-uncover test on a client to test for atropia. When the left eye
was covered, the right eye moved inward. The finding indicated that the client had:
1. Exotropia.
2. Esotropia.
3. No strabismus.
4. Vertical phoria.
Answer: Exotropia.
Rationale:
Tropia is a functional defect that results from a break in visual fusion due to an imbalance or
misalignment of the extraocular muscles when both eyes are not covered. If the uncovered
eye moves inward, then it was fixed outward. This is exotropia. If the uncovered eye moves
outward, then it was fixed inward. This is esotropia. If the uncovered eye does not move, it
indicates the client does not have strabismus, which is a functional misalignment of the
extraocular muscles that causes the eyes not to focus together. If the uncovered eye moved up
or down, it would indicate vertical phoria.
9. A client is admitted with orbital cellulitis of the right eye. The most common cause of
orbital cellulitis in adults is an infection caused by staphylococci and streptococci as a result
of:
• Bacterial sinusitis.
• Traumatic induction of bacteria.
• Intraocular surgery.
• Conjunctivitis.
Answer: Bacterial sinusitis.
Rationale:
Orbital cellulitis is inflammation of the postseptal orbital tissue from the spread of bacteria
from elsewhere, usually from the nasal and sinus system. The most common causative
organisms in adults are staphylococci and streptococci from bacterial sinusitis. It can be
caused by traumatic induction of bacteria, but it is not the most common cause. Infection is a
risk of any surgery, but an infection from intraocular surgery generally does not cause orbital
cellulitis. Conjunctivitis is an inflammation of the conjunctiva caused by a bacteria, virus, or
allergen.
10. The nurse is caring for a client newly diagnosed with glaucoma. The client is
asymptomatic except for the increased intraocular pressure detected during a routine eye
examination. When developing a plan of care for this client, which of the following goals
should have the highest priority?
1. Stress importance of compliance with glaucoma eyedrops.
2. Assess for fall injuries.
3. Consider home maintenance issues.
4. Discuss risk factors.
Answer: Stress importance of compliance with glaucoma eyedrops.
Rationale:
All of the goals should be part of a nursing care plan for a client with glaucoma. However,
this client is asymptomatic and has not suffered any vision loss. To prevent vision loss, the
importance of client compliance with glaucoma eyedrops to decrease the intraocular pressure
should be given the highest priority. Discussion of risk factors is important, but the eyedrops
are the most effective method of decreasing the chance of vision loss. Assessing for fall
injuries and home maintenance issues are more relevant to clients who already have vision
loss.
11. Following a severe eyelid laceration, the most important aspect of client education is:
1. Prescribed medication regimen.
2. Care of the eye patch.
3. Surgical reconstruction.
4. Use of ice packs.
Answer: Prescribed medication regimen.
Rationale:
Client education about the prescribed medication regimen is a must to prevent the risk of
noncompliance. When discussing the medications, it is important to stress good hand hygiene
before applying eyedrops or ointments to prevent the risk of infection. A patch is
contraindicated if an intraocular foreign body is present. Surgical reconstruction may not be
necessary depending on the severity of the injury. Ice packs may be used to control bleeding,
reduce swelling, and may provide some comfort. Ice packs must be used correctly, but client
education in this area is a lower priority.
12. Phenylephrine (Neo-Synephrine) is administered to a client before a diagnostic
procedure. The client education about this medication should include:
1. Driving may be difficult.
2. Tears will be yellow.
3. May cause burning.
4. Sunlight will improve vision.
Answer: Driving may be difficult.
Rationale:
Phenylephrine causes pupillary dilation. The nurse should inform the client that driving with
eyes dilated may cause difficulty, especially on a sunny day. Patients should be instructed to
wear sunglasses to block ultraviolet (UV) exposure. The pupils are unable to react to or
decrease the amount of light entering the eye. Burning is an adverse reaction to
phenylephrine. Medications that numb the eye, such as Proparacaine, will cause the tears to
be yellow.
13. A client recovering from a head injury has adult strabismus. This client would probably
be referred for the most common treatment of adult strabismus, which is/are:
1. Eye muscle surgery.
2. Eye muscle exercises.
3. Botox injections.
4. Glasses.
Answer: Eye muscle surgery.
Rationale:
Eye muscle surgery is the most common treatment. It is used to loosen or tighten the muscles
around the eye in order to correct the misalignment. Eye muscle exercise is used when
treating a form of adult strabismus called convergence insufficiency. Botox injections are an
effective treatment when overactive eye muscles are causing strabismus. Prism eyeglasses
can be used to correct mild double vision associated with adult strabismus.
14. A pregnant woman with retinitis pigmentosa is concerned about the possibility that the
baby will also develop the disorder. An appropriate referral source would be:
1. Genetic counseling.
2. An ophthalmologist.
3. A gynecologist.
4. A nutritionist.
Answer: Genetic counseling.
Rationale:
Retinitis pigmentosa is a hereditary disorder. Genetic counseling would give the client
information regarding hereditary traits. An ophthalmologist, gynecologist, and nutritionist are
all important resources for this patient, but are not the best resource for discussing hereditary
traits.
15. A client with blindness resulting from diabetic retinopathy is being cared by a family
member. When developing a plan of care for this client, the highest priority in this situation
would be an assessment to determine if a referral is needed for:
1. Respite services.
2. A low-vision rehabilitation specialist.
3. Assistive devices.
4. Housekeeping assistance.
Answer: Respite services.
Rationale:
An individual who is the sole caregiver may need respite services if he or she is the only
support system for the family. It is difficult for a single individual to be a sole caregiver, and
the individual would likely need some type of respite service. A client who is blind would
probably not benefit from a referral to a low-vision specialist. Assistive devices and
housekeeping assistance may be necessary, but assessment for the need for respite services
would be a higher priority.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
