Question 1

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?

Accepted Answer

A) Dilation of the pupils 
B) Consensual light reflex 
C) Conjugate movement of the eyes 
D) Convergence of the axes of the eyes 
A) Dilation of the pupils 
B) Consensual light reflex 
C) Conjugate movement of the eyes 
D) Convergence of the axes of the eyes

Question 2

When examining a patient's eyes,the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

Accepted Answer

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. 
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.

Question 3

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

Accepted Answer

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 
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

Question 4

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

Accepted Answer

A) Increased night vision 
B) Dark retinal background 
C) Increased photosensitivity 
D) Narrowed palpebral fissures 
A) Increased night vision 
B) Dark retinal background 
C) Increased photosensitivity 
D) Narrowed palpebral fissures

Question 5

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

Accepted Answer

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 child's 2-year checkup. 
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 child's 2-year checkup.

Question 6

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

Accepted Answer

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. 
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.

Question 7

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

Accepted Answer

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 
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

Question 8

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

Accepted Answer

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 
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

Question 9

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:

Accepted Answer

A) Hypopyon. 
B) Hyphema. 
C) Corneal abrasion. 
D) Pterygium. 
A) Hypopyon. 
B) Hyphema. 
C) Corneal abrasion. 
D) Pterygium.

Question 10

When a light is directed across the iris of a patient's eye from the temporal side,the nurse is assessing for:

Accepted Answer

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. 
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.

Question 11

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:

Accepted Answer

A) Chalazion. 
B) Hordeolum (stye). 
C) Dacryocystitis. 
D) Blepharitis. 
A) Chalazion. 
B) Hordeolum (stye). 
C) Dacryocystitis. 
D) Blepharitis.

Question 12

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

Accepted Answer

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. 
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.

Question 13

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

Accepted Answer

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 
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

Question 14

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

Accepted Answer

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. 
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.

Question 15

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

Accepted Answer

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 
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

Question 16

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:

Accepted Answer

A) Examine the external structures of the eye. 
B) Assess visual acuity with the Snellen eye chart. 
C) Assess the child's visual fields with the confrontation test. 
D) Test for strabismus by performing the corneal light reflex test. 
A) Examine the external structures of the eye. 
B) Assess visual acuity with the Snellen eye chart. 
C) Assess the child's visual fields with the confrontation test. 
D) Test for strabismus by performing the corneal light reflex test.

Question 17

The nurse is examining a patient's retina with an ophthalmoscope.Which finding is considered normal?

Accepted Answer

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 
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

Question 18

When examining the eye,the nurse notices that the patient's eyelid margins approximate completely.The nurse recognizes that this assessment finding:

Accepted Answer

A) Is expected. 
B) May indicate a problem with extraocular muscles. 
C) May result in problems with tearing. 
D) Indicates increased intraocular pressure. 
A) Is expected. 
B) May indicate a problem with extraocular muscles. 
C) May result in problems with tearing. 
D) Indicates increased intraocular pressure.

Question 19

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

Accepted Answer

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. 
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.

Question 20

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

Accepted Answer

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. 
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.

Exam 14: Eyes

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?

When examining a patient's eyes,the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

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

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

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

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

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

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

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:

When a light is directed across the iris of a patient's eye from the temporal side,the nurse is assessing for:

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:

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

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

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

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

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:

The nurse is examining a patient's retina with an ophthalmoscope.Which finding is considered normal?

When examining the eye,the nurse notices that the patient's eyelid margins approximate completely.The nurse recognizes that this assessment finding:

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

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

Evidence-Based Assessment

Cultural Competence

The Interview

The Complete Health History

Mental Status Assessment

Substance Use Assessment

Domestic and Family Violence Assessments

Assessment Techniques and Safety in the Clinical Setting

General Survey, Measurement, Vital Signs

Pain Assessment: The Fifth Vital Sign

Nutritional Assessment

Skin, Hair, and Nails

Head, Face, and Neck, Including Regional Lymphatics

Ears

Nose, Mouth, and Throat

Breasts and Regional Lymphatics

Thorax and Lungs

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Musculoskeletal System

Neurologic System

Male Genitourinary System

Anus,Rectum,and Prostate

Female Genitourinary System

The Complete Health Assessment: Adult

The Complete Physical Assessment: Infant, Child, and Adolescent

Bedside Assessment of the Hospitalized Patient

The Pregnant Woman

Functional Assessment of the Older Adult

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