Question 1

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

Accepted Answer

A)  An optic disc that is a yellow-orange color 
B)  Optic disc margins that are blurred around the edges 
C)  The presence of pigmented crescents in the macular area 
D)  The presence of the macula located on the nasal side of the retina 
A)  An optic disc that is a yellow-orange color 
B)  Optic disc margins that are blurred around the edges 
C)  The presence of pigmented crescents in the macular area 
D)  The presence of the macula located on the nasal side of the retina A

Question 2

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

Accepted Answer

A)  decreased in the elderly. 
B)  impaired in a patient with cataracts. 
C)  stimulated by cranial nerves I and II. 
D)  stimulated by cranial nerves III, IV, and VI. 
A)  decreased in the elderly. 
B)  impaired in a patient with cataracts. 
C)  stimulated by cranial nerves I and II. 
D)  stimulated by cranial nerves III, IV, and VI. D

Question 3

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 this an abnormal finding and refer him to an ophthalmologist. 
D)  know that floaters are usually not significant 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 this an abnormal finding and refer him to an ophthalmologist. 
D)  know that floaters are usually not significant and are caused by condensed vitreous fibers. D

Question 4

A 68-year-old woman is in the eye clinic for a checkup.She tells the nurse that she has been having trouble with 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:

Accepted Answer

A)  she may have macular degeneration. 
B)  her vision is normal for someone her age. 
C)  she has the beginning stages of cataract formation. 
D)  she has increased intraocular pressure or glaucoma. 
A)  she may have macular degeneration. 
B)  her vision is normal for someone her age. 
C)  she has the beginning stages of cataract formation. 
D)  she has increased intraocular pressure or glaucoma.

Question 5

When performing the corneal light reflex assessment,the nurse notes that the light is reflected at 2 o'clock in each eye.The nurse should:

Accepted Answer

A)  consider this a normal finding. 
B)  refer the individual for further evaluation. 
C)  document this as an asymmetric light reflex. 
D)  perform the confrontation test to validate the findings. 
A)  consider this a normal finding. 
B)  refer the individual for further evaluation. 
C)  document this as an asymmetric light reflex. 
D)  perform the confrontation test to validate the findings.

Question 6

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?

Accepted Answer

A)  Perform the confrontation test. 
B)  Assess the individual's near vision. 
C)  Observe the distance between the palpebral fissures. 
D)  Perform the corneal light test and look for symmetry of the light reflex. 
A)  Perform the confrontation test. 
B)  Assess the individual's near vision. 
C)  Observe the distance between the palpebral fissures. 
D)  Perform the corneal light test and look for symmetry of the light reflex.

Question 7

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

Accepted Answer

A)  The presence of tears along the inner canthus 
B)  A blocked nasolacrimal duct in a newborn infant 
C)  A slight swelling over the upper lid and along the bony orbit if the individual has a cold 
D)  The absence of drainage from the puncta when pressing against the inner orbital rim 
A)  The presence of tears along the inner canthus 
B)  A blocked nasolacrimal duct in a newborn infant 
C)  A slight swelling over the upper lid and along the bony orbit if the individual has a cold 
D)  The absence of drainage from the puncta when pressing against the inner orbital rim

Question 8

A patient is unable to read even the largest letters on the Snellen chart.The nurse should take which action next?

Accepted Answer

A)  Refer the patient to an ophthalmologist or optometrist for further evaluation. 
B)  Assess whether the patient can count the nurse's 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 it is seen and record that distance. 
A)  Refer the patient to an ophthalmologist or optometrist for further evaluation. 
B)  Assess whether the patient can count the nurse's 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 it is seen and record that distance.

Question 9

During an ophthalmoscopic examination of the eye,the nurse notices areas of exudate that look like "cotton wool" or fluffy gray-white cumulus clouds.This finding indicates which possible problem?

Accepted Answer

A)  Diabetes 
B)  Hyperthyroidism 
C)  Glaucoma 
D)  Hypotension 
A)  Diabetes 
B)  Hyperthyroidism 
C)  Glaucoma 
D)  Hypotension

Question 10

In using the ophthalmoscope to assess a patient's eyes,the nurse notices a red glow in the patient's pupils.On the basis of this finding,the nurse would:

Accepted Answer

A)  suspect that there is an opacity in the lens or cornea. 
B)  check the light source of the ophthalmoscope to verify that it is functioning. 
C)  consider this a normal reflection of the ophthalmoscope light off the inner retina. 
D)  continue with the ophthalmoscopic examination and refer the patient for further evaluation. 
A)  suspect that there is an opacity in the lens or cornea. 
B)  check the light source of the ophthalmoscope to verify that it is functioning. 
C)  consider this a normal reflection of the ophthalmoscope light off the inner retina. 
D)  continue with the ophthalmoscopic examination and refer the patient for further evaluation.

Question 11

The nurse is conducting a visual examination.Which of these statements regarding visual pathways and visual fields is true?

Accepted Answer

A)  The right side of the brain interprets 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)  The light impulses are conducted through the optic nerve to the temporal lobes of the brain. 
A)  The right side of the brain interprets 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)  The light impulses are conducted through the optic nerve to the temporal lobes of the brain.

Question 12

A patient's vision is recorded as 20/80 in each eye.The nurse interprets this finding to mean that the patient:

Accepted Answer

A)  has poor vision. 
B)  has acute vision. 
C)  has normal vision. 
D)  is presbyopic. 
A)  has poor vision. 
B)  has acute vision. 
C)  has normal vision. 
D)  is presbyopic.

Question 13

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.

Accepted Answer

A)  The patient may experience sensitivity to light, nausea, and halos around lights. 
B)  The patient experiences tunnel vision in late stages. 
C)  Immediate treatment is needed. 
D)  Vision loss begins with peripheral vision. 
E)  It causes sudden attacks of increased pressure that cause blurred vision.
F) There are virtually no symptoms. 
A)  The patient may experience sensitivity to light, nausea, and halos around lights. 
B)  The patient experiences tunnel vision in late stages. 
C)  Immediate treatment is needed. 
D)  Vision loss begins with peripheral vision. 
E)  It causes sudden attacks of increased pressure that cause blurred vision.
F) There are virtually no symptoms.

Question 14

In a patient who has anisocoria,the nurse would expect to observe:

Accepted Answer

A)  dilated pupils. 
B)  excessive tearing. 
C)  pupils of unequal size. 
D)  an uneven curvature of the lens. 
A)  dilated pupils. 
B)  excessive tearing. 
C)  pupils of unequal size. 
D)  an uneven curvature of the lens.

Question 15

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

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 "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

During an assessment of the sclera of an African-American 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)  The 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)  The presence of small brown macules on the sclera

Question 18

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

Accepted Answer

A)  a chalazion. 
B)  a hordeolum (stye). 
C)  dacryocystitis. 
D)  blepharitis. 
A)  a chalazion. 
B)  a hordeolum (stye). 
C)  dacryocystitis. 
D)  blepharitis.

Question 19

A patient's vision is recorded as 20/30 when the Snellen eye chart is used.The nurse interprets these results to indicate that:

Accepted Answer

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. 
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.

Question 20

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 (CN V) and the trochlear (CN IV) nerves 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 (CN V) and the trochlear (CN IV) nerves 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.

Exam 14: Eyes

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

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

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

When performing the corneal light reflex assessment,the nurse notes that the light is reflected at 2 o'clock in each eye.The nurse should:

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?

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

A patient is unable to read even the largest letters on the Snellen chart.The nurse should take which action next?

During an ophthalmoscopic examination of the eye,the nurse notices areas of exudate that look like "cotton wool" or fluffy gray-white cumulus clouds.This finding indicates which possible problem?

In using the ophthalmoscope to assess a patient's eyes,the nurse notices a red glow in the patient's pupils.On the basis of this finding,the nurse would:

The nurse is conducting a visual examination.Which of these statements regarding visual pathways and visual fields is true?

A patient's vision is recorded as 20/80 in each eye.The nurse interprets this finding to mean that the patient:

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.

In a patient who has anisocoria,the nurse would expect to observe:

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

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 "lazy eye" and should:

During an assessment of the sclera of an African-American patient,the nurse would consider which of these an expected finding?

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 patient's vision is recorded as 20/30 when the Snellen eye chart is used.The nurse interprets these results to indicate that:

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

Evidence Based Assessment

Cultural Competence: Cultural Care

The Interview

The Complete Health History

Mental Status Assessment

Substance Use Assessment

Domestic Violence Assessment

Assessment Techniques and 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: Putting It All Together

Bedside Assessment of the Hospitalized Adult

The Pregnant Woman

Functional Assessment of the Older Adult

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