MULTIPLE CHOICE
1. The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing?
a. A Tono-pen will be applied to th
...
MULTIPLE CHOICE
1. The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing?
a. A Tono-pen will be applied to the surface of the eye.
b. The test involves reading a Snellen chart from 20 feet.
c. Medications will be used to dilate the pupils for the test.
d. The examination involves checking the pupils reaction to light.
ANS: A
Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
2. The nurse is performing an eye examination on a 76-year-old patient. The nurse should refer the patient for a more extensive assessment based on which finding?
a. The patients sclerae are light yellow.
b. The patient reports persistent photophobia.
c. The pupil recovers slowly after responding to a bright light.
d. There is a whitish gray ring encircling the periphery of the iris.
ANS: B
Photophobia is not a normally occurring change with aging, and would require further assessment. The other assessment data are common gerontologic differences and would not be unusual in a 76-year-old patient.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse performing an eye examination will document normal findings for accommodation when
a. shining a light into the patients eye causes pupil constriction in the opposite eye.
b. a blink reaction follows touching the patients pupil with a piece of sterile cotton.
c. covering one eye for 1 minute and noting pupil constriction as the cover is removed.
d. the pupils constrict while fixating on an object being moved closer to the patients eyes.
ANS: D
Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object being moved far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
4. Which assessment finding alerts the nurse to provide patient teaching about cataract development?
a. History of hyperthyroidism
b. Unequal pupil size and shape
c. Blurred vision and light sensitivity
d. Loss of peripheral vision in both eyes
ANS: C
Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is indicative of anisocoria, not cataracts. Loss of peripheral vision is a sign of glaucoma.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
5. Assessment of a patients visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding?
a. OS 20/50; OD 20/40
b. OU 20/40; OS 50/20
c. OD 20/40; OS 20/50
d. OU 40/20; OD 50/20
ANS: A
When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patients visual acuity.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
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