502 EXAM 2 QUESTIONS AND ANSWERS
Which finding by the nurse performing an eye examination indicates that
the patient has normal accommodation?
a. After covering one eye for 1 minute, the pupil constricts as the cover
is removed.
b. Shining a light into the patient's eye causes pupil constriction in the
opposite eye.
c. A blink reaction occurs after touching the patient's pupil with a piece of
sterile cotton
d. The pupils constrict while fixating on an object being moved towards
the patient's eyes - CORRECT ANSWER- D
Accommodation is defined as the ability of the lens to adjust to various
distances. The pupils constrict while fixating on an object that is being
moved from 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.
The nurse is performing an eye examination on a 76-yr-old patient.
Which finding indicates that the nurse should refer the patient for a more
extensive assessment?
a. The patient's 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. -
CORRECT ANSWER- B
Photophobia is not a normally occurring change with aging and would
require further assessment. The other assessment data are common
gerontologic differences in assessment and would not be unusual in a
76-yr-old patient.
Which assessment finding alerts the nurse to provide patient teaching
about cataract development?
a. Unequal pupil size
,b. Sensitivity to light
c. Loss of peripheral vision
d. History of hyperthyroidism - CORRECT ANSWER- B
Classic signs of cataracts include blurred vision and light sensitivity.
Thyroid problems are a major cause of exophthalmos. Unequal pupil is
not indicative of cataracts. Loss of peripheral vision is a sign of
glaucoma.
A 65-yr-old patient is being evaluated for glaucoma. Which information
given by the patient has implications for the patient's treatment plan?
a. "I take metoprolol (Lopressor) for angina."
b. "I take aspirin when I have a sinus headache."
c. "I have had frequent episodes of conjunctivitis."
d. "I have not had an eye examination of 10 years" - CORRECT
ANSWER- A
It is important to note whether the patient takes any -adrenergic blockers
because this classification of medications is also used to treat glaucoma,
and there may be an increase in adverse effects. The use of aspirin
does not increase intraocular pressure and is safe for patients with
glaucoma. Although older patients should have yearly eye examinations,
treatment will not be affected by the 10-year gap in eye care.
Conjunctivitis does not increase the risk for glaucoma.
A patient who underwent eye surgery must wear an eye patch until the
scheduled postoperative clinic visit. Which patient problem will the nurse
address in the plan of care?
a. Risk for falls
b. Difficulty coping
c. Disturbed body image
d. Inability to care for home - CORRECT ANSWER- A
The loss of stereoscopic vision created by the eye patch impairs the
patient's ability to see in three dimensions and to judge distances. This
increases the risk for falls. There is no evidence in the assessment data
for inability to care for home, disturbed body image, or difficulty coping.
The nurse is assessing a 65-yr-old patient for presbyopia. Which
instruction will the nurse give the patient before the test?
a. "Hold this card and read the print out loud."
,b. "Cover one eye while reading the wall chart."
c. "You'll feel a short burst of air directed at your eyeball."
d. "A light will be used to look for a change in your pupils." - CORRECT
ANSWER- A
The Jaeger card is used to assess near vision problems and presbyopia
in persons older than 40 years of age. The card should be held 14
inches away from eyes while the patient reads words in various print
sizes. Using a penlight to determine pupil change is testing pupil
response. A short burst of air may be used to test intraocular pressure
but is not used for testing presbyopia. Covering one eye at a time while
reading a wall chart at 20 feet describes the Snellen test.
Which action can the nurse working in the emergency department
delegate to an experienced unlicensed assistive personnel (UAP)?
a. Ask a patient with decreased visual acuity about medications taken at
home.
b. Perform Snellen testing of visual acuity for a patient with a history of
cataracts.
c. Obtain information from a patient about any history of childhood ear
infections.
d. Inspect a patient's external ear for redness, swelling, or presence of
skin lesions. - CORRECT ANSWER- B
The Snellen test does not require nursing judgment and is appropriate to
delegate to UAP who have been trained to perform it. History taking
about infection or medications and assessment are actions that require
critical thinking and should be done by the RN.
The nurse working in the clinic receives telephone calls from several
patients who want appointments as soon as possible. Which patient
should be seen first?
a. 71-yr-old who has noticed increasing loss of peripheral vision
b. 74-yr-old who has difficulty seeing well enough to drive at night
c. 60-yr-old who is reporting dry eyes with decreased tear formation
d. 64-yr-old who states that it is becoming difficult to read news print -
CORRECT ANSWER- A
Increasing loss of peripheral vision is characteristic of glaucoma, and the
patient should be scheduled for an examination as soon as possible.
, The other patients have symptoms commonly associated with aging:
presbyopia, decreased tear formation, and impaired night vision.
What should the nurse assess to evaluate the effectiveness of treatment
for the patient's myopia and presbyopia?
a. Strength of the eye muscles.
b. Both near and distant vision.
c. Cloudiness in the eye lenses.
d. Intraocular pressure changes. - CORRECT ANSWER- B
Lenses are prescribed to correct the patient's near and distant vision.
The nurse may assess for cloudiness of the lenses, increased
intraocular pressure and eye movement, but these data do not evaluate
whether the patient's bifocals are effective
What is the safest technique for the nurse to use when assisting a blind
patient to ambulate to the bathroom?
a. Lead the patient slowly to the bathroom, holding on to the patient by
the arm.
b. Stay beside the patient and describe any obstacles on the path to the
bathroom.
c. Walk slightly ahead of the patient, allowing the patient to hold the
nurse's elbow.
d. Have the patient place a hand on the nurse's shoulder and guide the
patient forward. - CORRECT ANSWER- C
When using the sighted-guide technique, the nurse walks slightly in front
and to the side of the patient and has the patient hold the nurse's elbow.
The other techniques are not as safe in assisting a blind patient.
Which teaching point should the nurse plan to include when caring for a
patient whose vision is corrected to 20/200?
a. How to access audio books?
b. How to use a white cane safely?
c. Where Braille instruction is available?
d. Where to obtain hand-held magnifiers? - CORRECT ANSWER- D
Various types of magnifiers can enhance the remaining vision enough to
allow the performance of many tasks and activities of daily living. Audio
books, Braille instruction, and canes usually are reserved for patients
with no functional vision.
Which finding by the nurse performing an eye examination indicates that
the patient has normal accommodation?
a. After covering one eye for 1 minute, the pupil constricts as the cover
is removed.
b. Shining a light into the patient's eye causes pupil constriction in the
opposite eye.
c. A blink reaction occurs after touching the patient's pupil with a piece of
sterile cotton
d. The pupils constrict while fixating on an object being moved towards
the patient's eyes - CORRECT ANSWER- D
Accommodation is defined as the ability of the lens to adjust to various
distances. The pupils constrict while fixating on an object that is being
moved from 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.
The nurse is performing an eye examination on a 76-yr-old patient.
Which finding indicates that the nurse should refer the patient for a more
extensive assessment?
a. The patient's 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. -
CORRECT ANSWER- B
Photophobia is not a normally occurring change with aging and would
require further assessment. The other assessment data are common
gerontologic differences in assessment and would not be unusual in a
76-yr-old patient.
Which assessment finding alerts the nurse to provide patient teaching
about cataract development?
a. Unequal pupil size
,b. Sensitivity to light
c. Loss of peripheral vision
d. History of hyperthyroidism - CORRECT ANSWER- B
Classic signs of cataracts include blurred vision and light sensitivity.
Thyroid problems are a major cause of exophthalmos. Unequal pupil is
not indicative of cataracts. Loss of peripheral vision is a sign of
glaucoma.
A 65-yr-old patient is being evaluated for glaucoma. Which information
given by the patient has implications for the patient's treatment plan?
a. "I take metoprolol (Lopressor) for angina."
b. "I take aspirin when I have a sinus headache."
c. "I have had frequent episodes of conjunctivitis."
d. "I have not had an eye examination of 10 years" - CORRECT
ANSWER- A
It is important to note whether the patient takes any -adrenergic blockers
because this classification of medications is also used to treat glaucoma,
and there may be an increase in adverse effects. The use of aspirin
does not increase intraocular pressure and is safe for patients with
glaucoma. Although older patients should have yearly eye examinations,
treatment will not be affected by the 10-year gap in eye care.
Conjunctivitis does not increase the risk for glaucoma.
A patient who underwent eye surgery must wear an eye patch until the
scheduled postoperative clinic visit. Which patient problem will the nurse
address in the plan of care?
a. Risk for falls
b. Difficulty coping
c. Disturbed body image
d. Inability to care for home - CORRECT ANSWER- A
The loss of stereoscopic vision created by the eye patch impairs the
patient's ability to see in three dimensions and to judge distances. This
increases the risk for falls. There is no evidence in the assessment data
for inability to care for home, disturbed body image, or difficulty coping.
The nurse is assessing a 65-yr-old patient for presbyopia. Which
instruction will the nurse give the patient before the test?
a. "Hold this card and read the print out loud."
,b. "Cover one eye while reading the wall chart."
c. "You'll feel a short burst of air directed at your eyeball."
d. "A light will be used to look for a change in your pupils." - CORRECT
ANSWER- A
The Jaeger card is used to assess near vision problems and presbyopia
in persons older than 40 years of age. The card should be held 14
inches away from eyes while the patient reads words in various print
sizes. Using a penlight to determine pupil change is testing pupil
response. A short burst of air may be used to test intraocular pressure
but is not used for testing presbyopia. Covering one eye at a time while
reading a wall chart at 20 feet describes the Snellen test.
Which action can the nurse working in the emergency department
delegate to an experienced unlicensed assistive personnel (UAP)?
a. Ask a patient with decreased visual acuity about medications taken at
home.
b. Perform Snellen testing of visual acuity for a patient with a history of
cataracts.
c. Obtain information from a patient about any history of childhood ear
infections.
d. Inspect a patient's external ear for redness, swelling, or presence of
skin lesions. - CORRECT ANSWER- B
The Snellen test does not require nursing judgment and is appropriate to
delegate to UAP who have been trained to perform it. History taking
about infection or medications and assessment are actions that require
critical thinking and should be done by the RN.
The nurse working in the clinic receives telephone calls from several
patients who want appointments as soon as possible. Which patient
should be seen first?
a. 71-yr-old who has noticed increasing loss of peripheral vision
b. 74-yr-old who has difficulty seeing well enough to drive at night
c. 60-yr-old who is reporting dry eyes with decreased tear formation
d. 64-yr-old who states that it is becoming difficult to read news print -
CORRECT ANSWER- A
Increasing loss of peripheral vision is characteristic of glaucoma, and the
patient should be scheduled for an examination as soon as possible.
, The other patients have symptoms commonly associated with aging:
presbyopia, decreased tear formation, and impaired night vision.
What should the nurse assess to evaluate the effectiveness of treatment
for the patient's myopia and presbyopia?
a. Strength of the eye muscles.
b. Both near and distant vision.
c. Cloudiness in the eye lenses.
d. Intraocular pressure changes. - CORRECT ANSWER- B
Lenses are prescribed to correct the patient's near and distant vision.
The nurse may assess for cloudiness of the lenses, increased
intraocular pressure and eye movement, but these data do not evaluate
whether the patient's bifocals are effective
What is the safest technique for the nurse to use when assisting a blind
patient to ambulate to the bathroom?
a. Lead the patient slowly to the bathroom, holding on to the patient by
the arm.
b. Stay beside the patient and describe any obstacles on the path to the
bathroom.
c. Walk slightly ahead of the patient, allowing the patient to hold the
nurse's elbow.
d. Have the patient place a hand on the nurse's shoulder and guide the
patient forward. - CORRECT ANSWER- C
When using the sighted-guide technique, the nurse walks slightly in front
and to the side of the patient and has the patient hold the nurse's elbow.
The other techniques are not as safe in assisting a blind patient.
Which teaching point should the nurse plan to include when caring for a
patient whose vision is corrected to 20/200?
a. How to access audio books?
b. How to use a white cane safely?
c. Where Braille instruction is available?
d. Where to obtain hand-held magnifiers? - CORRECT ANSWER- D
Various types of magnifiers can enhance the remaining vision enough to
allow the performance of many tasks and activities of daily living. Audio
books, Braille instruction, and canes usually are reserved for patients
with no functional vision.
