502 Exam 2 Questions With Correct
Answers
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 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. | | | | | |
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. | | | |
Answers
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 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. | | | | | |
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. | | | |
