LEWIS'S MEDICAL SURGICAL NURSING TEST BANK 11TH EDITION BY HARDING

Chapter 20: Assessment and Management: Visual Problems Test Bank 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. Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 196 LEWIS'S MEDICAL SURGICAL NURSING TEST BANK 11TH EDITION BY HARDING 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 Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 197 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 6. When assessing a patients consensual pupil response, the nurse should a. have the patient cover one eye while facing the nurse. b. observe for a light reflection in the center of both corneas. c. instruct the patient to follow a moving object using only the eyes. d. shine a light into one pupil and observe the response of both pupils. ANS: D The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye, then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 7. When obtaining a health history from a 49-year-old patient, which patient statement is most important to communicate to the primary health care provider? a. My eyes are dry now. b. It is hard for me to see at night. c. My vision is blurry when I read. d. I cant see as far over to the side. ANS: D The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 198 8. A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patients treatment? a. I use aspirin when I have a sinus headache. b. I have had frequent episodes of conjunctivitis. c. I take metoprolol (Lopressor) daily for angina. d. I have not had an eye examination for 10 years. ANS: C It is important to note whether the patient takes any b-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, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 9. The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurses instructions for this test include asking the patient to a. stand 20 feet from the wall chart. b. follow the examiners finger with the eyes only. c. look at an object far away and then near to the eyes. d. look straight ahead while a light is shone into the eyes. ANS: A When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiners fingers with the eyes tests extraocular movements. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care? a. Disturbed body image related to eye trauma and eye patch b. Risk for falls related to temporary decrease in stereoscopic vision Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 199 c. Ineffective health maintenance related to inability to see surroundings d. Ineffective denial related to inability to admit the impact of the eye injury ANS: B The loss of stereoscopic vision created by the eye patch impairs the patients ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective health maintenance, disturbed body image, or ineffective denial. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 11. Which information will the nurse provide to the patient scheduled for refractometry? a. You will need to wear sunglasses for a few hours after the exam. b. The surface of your eye will be numb while the doctor does the exam. c. You should not take any of your eye medicines before the examination. d. The doctor will shine a bright light into your eye during the examination. ANS: A The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse is assessing a 65-year-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 at a time 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. ANS: A The Jaeger card is used to assess near vision problems and presbyopia in persons over 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 Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 200 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. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to a. hold a card and fixate on the center dot. b. report any burning or pain at the IV site. c. remain still while the cornea is anesthetized. d. let the examiner know when images shown appear clear. ANS: B Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity