Nokea
A client presents to the emergency room with symptoms of blurred vision. Which type of question would be best to ask first?
- A. Have you ever had these symptoms before?
- B. Did these symptoms come on abruptly?
- C. Do you have a family history of vision problems?
- D. Do you have any other diseases?
Correct Answer: A
Rationale: When a client presents with unusual symptoms, a first question assesses if the client has ever had these symptoms before. This prepares a starting place for the assessment. If the client did have these symptoms before, questions regarding the specific nature and similarities of that experience guide the assessment.
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A client comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to this client?
- A. To control the amount of sunlight that enters the eye
- B. To minimize the impact of the wind on the eye and to trap foreign debris
- C. To clear the dust and particles from the surface of the eyes
- D. To prevent the collection of tears over the surface of the eye
Correct Answer: C
Rationale: Periodic blinking clears the dust and particles from the surface of the eyes. The eyelids also spread tears over the surface of the eye, which helps bathe and lubricate the surface. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye, whereas the eyelashes trap foreign debris.
The nurse is assisting the eye surgeon in completing an examination of a client's eye. Which piece of equipment would the nurse provide to the surgeon to examine the optic disc under magnification?
- A. Retinoscope
- B. Ophthalmoscope
- C. #NAME?
- D. Amsler grid
Correct Answer: B
Rationale: The nurse is correct to provide an ophthalmoscope to the surgeon for examination of the optic disc. A retinoscope is used to determine errors in refraction. A tonometer measures intraocular pressure. An Amsler grid tests for problems with the macula.
The nurse is caring for geriatric clients who state that they are prescribed reading glasses. Some individuals state needing assistance with seeing writing far away, and others need assistance with closer vision. What does the nurse understand to be related to visual changes caused by aging?
- A. Changes in refraction
- B. Changes in the visual field
- C. Changes in central vision
- D. Changes in accommodation
Correct Answer: D
Rationale: The changes that occur in vision during aging, which include difficulty reading and the need for reading glasses, include changes in accommodation. Accommodation occurs when the ciliary muscles contract or relax to focus an image on the retina.
The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential?
- A. Raise your hand when you hear the vibration.
- B. Raise your hand when you no longer hear sound.
- C. Raise your hand when the vibration exceeds the sound.
- D. Raise your hand when the sound exceeds the vibration.
Correct Answer: B
Rationale: It is essential to provide clear directions on when the client is to notify the nurse of client response. The information gleaned from the response is what the nurse uses to interpret the test. The correct time to induce feedback is when the vibration is heard.
When caring for a client with a foreign object removed from the eye, the nurse is most correct to assess the eye protective functions of which structure(s)? Select all that apply.
- A. Eyelids and lashes
- B. Aqueous humor
- C. Superior and inferior oblique muscles
- D. Conjunctiva
- E. Sclera
- F. Tears
Correct Answer: A,F
Rationale: The nurse is correct to assess the eyelids and lashes and also tears as the protective structures. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye. The eyelashes trap foreign debris. Periodic blinking clears dust and particles from the surface of the eyes. The aqueous humor and sclera are intraocular structures. Oblique muscles move the eye left and right. The conjunctiva is a sensitive transparent mucous membrane that alerts the individual to a foreign object in the eye.