Nokea
The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?
- A. Ultrasonography
- B. Retinal Imaging
- C. Retinal Angiography
- D. Retinoscopy
Correct Answer: C
Rationale: The nurse is correct to instruct the client that skin and urine may turn yellow following a retinal angiography. Sodium fluorescein is a water-soluble dye that is injected into a vein. The dye then travels to the retinal arteries and capillaries, where pictures are obtained of the vascular supply. The other options do not include a dye injection.
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The nurse is caring for a client with increased fluid accumulation in the eye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber?
- A. Fovea centralis
- B. Canthus
- C. Canal of Schlemm
- D. Choroid
Correct Answer: C
Rationale: The canal of Schlemm drains the anterior chamber of the eye. By draining the fluid, it decreases the fluid amount and pressure in the eye. The other options have no draining ability.
The nurse is conducting hearing tests at the local junior high school. Which of the following indicates normal hearing in a child?
- A. A client who first perceives sound at 20 dB
- B. A client who first perceives sound at 40 dB
- C. A client for whom the painful sound occurs at 80 dB
- D. A client for whom the painful sound occurs at 100 dB
Correct Answer: A
Rationale: The lowest level of sound that normal persons may first perceive is 20 dB. The painful sounds occur at 120 dB. The hearing acuity is determined by measuring the intensity at which a person first perceives sound.
The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate?
- A. A burning sensation and the sensation of an object in the eye
- B. Blurred or cloudy vision
- C. Inability to produce sufficient tears
- D. A swollen lacrimal caruncle
Correct Answer: B
Rationale: When a cataract forms, the light is blocked from reaching the macula and the visual image becomes blurred or cloudy. The client does not experience any burning or the sensation of an object in the eye, an inability to produce sufficient tears, or a swollen lacrimal caruncle.
The nurse is evaluating the client taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision?
- A. The nurse would anticipate the client identifying numbers and shapes.
- B. The nurse would anticipate a cross-eyed appearance.
- C. The nurse would anticipate responding to the color names in the pictures.
- D. The nurse would anticipate no differentiation in between colors.
Correct Answer: A
Rationale: The nurse is correct to anticipate the client being able to identify numbers and shapes dictated by different color codes. The other options do not test for color vision or indicate an inability to differentiate colors.
The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand?
- A. A 10-feet distance
- B. A 20-feet distance
- C. A 30-feet distance
- D. A 40-feet distance
Correct Answer: B
Rationale: The nurse is correct in instructing the client to stand at a 20-feet distance from the Snellen chart. Often, the nurse places tape on the floor to denote the correct distance for the client to stand.