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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.
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The nurse is completing a corneal light reflex test on a client, using a penlight. Which result would indicate a normal test result?
- A. The pupils have reaction to light.
- B. The eyes follow the light in all four directions.
- C. The client can see the light using peripheral vision.
- D. The light reflection is in the same spot on each eye.
Correct Answer: D
Rationale: A normal corneal light reflex test is when the light reflex is even, reflecting the light at the same spot on both eyes. If the light reflex is uneven, it indicates deviated alignment of the eyes, possibly due to muscle weakness or paralysis.
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 instructing a nursing student when a new client comes to the eye clinic. The client reports suspecting a corneal abrasion. The nurse should explain what to the student nurse?
- A. To detect corneal abrasions, an ophthalmoscope is used.
- B. To detect corneal abrasions, ultrasonography is used.
- C. To detect corneal abrasions, a slit lamp is used.
- D. To detect corneal abrasions, retinal angiography is used.
Correct Answer: C
Rationale: A slit lamp is a binocular microscope that magnifies the surface of the eye. A beam of light, narrowed to a slit, is directed at the cornea, facilitating an examination of structures and fluid in the anterior segment of the eye. This examination is used to identify disorders such as corneal abrasions, iritis, conjunctivitis, and cataracts. The other options are not used to detect corneal abrasions.
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.
A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurses observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting the assessment findings to the health care provider, which description is appropriate?
- A. Signs and symptoms of conjunctivitis
- B. Signs and symptoms of ptosis
- C. Signs and symptoms of nystagmus
- D. Signs and symptoms of proptosis
Correct Answer: A
Rationale: Conjunctivitis often stems from an allergy causing inflammation of the conjunctiva, which is a thin, transparent mucous membrane. Conjunctivitis can cause symptoms of itchiness, redness, and watery eyes. Ptosis is drooping of the upper eyelid. Proptosis is an extended and upper eyelid that delays in closing or remains partially open. Nystagmus is an uncontrolled oscillating movement of the eyeball.