Nokea
The nurse is obtaining a visual history from a client who has noted an increase in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis?
- A. Identification of opacities on the lens
- B. Identification of white circle around the cornea
- C. Identification of yellowish aging spot on the retina
- D. Identification of redness of the sclera
Correct Answer: A
Rationale: The client states an increased glare and changes in color perception, which indicates a cataract. Identification of opacities on the lens confirms that diagnosis. A white circle around the cornea and a yellowish aging spot are also symptoms of aging but with different symptoms. Redness of the sclera indicates irritation.
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The nurse is obtaining a history on a client stating the inability to read the newspaper and seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis?
- A. Assess if the pupils are equal and reactive to light.
- B. Assess vision on the Snellen chart.
- C. Assess peripheral vision.
- D. Assess color vision.
Correct Answer: C
Rationale: The client states symptoms of the inability to discriminate letters, words, and details of an image, indicating the degeneration of the macula. If the macula is damaged, the client will only have the ability to see movement and gross objects in the peripheral fields. Assessing the peripheral vision will add essential information. The other visual tests are not as important at this time.
The nurse is assessing a client for objective symptoms of hearing difficulties. Which sign leads the nurse to take alternate measures to ensure client understanding of teaching?
- A. The client interrupts by asking the nurse to repeat instruction.
- B. The client is quiet and responds appropriately.
- C. The client leans forward and turns the head.
- D. The client quietly reads the instructional literature.
Correct Answer: C
Rationale: The nurse assesses objective signs of leaning forward and turning the head as indicative of difficulty hearing. The nurse would use alternate formats of teaching to reinforce key points. Asking to repeat information is a subjective indication of hearing difficulty. Responding appropriately and reading instructional literature does not indicate a hearing difficulty.
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 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 assessing a client's eyes as part of the inspection part of the assessment process. For which reason does the nurse identify a normal variation in the angle of the lateral and medial canthus?
- A. Ethnic differences
- B. Chromosomal differences
- C. Structural changes
- D. Cosmetic alterations
Correct Answer: A
Rationale: The line between the lateral and medial canthus is usually horizontal. Variations are noted abnormally in children with Down syndrome and normally in individuals of Asian descent. Structural changes and cosmetic variations are not considered normal changes noted on assessment.