Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 14 Eyes

1. A client asks the nurse why it is important to protect their eyes from the sun. Which response should the nurse provide to the client?

1. Excessive sun exposure places you at risk for cataracts.

2. Excessive sun exposure places you at risk for night blindness.

3. Excessive sun exposure places you at risk for increased intraocular pressure.

4. Excessive sun exposure places you at risk for excessive corneal dryness.

Page Ref: 242

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.1: Describe the anatomy and physiology of the eyes.

MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.

1. The nurse notes that a client is unable to control the amount of light that enters the eye. Which structure's dysfunction is the most likely cause of this problem?

1. Cornea.

2. Sclera.

3. Conjunctiva.

4. Iris.

Page Ref: 237

Cognitive Level: Remembering

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.

1. The nurse has elicited a blink reflex in a client. Which structure of the eye is responsible for the reflex?

1. Lens.

2. Macula.

3. Cornea.

4. Iris.

Page Ref: 237

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.1: Describe the anatomy and physiology of the eyes.

MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.

1. The nurse taught the client how to self-administer eye drops. During the return demonstration, the client inadvertently touched the applicator to their cornea, which caused the client to blink and produce tears. Which term should the nurse describe the reflex elicited by the client?

1. Abnormal and should be reported to the healthcare provider.

2. Hyperactive.

3. A medication side effect.

4. A normal response.

Page Ref: 237

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.5: Generate the appropriate documentation to describe the assessment of the eyes.

MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.

1. A client asks the nurse what is the name of the structure of the eye that is colored.

1. Optic disc.

2. Iris.

3. Cornea.

4. Sclera.

Page Ref: 237

Cognitive Level: Remembering

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14.1: Describe the anatomy and physiology of the eyes.

MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.

1. The nurse is preparing to review the secondary sources of data for a patient with glaucoma. Which diagnostic testing should the nurse anticipate to be included?

1. Tonometry.

2. Ultrasonography.

3. Fluorescein angiography.

4. Refraction test.

Page Ref: 242

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Assess adaptation of a client to health alteration, illness, and/or disease.

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.3: Determine which questions about the eyes to use for the focused interview.

MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.

1. The nurse is preparing to perform the cover and uncover test on a client. Which explanation will the nurse provide the client prior to performing the exam?

1. This will test the muscles that control your eye movement.

2. This will test the ability of your pupil size to change.

3. This will test the balance mechanism that keeps your eyes parallel.

4. This will test the ability of your eyes to focus on distant objects.

Page Ref: 252

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.4: Outline the techniques for assessment of the eyes.

MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.

1. The nurse is assessing the eyes of an older adult client. Which finding is expected by the nurse based on the client's age?

1. The client has difficulty reading from a paper held at far range without corrective glasses.

2. There is a noticeable increase in fat within the orbit of the eye.

3. The client states that they feel that their tear production has increased over the years.

4. The client is unable to clearly read from a paper held at close range.

Page Ref: 249

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse is performing a visual examination on a client with complaints of black dots appearing in the visual field. Which statement by the nurse is most appropriate in this situation?

1. "The black dots are known as floaters and are usually normal."

2. "We need to refer you to an eye surgeon immediately."

3. "You may have glaucoma."

4. "You may have a cataract."

Page Ref: 244

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. A client tells the nurse they see halos around light. Which question should the nurse ask the client?

1. "Do you take any routine medications?"

2. "Do you wear corrective lenses?"

3. "Have you experienced any eye trauma?"

4. "When was your last eye examination?"

Page Ref: 244

Cognitive Level: Applying

Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.3: Determine which questions about the eyes to use for the focused interview.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. A client tells the nurse they are experiencing blurred vision. Which initial question should the nurse ask the client?

1. "Can you describe your vision?"

2. "Are you experiencing double vision?"

3. "Have you recently had any eye pain?"

4. "What kinds of activities do you perform at work?"

Page Ref: 242

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.3: Determine which questions about the eyes to use for the focused interview.

MNL Learning Outcome: 14.2: Plan questions about the eyes to use for the focused interview.

1. During an eye assessment, a young adult client reports difficulty seeing items within close range. This assessment data is consistent with which factor?

1. Aging.

2. Presbyopia.

3. Hyperopia.

4. Astigmatism.

Page Ref: 262

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse is reviewing the records of a client with astigmatism. Which visual changes should the nurse anticipate?

1. Double vision.

2. Presence of floaters.

3. Decreased field of vision.

4. Inability to see things at a close range.

Page Ref: 262

Cognitive Level: Understanding

Client Need & Sub: Physiological Integrity; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. During an eye examination, the nurse requests that the client read letters located on the Snellen E chart. The client's vision is determined to be 20/200. Which statements regarding this client's vision are accurate? Select all that apply.

1. The client is legally blind.

2. The client is unable to read from a paper at close range.

3. The client is found to be farsighted.

4. The client is myopic.

5. This is common in clients who are over 45 years old.

Page Ref: 248

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse is assessing a client's visual fields by confrontation. Which actions by the nurse indicate appropriate practice? Select all that apply.

1. The nurse asks the client to cover one of her eyes with a card.

2. The nurse uses a penlight to assist with performing the test.

3. The nurse asks the client to sit 20 feet away.

4. The client tells the nurse when she first sees the object.

5. The nurse asks the client to stand 4 feet away.

Page Ref: 249, 250

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.4: Outline the techniques for assessment of the eyes.

MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.

1. A client tells the nurse they experience double vision. Which question should the nurse ask the client?

1. "Do you take any medications?"

2. "Do you have a history of hyperthyroidism?"

3. "Do you have a history of diabetes?"

4. "Do you have a history of renal disease?"

Page Ref: 244

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.3: Determine which questions about the eyes to use for the focused interview.

MNL Learning Outcome: 14.2: Plan questions about the eyes to use for the focused interview.

1. The nurse reviewing the records of a client notes there is a diagnosis of nystagmus. Which should the nurse recognize is a causative factor of the condition?

1. Eye infection.

2. The development of cataracts.

3. Weakness in the extraocular muscles.

4. Inability of the lens of the eye to accommodate.

Page Ref: 251

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse is assessing the client's vision. Which information should the nurse provide the client?

1. "I am going to perform this test with you standing."

2. "You may leave your glasses on during the exam."

3. "I am going to have you close your covered eye."

4. "I will have you stand 20 feet from the chart."

Page Ref: 247

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.4: Outline the techniques for assessment of the eyes.

MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.

1. The nurse is assessing the fundus of the older adult client's eye with an ophthalmoscope. The nurse determines that there is a cyst within the macula. Which client symptom does the nurse anticipate?

1. Impaired central vision.

2. Impaired peripheral vision.

3. Consistently elevated serum glucose levels.

4. Uncontrolled hypertension.

Page Ref: 259

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse is preparing to visually inspect a client's eye. Which should the nurse anticipate to note? Select all that apply.

1. Clear lens.

2. Moist conjunctiva.

3. White Sclera.

4. Round irises.

5. Clear cornea.

Page Ref: 253

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.1: Describe the anatomy and physiology of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse is assessing a client's eyes during a comprehensive health assessment. Which assessment finding would require immediate intervention?

1. Acute glaucoma.

2. Blepharitis.

3. Periorbital edema.

4. Anisocoria.

Page Ref: 258

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse is performing the cover test and notes inward turning of the client's eye. Which term will the nurse use to document this finding?

1. Exophoria.

2. Strabismus.

3. Esophoria.

4. Mydriasis.

Page Ref: 264

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Generate the appropriate documentation to describe the assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. After a comprehensive eye examination, it is determined that the client requires corrective lenses for myopia. Which explanation by the nurse to the client is the most appropriate?

1. "Your glasses will help you to see objects in the distance."

2. "Your glasses will help you to see objects that are very close to you."

3. "Your glasses will help you to improve your eyes' ability to focus and reduce your blurred vision."

4. "Your age has made it more difficult to read items that are at close range. Your new glasses will help."

Page Ref: 262

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse is assessing the client's pupillary responses. The client is found to have no consensual response. Which conclusion by the nurse is the most appropriate?

1. Cranial nerve III may not be functioning appropriately.

2. This is a normal finding.

3. This is evidence of increased intracranial pressure.

4. This is evidence of optic nerve damage.

Page Ref: 260

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. During the assessment of a client's eyes, the nurse suspects the client has entropion. Which assessment data caused the nurse to come to this conclusion?

1. Eversion of the lower eyelid.

2. Inversion of the lid and eyelashes.

3. Swollen, red hair follicles.

4. Firm, non-tender nodule on the eyelid.

Page Ref: 256

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. During the assessment of a client's eyes, the nurse suspects that the client has ptosis. Which assessment data caused the nurse to come to this conclusion?

1. The palpebral conjunctiva is exposed.

2. The iris and cornea are reddened.

3. The eyelid is drooping.

4. The eyelids are swollen and puffy.

Page Ref: 256

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse notes a client has an absence of the lateral third of the eyebrow. Which question should the nurse ask the client?

1. "Do you have a history of cardiovascular disease?"

2. "Do you have a history of obsessive-compulsive disorder?"

3. "Do you have a history of thyroid disease?"

4. "Do you have a history of diabetes?"

Page Ref: 253

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.3: Determine which questions about the eyes to use for the focused interview.

MNL Learning Outcome: 14.2: Plan questions about the eyes to use for the focused interview.

1. The nurse notes there is a lack of convergence when testing a client's accommodation. Which cranial nerves should the nurse recognize are potentially dysfunctional? Select all that apply.

1. II.

2. III.

3. VII.

4. IV.

5. VI.

Page Ref: 254

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse examining the eyes of a client notes bilateral subconjunctival hemorrhage. Which next action should the nurse take?

1. Obtain a culture.

2. Assess the client's blood pressure.

3. Inquire about allergies.

4. Assess the client's blood glucose.

Page Ref: 257

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.2: Plan questions about the eyes to use for the focused interview.

1. The nurse is preparing to assess the vision of a 5-year-old child. Which Snellen chart is most appropriate for the nurse to use?

1. Chart with letters.

2. Chart with symbols.

3. Chart with numbers.

4. Chart with pictures.

Page Ref: 248

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14.4: Outline the techniques for assessment of the eyes.

MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.

1. The nurse is performing a focused interview and eye assessment on a client. Which assessment findings indicate the client's is experiencing a vision problem? Select all that apply.

1. The client is frowning and squinting while she is reading the Snellen chart.

2. The client exhibits a symmetrical pupillary light reflex response.

3. As the nurse checks for accommodation, the pupils remain dilated.

4. The client's near vision acuity is 14/14 bilaterally.

5. When the cornea is lightly touched in the right eye, both eyelids close.

Page Ref: 242, 253

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. The nurse is preparing to test the near vision of a client. Which instructions should the nurse include?

1. Hold the chart 12 to 14 inches from the eyes.

2. Instruct the client to initially read the smallest line they can see.

3. Request the client to remove corrective lenses for reading prior to the exam.

4. Initially, have the client read the lines prior to covering a single eye at a time.

Page Ref: 248

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.4: Outline the techniques for assessment of the eyes.

MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.

1. The nurse notes that a client's pupils are fixed and dilated. Which should the nurse suspect has occurred?

1. Damage to the pons.

2. Syphilis.

3. Glaucoma.

4. Monocular blindness.

Page Ref: 260

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes.

MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.

1. Prior to conducting an eye assessment, which statement by the nurse is appropriate to prepare the client for the examination process?

1. "You can choose which eye to cover during your assessment."

2. "Are you able to read English words?"

3. "Apply pressure to the eye while it is covered during the examination."

4. "You will need to stand 10 feet from the chart for an accurate assessment."

Page Ref: 242

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.

MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.