ch71.doc

[Osborn] chapter 71

Learning Outcomes [Number and Title] Learning Outcome 1 Identify the normal basic anatomy and physiology of the eye.Learning Outcome 2 Perform basic assessment, tests, and examination of the eye to

obtain meaningful data for management and treatment.Learning Outcome 3 Describe different types of visual and ocular conditions and

problems.Learning Outcome 4 Apply nursing diagnosis, nursing process, and patient teaching

associated with visual and ocular problems of the adult.Learning Outcome 5 Discuss and provide meaningful resources for patients with

visual and ocular problems.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.

1. The function of the lens of the eye is accommodation. This allows the individual to:1. See objects at close and at far range.2. See at night.3. Prevent too much light from entering the eye.4. Distinguish color.

Correct Answer: See objects at close and at far range.

Rationale: The lens is the focusing structure of accommodation that allows seeing objects at close and at far range. Night vision and color vision are a function of rods and cone receptors in the retina. The pupil controls the amount of light entering the eye. Cognitive Level: ComprehensionNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


2. An examination of a client indicates there is limited central vision. This would indicate a problem with the:

1. Macula.2. Lens.3. Sclera.4. Extraocular muscles.

Correct Answer: Macula.

Rationale: The center of the retina, called the macula, is where the greatest numbers of cone receptors are located for central and color vision. The sclera is the outer protective layer of the eyeball that helps maintain its shape. The lens is the focusing structure of accommodation. The extraocular muscles move the eyeball.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


3. A client complains that sometimes there appears to be gnats in his field of vision. The nurse realizes the client is talking about:

1. Floaters.2. Conjunctivitis.3. Nystagmus.4. Strabismus.

Correct Answer: Floaters.

Rationale: The vitreous gel is made up mainly of water with a collagen framework. The collagen network can be aggregated by vitreous collapse due to aging and form opacities, which cast shadows on the retina. These shadows are referred to as floaters. The client often describes this as seeing gnats or a fine filament floating in the line of sight. Conjunctivitis is an inflammation of the conjunctiva. The main symptom is a discharge from the eyes. Nystagmus is an involuntary tremor or jerky movement of the eyeball. Strabismus is a functional misalignment of the extraocular muscles that causes the eyes not to focus together.



4. During an initial examination of the eye, the intraocular pressure should be measured. The nurse would use a _______________ to determine to pressure.

1. Tonometer2. Ophthalmoscope3. Pen light4. Snellen acuity chart

Correct Answer: Tonometer

Rationale: A tonometer is used to measure the intraocular pressure. An ophthalmoscope is used to view the fundus of the eye by viewing through the pupil. A pen light is used for external examination of the eye. The Snellen acuity chart is used to measure visual acuity.



5. During an assessment of the eye, the optic nerve can be evaluated by:1. Direct ophthalmoscope examination.2. Using dilation eyedrops.3. Shining a pen light into the eye.4. A tonometer.

Correct Answer: Direct ophthalmoscope examination.

Rationale: Direct ophthalmoscope examination is used to check the fundus of the eye, viewing through the pupil. The optic nerve can be visualized and should be checked for color, shape, and vessels. Dilation eyedrops are used for many diagnostic tests, but are not required to see the optic nerve with an ophthalmoscope. The optic nerve cannot be seen by shining a pen light into the eye. A tonometer is used to measure intraocular pressure.



6. A visual field test is performed on a client to test peripheral visual acuity. The nurse finds that the client’s angle of recognition of the test object is decreased in two of the four quadrants. The appropriate response of the nurse should be to:

1. Refer for further testing.2. Document it is a normal test result.3. Repeat the test.4. Repeat the test with the client’s glasses on.

Correct Answer: Refer for further testing.

Rationale: If any visual field defects are noted, the client should be sent for sophisticated visual field testing. The degree of angle recognition must approximate normal degrees for all four quadrants to be documented as normal results. The test does not need to be repeated if administered correctly. The client’s glasses should be off because the glasses frame may interfere with the field of vision.



7. A client has been diagnosed with primary glaucoma. Primary glaucoma refers to form of glaucoma that:

1. Has no relation to other ocular conditions.2. Is the result of another preexisting ocular condition.3. Is caused by a congenital anomaly.4. Is not as serious as other forms of glaucoma.

Correct Answer: Has no relation to other ocular conditions.

Rationale: Primary glaucoma infers that it has no relation to other ocular conditions, and secondary glaucoma is the result of another preexisting ocular condition. A congenital anomaly is a cause of secondary glaucoma. Glaucoma is always serious and can cause blindness because the increased intraocular pressure can cause optic nerve changes.



8. The nurse performed a cover-uncover test on a client to test for atropia. When the left eye was covered, the right eye moved inward. The finding indicated that the client had:

1. Exotropia.2. Esotropia.3. No strabismus.4. Vertical phoria.

Correct Answer: Exotropia.

Rationale: Tropia is a functional defect that results from a break in visual fusion due to an imbalance or misalignment of the extraocular muscles when both eyes are not covered. If the uncovered eye moves inward, then it was fixed outward. This is exotropia. If the uncovered eye moves outward, then it was fixed inward. This is esotropia. If the uncovered eye does not move, it indicates the client does not have strabismus, which is a functional misalignment of the extraocular muscles that causes the eyes not to focus together. If the uncovered eye moved up or down, it would indicate vertical phoria.



9. A client is admitted with orbital cellulitis of the right eye. The most common cause of orbital cellulitis in adults is an infection caused by staphylococci and streptococci as a result of:

Bacterial sinusitis. Traumatic induction of bacteria. Intraocular surgery. Conjunctivitis.

Correct Answer: Bacterial sinusitis.

Rationale: Orbital cellulitis is inflammation of the postseptal orbital tissue from the spread of bacteria from elsewhere, usually from the nasal and sinus system. The most common causative organisms in adults are staphylococci and streptococci from bacterial sinusitis. It can be caused by traumatic induction of bacteria, but it is not the most common cause. Infection is a risk of any surgery, but an infection from intraocular surgery generally does not cause orbital cellulitis. Conjunctivitis is an inflammation of the conjunctiva caused by a bacteria, virus, or allergen.



10. The nurse is caring for a client newly diagnosed with glaucoma. The client is asymptomatic except for the increased intraocular pressure detected during a routine eye examination. When developing a plan of care for this client, which of the following goals should have the highest priority?

1. Stress importance of compliance with glaucoma eyedrops.2. Assess for fall injuries.3. Consider home maintenance issues.4. Discuss risk factors.

Correct Answer: Stress importance of compliance with glaucoma eyedrops.

Rationale: All of the goals should be part of a nursing care plan for a client with glaucoma. However, this client is asymptomatic and has not suffered any vision loss. To prevent vision loss, the importance of client compliance with glaucoma eyedrops to decrease the intraocular pressure should be given the highest priority. Discussion of risk factors is important, but the eyedrops are the most effective method of decreasing the chance of vision loss. Assessing for fall injuries and home maintenance issues are more relevant to clients who already have vision loss.

Cognitive Level: AnalysisNursing Process: PlanningClient Need: Physiological IntegrityLO: 4


11. Following a severe eyelid laceration, the most important aspect of client education is:1. Prescribed medication regimen.2. Care of the eye patch.3. Surgical reconstruction.4. Use of ice packs.

Correct Answer: Prescribed medication regimen.

Rationale: Client education about the prescribed medication regimen is a must to prevent the risk of noncompliance. When discussing the medications, it is important to stress good hand hygiene before applying eyedrops or ointments to prevent the risk of infection. A patch is contraindicated if an intraocular foreign body is present. Surgical reconstruction may not be necessary depending on the severity of the injury. Ice packs may be used to control bleeding, reduce swelling, and may provide some comfort. Ice packs must be used correctly, but client education in this area is a lower priority.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological IntegrityLO: 4


12. Phenylephrine (Neo-Synephrine) is administered to a client before a diagnostic procedure. The client education about this medication should include:

1. Driving may be difficult.2. Tears will be yellow.3. May cause burning.4. Sunlight will improve vision.

Correct Answer: Driving may be difficult.

Rationale: Phenylephrine causes pupillary dilation. The nurse should inform the client that driving with eyes dilated may cause difficulty, especially on a sunny day. Patients should be instructed to wear sunglasses to block ultraviolet (UV) exposure. The pupils are unable to react to or decrease the amount of light entering the eye. Burning is an adverse reaction to phenylephrine. Medications that numb the eye, such as Proparacaine, will cause the tears to be yellow.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological IntegrityLO: 4


13. A client recovering from a head injury has adult strabismus. This client would probably be referred for the most common treatment of adult strabismus, which is/are:

1. Eye muscle surgery.2. Eye muscle exercises.3. Botox injections.4. Glasses.

Correct Answer: Eye muscle surgery.

Rationale: Eye muscle surgery is the most common treatment. It is used to loosen or tighten the muscles around the eye in order to correct the misalignment. Eye muscle exercise is used when treating a form of adult strabismus called convergence insufficiency. Botox injections are an effective treatment when overactive eye muscles are causing strabismus. Prism eyeglasses can be used to correct mild double vision associated with adult strabismus.

Cognitive Level: ApplicationNursing Process: PlanningClient Need: Physiological IntegrityLO: 5


14. A pregnant woman with retinitis pigmentosa is concerned about the possibility that the baby will also develop the disorder. An appropriate referral source would be:

1. Genetic counseling.2. An ophthalmologist.3. A gynecologist.4. A nutritionist.

Correct Answer: Genetic counseling.

Rationale: Retinitis pigmentosa is a hereditary disorder. Genetic counseling would give the client information regarding hereditary traits. An ophthalmologist, gynecologist, and nutritionist are all important resources for this patient, but are not the best resource for discussing hereditary traits.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Physiological IntegrityLO: 5


15. A client with blindness resulting from diabetic retinopathy is being cared by a family member. When developing a plan of care for this client, the highest priority in this situation would be an assessment to determine if a referral is needed for:

1. Respite services.2. A low-vision rehabilitation specialist.3. Assistive devices.4. Housekeeping assistance.

Correct Answer: Respite services.

Rationale: An individual who is the sole caregiver may need respite services if he or she is the only support system for the family. It is difficult for a single individual to be a sole caregiver, and the individual would likely need some type of respite service. A client who is blind would probably not benefit from a referral to a low-vision specialist. Assistive devices and housekeeping assistance may be necessary, but assessment for the need for respite services would be a higher priority.



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