Eyes & Ears

When the nurse performs the confrontation test, the nurse has assessed:

A) extraocular eye muscles (EOMs).

B) pupils (PERRLA).

C) near vision.

D) visual fields.

ANS: D) visual fields

The confrontation test assesses visual fields. The other options are not tested with the confrontation test.

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During a complete health assessment, how would the nurse test the patient's hearing?

A) By observing how the patient participates in normal conversation

B) Using the whispered voice test

C) Using the Weber and Rinne tests

D) Testing with an audiometer

ANS: B) Using the whispered voice test

During the complete health assessment, the nurse should test hearing with the whispered voice test. The other options are not correct.

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The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations?

a. Snellen

b. Shetllen

c. Smoollen

d. Snell

A

The nurse will measure a patient’s near vision with which tool?

a. Snellen eye chart with letters

b. Snellen “E” chart

c. Jaeger card

d. Ophthalmoscope

C

When the nurse records the results to the Hirschberg test, the nurse has:

a. Tested the patellar reflex

b. Assessed for appendicitis

c. Tested the corneal light reflex

d. Assessed for thrombophlebitis

C

The Hirschberg test assesses the corneal light reflex (see Chapter 15)

While examining a 48-year-old patient’s eyes, the nurse notices that he had to move the

handheld vision screener farther away from his face. The nurse would suspect:

a. Myopia

b. Omniopia

c. Hyperopia

d. Presbyopia

D

Presbyopia, the decrease in power of accommodation with aging, is suggested when the handheld vision screener card is moved farther away (see Chapter 15).

The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope:

a. Is often used to direct light onto the sinuses.

b. Uses a short, broad speculum to help visualize the ear.

c. Is used to examine the structures of the internal ear.

d. Directs light into the ear canal and onto the tympanic membrane.

ANS: D

The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. A short, broad speculum is used to visualize the nares.

An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed?

a. Using the large full circle of light when assessing pupils that are not dilated

b. Rotating the lens selector dial to the black numbers to compensate for astigmatism

c. Using the grid on the lens aperture dial to visualize the external structures of the eye

d. Rotating the lens selector dial to bring the object into focus

ANS: D

The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus

The nurse is administering ear drops to a 68-year-old patient. The nurse will pull the area of the ear consisting of movable cartilage and skin, known as the ___________, upward and backward to open the ear canal.

a. Auricle

b. Concha

c. Outer meatus

d. Mastoid process

ANS: A

The external ear is called the auricle or pinna and consists of movable cartilage and skin.

The nurse is examining a patient’s ears and notices a yellow waxy substance in the external canal. The nurse recognizes this:

a. As a sign of an ear infection.

b. As indicative of poor ear hygiene.

c. As protection and lubrication of the ear.

d. As necessary for transmitting sound through the auditory canal.

ANS: C

The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear

When examining the ear with an otoscope, the nurse notes that the tympanic membrane is translucent and pearly. The nurse will:

a. Seek assistance from a colleague.

b. Document the finding as normal.

c. Refer the patient to a specialist.

d. Recommend irrigating the ear.

ANS: B

The tympanic membrane is a translucent membrane with a pearly grey colour and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its centre by the malleus, which is one of the middle ear ossicles.

When reviewing the structures of the ear with a class of nursing students, the nurse discusses the importance of the function of the eustachian tube in:

a. The production of cerumen.

b. Remaining open except when swallowing or yawning.

c. Allowing the passage of air between the middle and outer ear.

d. Helping equalize air pressure on both sides of the tympanic membrane.

ANS: D

The eustachian tube allows an equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture during, for example, altitude changes in an airplane. The tube is normally closed, but it opens with swallowing or yawning

A patient with a middle ear infection asks the nurse, “What does the middle ear do?” The nurse responds by telling the patient that the middle ear functions to:

a. Maintain balance.

b. Interpret sounds as they enter the ear.

c. Conduct vibrations of sounds to the inner ear.

d. Increase amplitude of sound for the inner ear to function.

ANS: C

Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear.

The nurse is assessing a patient who may have hearing loss. Which of these statements concerning air conduction is true?

a. Air conduction is the normal pathway for hearing.

b. Vibrations of the bones in the skull cause air conduction.

c. Amplitude of sound determines the pitch that is heard.

d. Loss of air conduction is called a conductive hearing loss.

ANS: A

The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear. The other statements are not true concerning air conduction.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:

a. Speak loudly so the patient can hear the questions.

b. Assess for middle ear infection as a possible cause.

c. Ask the patient about current medications.

d. Look for the source of the obstruction in the external ear.

ANS: C

A simple increase in amplitude may not enable the person to understand spoken words.

Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.

During an interview, the patient states he has the sensation that “everything around him is spinning.” The nurse recognizes that the portion of the ear responsible for this sensation is the:

a. Cochlea

b. CN VIII

c. Organ of Corti

d. Labyrinth

ANS: D

If the labyrinth ever becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong spinning and whirling sensation called vertigo

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant’s hearing?

a. Rubella may affect the mother’s hearing, but not the infant’s.

b. Rubella can damage the infant’s organ of Corti, which will impair hearing.

c. Rubella is only dangerous to the infant in the second trimester of pregnancy.

d. Rubella can impair the development of CN VIII and thus affect hearing.

ANS: B

If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing in the child

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?

a. “It is unusual for a small child to have frequent ear infections unless something else is wrong.”

b. “We need to check the immune system of your son to determine why he is having so many ear infections.”

c. “Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear.”

d. “Your son’s eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily.”

ANS: D

The infant’s eustachian tube is relatively shorter and wider than the adult’s eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear. The other responses are not appropriate

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of the television or radio. The most likely cause of his hearing loss is:

a. Otosclerosis.

b. Presbycusis.

c. Trauma to the bones.

d. Frequent ear infections.

ANS: A

Otosclerosis is a common cause of conductive hearing loss in young adults between ages 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he “can’t always tell where the sound is coming from” and the words often sound “mixed up.” What might the nurse suspect as the cause for this change?

a. Atrophy of the apocrine glands

b. Cilia becoming coarse and stiff

c. Nerve degeneration in the inner ear

d. Scarring of the tympanic membrane

ANS: C

Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in those living in a quiet environment. This sensorineural loss is gradual and caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is also impaired. This communication dysfunction is accentuated when background noise is present

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. The nurse recognizes this as:

a. The result of lesions from eczema in his ear.

b. Poor hygiene practices.

c. A normal finding and that no further follow-up is necessary.

d. Indicative of change in cilia and requires further assessment.

ANS: C

Individuals of Asian or Indigenous descent are more likely to have dry cerumen, whereas those of African or European descent usually have wet cerumen.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

a. “Do you ever notice ringing or crackling in your ears?”

b. “When was the last time you had your hearing checked?”

c. “Have you ever been told that you have any type of hearing loss?”

d. “Do you have any ear pain or discharge, and if so, when did they occur?”

ANS: D

Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include during history taking?

a. “Does your baby seem to startle with loud noises?”

b. “Has your baby had any surgeries on her ears?”

c. “Have you noticed any drainage from her ears?”

d. “How many ear infections has your baby had since birth?”

ANS: A

Children at risk for a hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella or to maternal ototoxic drugs

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

a. Tilting the person’s head forward during the examination

b. Once the speculum is in the ear, releasing the traction

c. Pulling the pinna up and back before inserting the speculum

d. Using the smallest speculum to decrease the amount of discomfort

ANS: C

The pinna is pulled up and back on an adult or older child, which helps straighten the “S” shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed

In performing a voice test to assess hearing, which of these actions would the nurse perform?

a. Shield the lips so that the sound is muffled.

b. Whisper a set of random numbers and letters and then ask the patient to repeat them.

c. Ask the patient to place his finger in his ear to occlude outside noise.

d. Stand approximately 4 feet away to ensure that the patient can really hear at this distance.

ANS: B

With the head half a metre (2 feet) from the patient’s ear, the examiner exhales and slowly whispers a set of random numbers and letters, such as “5, B, 6.” Normally, the patient is asked to repeat each number and letter correctly after hearing the examiner say them.

In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:

a. Omit the otoscopic examination if the child has a fever.

b. Pull the ear up and back before inserting the speculum.

c. Ask the mother to leave the room while examining the child.

d. Perform the otoscopic examination at the end of the assessment.

ANS: D

In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement regarding this examination is true?

a. Immobility of the drum is a normal finding.

b. An injected membrane would indicate an infection.

c. The normal membrane may appear thick and opaque.

d. The appearance of the membrane is identical to that of an adult.

ANS: C

During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look infected and have a mild redness from increased vascularity. The other statements are not correct

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:

a. Turns his or her head to localize the sound.

b. Shows no obvious response to the noise.

c. Shows a startle and acoustic blink reflex.

d. Stops any movement, and appears to listen for the sound.

ANS: A

With a loud sudden noise, the nurse should notice the infant turning the head to localize the sound and to respond to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops any movement and appears to listen

The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?

a. High-tone frequency loss

b. Increased elasticity of the pinna

c. Thin, translucent membrane

d. Shiny, pink tympanic membrane

ANS: A

A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in colour and more opaque and duller in the older person than in the younger adult

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

a. Red and bulging

b. Lack of mobility

c. Retraction with landmarks clearly visible

d. Flat, slightly pulled in at the centre, and moving with insufflation

ANS: B

An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases, the tympanic membrane begins to bulge

The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at the 5 o’clock position and visible landmarks. The nurse should:

a. Refer the patient for the possibility of a fungal infection.

b. Know that these are scars caused from frequent ear infections.

c. Consider that these findings may represent the presence of blood in the middle ear.

d. Be concerned about the ability to hear because of this abnormality on the tympanic membrane.

ANS: B

Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing

The nurse is preparing to perform an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure?

a. Pulling the pinna down

b. Pulling the pinna up and back

c. Slightly tilting the child’s head toward the examiner

d. Instructing the child to touch his chin to his chest

ANS: A

For an otoscopic examination on an infant or on a child younger than 3 years of age, the pinna is pulled down. The other responses are not part of the correct procedure.

The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections?

a. Family history

b. Air conditioning

c. Excessive cerumen

d. Passive cigarette smoke

ANS: D

Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest?

a. Malignancy

b. Viral infection

c. Blood in the middle ear

d. Yeast or fungal infection

ANS: D

A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis)

During an examination, the patient states he is hearing a buzzing sound and says, “It is driving me crazy!” The nurse recognizes that this symptom indicates:

a. Vertigo.

b. Pruritus

c. Tinnitus.

d. Cholesteatoma.

ANS: C

Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders

During an examination, the nurse notices that the patient stumbles a little while walking and that when she sits down, she holds on to the sides of the chair. The patient states, “It feels like the room is spinning!” The nurse documents that the patient is experiencing:

a. Objective vertigo.

b. Subjective vertigo.

c. Tinnitus.

d. Dizziness.

ANS: A

With objective vertigo, the patient feels like the room is spinning; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and lightheaded.

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, “I don’t know what the matter is. All of a sudden, I can’t hear you out of my left ear!” What should the nurse do next?

a. Make note of this finding for the report to the next shift

b. Prepare to remove cerumen from the patient’s ear

c. Notify the patient’s health care provider

d. Irrigate the ear with rubbing alcohol

ANS: C

Any sudden loss of hearing in one or both ears that is not associated with an upper respiratory infection needs to be reported at once to the patient’s health care provider. Hearing loss associated with trauma is often sudden. Irrigating the ear or removing cerumen is not appropriate at this time.

The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? **(Select all that apply.)**

a. Hearing loss related to aging begins in the mid-40s.

b. Progression of hearing loss is slow.

c. The aging person has low-frequency tone loss.

d. The aging person may find it harder to hear consonants than vowels.

e. Sounds may be garbled and difficult to localize.

f. Hearing loss reflects nerve degeneration of the middle ear.

ANS: B, D, E

Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years of age. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after age 50 years. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels, which makes words sound garbled. The ability to localize sound is also impaired.

The nurse is working with new parents to help decrease the incidence of childhood acute otitis media. The nurse provides recommendations which include: **(Select all that apply.)**

a. Propping the bottle for the baby in bed

b. Having a smoke-free home

c. Avoid letting the baby have a bottle lying flat in bed

d. Smoking in vehicle with the child, not in the home

e. Encouragement of breastfeeding from birth

ANS: B, C, E

The following risk factors predispose children to acute otitis media: absence of breastfeeding in the first 3 months of age, exposure to second-hand tobacco smoke, day care attendance, male sex, pacifier use, low birth weight, low socioeconomic status, and formula feeding in the supine position. Instruct parents to not prop the bottle or have the baby feed from the bottle in bed. Encouraging breastfeeding helps prevent this problem.

When examining the patient’s eyes, the nurse notices that his eyelid margins approximate completely when closed. The nurse will:

a. Document this as a normal finding.

b. Evaluate the extraocular muscles.

c. Refer the patient for problems with tearing.

d. Assess for increased intraocular pressure.

ANS: A

The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?

a. The outer layer of the eye is very sensitive to touch.

b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally.

c. The trigeminal nerve (cranial nerve V) and the trochlear nerve (cranial nerve IV) are stimulated when the outer surface of the eye is stimulated.

d. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

ANS: A

The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (cranial nerve V) and the facial nerve (cranial nerve VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.

When examining a patient’s eyes, the nurse uses eye drops to stimulate the sympathetic branch of the autonomic nervous system to:

a. Cause pupillary constriction.

b. Adjust the eye for near vision.

c. Elevate the eyelid and dilate the pupil.

d. Cause contraction of the ciliary body.

ANS: C

Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibres of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

a. The right side of the brain interprets the vision for the right eye.

b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

c. Light rays are refracted through the transparent media of the eye before striking the pupil.

d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.

ANS: B

The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.

When testing a patient’s visual accommodation the nurse notes a normal finding when the patient demonstrates:

a. Pupillary constriction when looking at a near object.

b. Pupillary dilation when looking at a far object.

c. Changes in peripheral vision in response to light.

d. Involuntary blinking in the presence of bright light.

ANS: A

The muscle fibres of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

The nurse recognizes that a patient has a normal pupillary light reflex when:

a. The eyes converge to focus on the light.

b. Light is reflected at the same spot in both eyes.

c. The eye focuses the image in the centre of the pupil.

d. Constriction of both pupils occurs in response to bright light.

ANS: D

The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

A mother asks when her newborn infant’s eyesight will be fully developed. The nurse should reply:

a. “Vision is not fully developed until 2 years of age.”

b. “Infants develop the ability to focus on an object at approximately 8 months of

age.”

c. “By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object.”

d. “Most infants have uncoordinated eye movements for the first year of life.”

ANS: C

Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate simultaneously on a single image with both eyes.

The nurse is reviewing age-related changes of the eye for a class. Which of these physiological changes is responsible for presbyopia?

a. Degeneration of the cornea

b. Loss of lens elasticity

c. Decreased adaptation to darkness

d. Decreased distance vision abilities

ANS: B

The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

During the health history interview with a 65-year-old male patient of African descent with hypertension, the nurse encourages the patient to have regular eye examinations because of his risk for:

a. Cataract.

b. Glaucoma.

c. Strabismus.

d. Proptosis.

ANS: B

Health care providers should encourage regular eye examinations, especially for patients with known risk factors. Risk factors for glaucoma include African descent, age greater than 60 years, and hypertension. (See Promoting Health: Screening for Glaucoma)

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should:

a. Examine the retina to determine the number of floaters.

b. Presume the patient has glaucoma and refer patient for further testing.

c. Consider these to be abnormal findings and refer patient to an ophthalmologist.

d. Document the findings as common with patient age.

ANS: D

Floaters are a common sensation with myopia or after middle age and are attributable to condensed vitreous fibres. Floaters or spots are not usually significant, but the acute onset of floaters may occur with retinal detachment

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

a. Perform the confrontation test.

b. Ask the patient to read the print on a handheld Jaeger card.

c. Use the Snellen chart positioned 20 feet away from the patient.

d. Determine the patient’s ability to read newsprint at 14 inches (35 cm) from eye.

ANS: C

The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision

A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

a. At 30 feet the patient can read the entire chart.

b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.

c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.

d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.

ANS: B

The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see an object

A patient is unable to read even the largest letters on the Snellen chart. What should the nurse do next?

a. Refer the patient to an ophthalmologist or optometrist for further evaluation

b. Assess whether the patient can count the nurse’s fingers when they are placed in front of his or her eyes

c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again

d. Shorten the distance between the patient and the chart until the letters are seen and record that distance

ANS: D

If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., “10/200”). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity

A patient’s vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient has:

a. Impaired vision.

b. Exophthalmos.

c. Normal vision.

d. Presbyopia.

ANS: A

Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer is the vision.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at the 2 o’clock position in each eye. The nurse should:

a. Consider this a normal finding.

b. Refer the individual for further evaluation.

c. Document this finding as an asymmetrical light reflex.

d. Perform the confrontation test to validate the findings.

ANS: A

Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetrical. If asymmetry is noted, then the nurse should administer the cover test.

The nurse is performing the diagnostic positions test and notes normal findings with:

a. Convergence of the eyes.

b. Parallel movement of both eyes.

c. Nystagmus in extreme superior gaze.

d. Lid lag when moving the eyes from a superior to an inferior position.

ANS: B

A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of the cranial nerve that innervates it.

During eye assessment of a dark-skinned patient, what normal finding does the nurse observe?

a. Yellow fatty deposits over the cornea

b. Pallor near the outer canthus of the lower lid

c. Yellow coloration of the sclera that extends up to the iris

d. Presence of small brown macules on the sclera

ANS: D

Normally in dark-skinned people, small brown macules may be observed in the sclera.

A 60-year-old man with suspected ptosis of one eye is at the clinic for an eye examination. The nurse confirms ptosis by:

a. Performing the confrontation test.

b. Assessing the patient’s near vision.

c. Observing the distance between the palpebral fissures.

d. Performing the corneal light test, and looking for symmetry of the light reflex.

ANS: C

Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis

During assessment of the lacrimal apparatus, the nurse would document the following as a normal finding:

a. Presence of tears along the inner canthus

b. Blocked nasolacrimal duct in a newborn infant

c. Slight swelling over the upper lid and along the bony orbit if the individual has a cold

d. Absence of drainage from the puncta when pressing against the inner orbital rim

ANS: D

No swelling, redness, or drainage from the puncta should be observed when it is pressed.

Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth

When assessing the pupillary light reflex, the nurse will:

a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction.

b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction.

c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.

d. Ask the patient to focus on a distant object and then to follow the penlight to approximately 7 cm from the nose.

ANS: C

To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

During examination of the patient’s eyes, the nurse notes that the pupils become smaller when the patient looks at an object moved closer to the eyes. The nurse will document this finding as:

a. Dilation of the pupils.

b. Consensual light reflex.

c. Conjugation.

d. Accommodation.

ANS: D

The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.

When using the ophthalmoscope to assess a patient’s eyes, the nurse notices a red glow in the patient’s pupils. The nurse will:

a. Document that an opacity is present in the lens or cornea.

b. Check the light source of the ophthalmoscope to verify that it is functioning.

c. Continue with the examination knowing that the red glow is a normal finding.

d. Refer the patient for further evaluation.

ANS: C

The red glow filling the person’s pupil is the red reflex and is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct

The nurse is examining a patient’s retina with an ophthalmoscope and notes the normal finding of:

a. An optic disc that is a yellow-orange colour.

b. Optic disc margins that are blurred around the edges.

c. The presence of pigmented crescents in the macular area.

d. The presence of the macula located on the nasal side of the retina.

ANS: A

The optic disc is located on the nasal side of the retina. Its colour is a creamy yellow-orange to a pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is caused by the accumulation of pigment in the choroid.

When examining a 2-week-old infant the nurse notices that he watches an object but does not follow it with his eyes when moved to different positions. The nurse will:

a. Document this as a normal finding.

b. Assess the pupillary light reflex for possible blindness.

c. Refer the infant to a specialist.

d. Continue assessment with the Allen chart.

ANS: A

By 2 to 4 weeks, an infant can fixate on an object. By age 1 month, the infant should fixate and follow a bright light or toy.

he nurse is conducting an eye-screening clinic at a daycare centre. When examining a 2-year-old child, the nurse suspects that the child has a “lazy eye” and will:

a. Examine the external structures of the eye.

b. Assess visual acuity with the Snellen eye chart.

c. Assess the child’s visual fields with the confrontation test.

d. Test for strabismus by performing the corneal light reflex test.

ANS: D

Testing for strabismus is done by performing the corneal light reflex test and the cover test.

The Snellen eye chart and confrontation test are not used to test for strabismus.

The nurse is performing an eye assessment on an 80-year-old patient and is concerned about finding that the patient has:

a. Decreased tear production.

b. Unequal pupillary constriction in response to light.

c. Arcus senilis around the cornea.

d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles.

ANS: B

Pupils are small in the older adult, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetrical. The assessment findings in the other responses are considered normal in older persons

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:

a. Check for the presence of exophthalmos.

b. Suspect that the patient has hyperthyroidism.

c. Ask the patient if he or she has a history of heart failure.

d. Assess for blepharitis, which is often associated with periorbital edema.

ANS: C

Periorbital edema occurs with local infections, crying, and systemic conditions, such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.

When a light is directed across the iris of a patient’s eye from the temporal side, the nurse is assessing for:

a. Drainage from dacryocystitis.

b. Presence of conjunctivitis over the iris.

c. Presence of shadows, which may indicate glaucoma.

d. Scattered light reflex, which may be indicative of cataracts.

ANS: C

The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This method is not correct for the assessment of dacryocystitis, conjunctivitis, or cataracts

In a patient who has anisocoria, the nurse would expect to observe:

a. Dilated pupils.

b. Excessive tearing.

c. Pupils of unequal size.

d. Uneven curvature of the lens.

ANS: C

Unequal pupil size is termed anisocoria. It normally exists in 5% of the population but may also be indicative of central nervous system disease

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he “can’t see well” from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

a. Loss of central vision.

b. Shadow or diminished vision in one quadrant or one-half of the visual field.

c. Loss of peripheral vision.

d. Sudden loss of pupillary constriction and accommodation.

ANS: B

With retinal detachment, the person has shadows or diminished vision in one quadrant or one-half of the visual field. The other responses are not signs of retinal detachment.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have:

a. Macular degeneration.

b. Vision that is normal for someone her age.

c. The beginning stages of cataract formation.

d. Increased intraocular pressure or glaucoma.

ANS: A

Macular degeneration is the most common cause of blindness. It is characterized by the loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not consistent with vision that is considered normal at any age.

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. The nurse recognizes that the patient may have a corneal abrasion when:

a. The corneas are smooth and clear.

b. The lens behind the cornea is opaque.

c. There are areas of bleeding across the cornea.

d. There is a shattered look to the light rays reflecting off the cornea.

ANS: D

A corneal abrasion causes irregular ridges in reflected light, which produce a shattered appearance to light rays. No opacities should be observed in the cornea. The other responses are not correct.

During an ophthalmoscopic examination of the eye, the nurse notices areas of exudate that appear similar to cotton wool or fluffy clouds. The nurse recognizes that the patient may have:

a. Diabetes.

b. Hyperthyroidism.

c. Glaucoma.

d. Hypotension.

ANS: A

Soft exudates or cotton wool areas that appear similar to fluffy grey-white cumulus clouds occur with diabetes, hypertension, subacute bacterial endocarditis, lupus, and papilledema of any cause. These exudates are not found with hyperthyroidism, glaucoma, or hypotension.

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? **(Select all that apply.)**

a. Patient may experience sensitivity to light, nausea, and halos around lights.

b. Patient experiences tunnel vision in the late stages.

c. Immediate treatment is needed.

d. Vision loss begins with peripheral vision.

e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision.

f. Virtually no symptoms are exhibited.

ANS: B, D, F

Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are exhibited. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma

The nurse is working at a community health fair to promote eye examinations for populations at higher risk to have vision problems, including: **(Select all that apply.)**

a. Indigenous people.

b. People of European descent.

c. People with diabetes.

d. People of African descent.

e. People of French descent.

f. People with a family history of glaucoma.

ANS: A, C, D, F

Patients with a predisposition to visual deficits include those who wear glasses or contact lenses, have diabetes, are of African descent, or have a strong family history of glaucoma, age-related macular degeneration (AMD), or retinal detachment. Incidence of diabetes is high among Indigenous peoples.