Eye and Vision 7th Edition

Chapter 48: Assessment of the
Eye and Vision Nursing School

Test Banks
Chapter 48: Assessment of the Eye and Vision
Test Bank
MULTIPLE CHOICE
1. Why is the optic disc considered to be a blind spot?
a. This area does not contain photoreceptors.

b. Light rays are unable to focus on this location.
c. Blood vessels form a meshwork and interfere with vision.
d. This area is heavily pigmented and light rays are absorbed.
ANS: A
The optic nerve enters the eyeball at this point and contains no photoreceptors. The
other responses are incorrect.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 1040
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. During assessment of an older adult, which finding does the nurse immediately
report to the health care provider?
a. Yellowing or bluing of the sclera

b. Lack of discrimination between green and violet
c. An opaque, bluish-white ring within the outer edge of the cornea
d. Pupil constriction in response to light occurring in 2 seconds
ANS: D
In an older client, it is normal for the sclera to turn yellow or blue with aging. It is also
common for the older adult to have problems discriminating between the colors of
green, blue, and violet. Arcus senilis, an opaque, bluish-white ring on the edge of the
cornea, is a common occurrence in the older adult. This does not cause vision loss.
Pupil constriction as a reaction to light should occur in less than 1 second. If pupil
constriction takes longer, then the reaction is considered sluggish and should be
reported to the provider.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in

Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
3. Which teaching is essential for a client who is going to have intraocular pressure
measurement with a slit lamp?
a. The test causes temporary blindness.

b. The test is quick and a local anesthetic is used.
c. The test does cause a little pain, but it is over quickly.
d. The test causes some tearing, but no pain.
ANS: B
The IOP test done with a slit lamp must have direct eye contact, which could cause
discomfort, so a local anesthetic is used. The test is quick but does not cause
temporary blindness.
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Teaching/Learning
4. The nurse performs an assessment of a clients extraocular movement and notes no

difficulty. Which additional assessment data assist in confirming this finding?
a. No episodes of double vision

b. Synchronized blinking movements
c. No reports of headaches and dizziness
d. Both pupils constricting equally in response to light
ANS: A
The voluntary muscles of the orbit rotate the eye and coordinate eye movements to
ensure that the retina of each eye receives an image at the same time, so that only a
single image is perceived. If the client has reported double vision, this would indicate
a problem with this coordination. The other answers are not related to extraocular eye
movements.
5. A client has paralysis of the right medial rectus muscle of the right eye. Which
assessment finding assists the nurse in validating this diagnosis?
a. Client is unable to turn the eye in toward the nose.

b. Client is unable to lift the upper eyelid.
c. Client cannot look downward.
d. Client cannot look upward.
ANS: A
Contraction of the medial rectus muscle turns the eye toward the nose. The superior
oblique muscle pulls the eye downward, and the inferior oblique muscle pulls the eye
upward. The ocular muscles do not lift the upper eyelid.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 48.1, p.1042
6. The nurse is assessing extraocular eye movements (EOMs) in an older adult client
and finds that the client is unable to sustain an upward gaze for longer than 2 seconds.
What does the nurse do next?
a. Repeat the test while holding the clients head in a fixed position.
b. Perform a cover-uncover eye test.
c. Document the finding and continue assessing.
d. Assess for additional signs of impending brain attack.
ANS: C
In the older adult, decreased muscle tone impairs the ability to maintain an upward
gaze and to sustain convergence. Therefore, this finding is normal for an older adult
client. The nurse would not repeat the test or hold the clients head in a fixed position.
The nurse would document the finding and continue to assess. This would not be a
cause for concern, nor would it be a symptom of impending brain attack. The cover-
uncover test is used for determining the degree of peripheral vision.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
7. The nurse is assessing an older adult client whose irises no longer fully dilate. What
is the best intervention for the nurse to suggest?
a. Wear dark glasses whenever you are outside.
b. Use eyedrops on a regular basis to prevent dryness.
c. Avoid rubbing your eyes to prevent corneal abrasions.
d. Turn up room lights when reading or doing close work.
ANS: D
With increasing age, the iris has less ability to dilate and clients have difficulty
adapting to a darker environment. Older adult clients may need additional light for
reading. Wearing dark glasses will not assist the client, and no indication suggests that
the clients eyes are dry. Rubbing the eyes should not cause corneal abrasions.
Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning
8. The nurse is performing vision screenings. Which client is at greatest risk for
developing vision problems?
a. Postpartum woman with no complications

b. Young client who has diabetes mellitus
c. Middle-aged adult who takes aspirin daily
d. Older client with chronic dry eye syndrome
ANS: B
The hyperglycemia that characterizes diabetes mellitus causes numerous vascular

problems in the eye and damages the nerves. Although good control of blood glucose
levels delays visual problems, it does not eliminate these problems in the diabetic
population. Daily aspirin therapy does not place a client at risk for vision problems.
Dry eyes are a common finding with older clients because tear production is
decreased, but this does not necessarily interfere with the clients vision. Postpartum
women should not be at risk for vision problems.
9. A client relates that the vision in the left eye is greatly decreased from the day
before. What does the nurse do first?
a. Assess current medications.

b. Patch the left eye.
c. Notify the ophthalmologist.
d. Perform an in-depth interview.
ANS: D
A client with a sudden or persistent loss of vision needs to undergo a complete history
and assessment first to identify the possible cause. Information such as current
medications must be available before the ophthalmologist is called. The nurse cannot
patch the left eye without completing an interview first.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic

Tests) MSC: Integrated Process: Nursing Process (Assessment)
10. During assessment, the nurse notes that a clients right pupil is 2 mm larger than the
left pupil. Which is the nurses first action?
a. Ask the client how long this condition has been present.
b. Attempt to elicit a red reflex in both eyes.
c. Document the finding as the only action.
d. Identify the medications that the client is taking.
ANS: A
Although both pupils are normally the same size and a difference in size can indicate
various pathologies, approximately 5% of people have a noticeable difference in the
size of their pupils. The nurse should first determine whether this condition represents
a change or has been present for a long time.
11. The nurse is assessing the blink reflex in a client who is blind. Which is the best
technique to use?
a. Ask the client to blink first with one eye and then with the other.
b. Expel a syringe of air toward the clients eyes.
c. Shine a bright light at the clients pupils one at a time.
d. Suddenly bring a finger toward the clients face.
ANS: B
A blind client cannot respond with a blink reflex to visually threatening movements
such as bright light or bringing a finger toward the client. Air blowing suddenly at the
eye should elicit the blink reflex as a protective response. Asking the client to blink
first with one eye and then with the other will not elicit the blink reflex.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-

Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)
12. The nurse is performing an eye assessment on a client. Which finding confirms
normal accommodation during visual assessment?
a. Both pupils constrict when a light is shined at one eye.

b. The client blinks in response to a threatening movement.
c. Both pupils constrict when focusing on an object being moved in toward
the nose.
d. The client is able to hold an upward gaze without moving the head for 15
seconds.
ANS: C
Normal accommodation is seen when the clients eyes converge. The pupils constrict
when the client focuses on an object that is being moved from about 18 cm from the
clients nose in closer toward the nose. Consensual response occurs when both pupils
constrict after a light is shined at one eye. The blink reflex occurs in response to a
sudden movement. Extraocular muscle function is tested when the client is asked to
hold an upward gaze while keeping the head still.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 1046
13. The nurse is assessing a client for the possibility of a lens opacity. Which
assessment finding confirms this problem?
a. Increased intraocular pressure

b. Absence of a red reflex
c. Decreased central vision
d. Positive corneal staining
ANS: B
The red reflex is elicited with an ophthalmoscope and represents reflection of the
ophthalmoscopic light through the lens onto the vascular retina. The absence of a red
reflex strongly indicates a lens opacity that does not allow light to penetrate through to
the retina. The other answers are not related to a lens opacity. Increased intraocular
pressure is measured by tonometry and could indicate glaucoma. Decreased central
vision is measured by a Snellen chart and a Jaeger card and indicates decreased visual
acuity. Positive corneal staining with topical dye could indicate corneal abrasion.
14. A client is scheduled for electroretinography. Which statement indicates that the
client understands the teaching about this procedure?
a. I will wear dark glasses in sunlight to prevent eye pain.

b. I am going to drink at least 3 liters of water to flush the dye out of my
system.
c. I will avoid rubbing my eyes until the anesthetic drops have worn off.
d. I will not drive for the first 24 hours after the procedure.
ANS: C
A local anesthetic agent is used for this procedure because an electrode is placed on
the cornea. The client could inadvertently scratch or harm the eye by touching or
rubbing it while the anesthetic effect is present. No eye pain should be noted with this
procedure, no dye is used, and restricting driving for 24 hours is not necessary.

Tests) MSC: Integrated Process: Teaching/Learning
15. The nurse is evaluating a clients technique for instilling eyedrops. Which behavior
indicates that the client needs more teaching?
a. Closing they eye after the drops are in

b. Touching the eye with the tip of the dropper
c. Allowing the drops to spread across the eye surface
d. Getting the drops into the conjunctival pocket
ANS: B
Touching the eye with the tip of the dropper contaminates the dropper and the
medication. If the client has an infection in the eye that is touched, the dropper cannot
even be used on the clients other eye. The other answers indicate correct technique.
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral

TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Evaluation)
16. The nurse is educating a client about the instillation of eyedrops. Which client
statement indicates the need for additional teaching?
a. Squeezing my eye tightly after I put the drops in may force the drops out
of my eye too quickly.
b. If the drops are kept in the refrigerator, I will be able to tell when they
are in my eye because they will feel cold.
c. My sister has the same prescription, so we can use the same bottle of
eyedrops.
d. I will wash my hands before I use these eyedrops.
ANS: C
Eyedrops or eye ointment should never be shared because of the risk of spreading
infection. The other answers indicate correct technique.

TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Evaluation)
17. A client with presbyopia asks her nurse about corrective lenses. Which is the
nurses best response?
a. This type of problem cannot be helped with corrective lenses.

b. Corrective lenses are needed for both near and distance vision.
c. Corrective lenses can be used for reading and close work.
d. Corrective lenses are needed for distance only.
ANS: C
Presbyopia is caused by stiffening of the lens as a result of water loss as the lens ages.
Consequently, the lens does not refract as well and light waves converge behind the
retinaa condition similar to farsightedness (hyperopia). The condition makes near
vision blurry. Corrective lenses for presbyopia increase light wave refraction and are
used for reading or close work. Therefore the other answers are incorrect. Presbyopia
can be helped with corrective lenses but only for near vision, not for distance vision.
Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
18. A teenager is admitted to the emergency department with a possible fracture of the
left orbit after getting hit in the face with a baseball. All tests are negative and the
client is being discharged. Which is important for the nurse to teach the client?
a. Keep an eye patch on the eye for 48 hours.

b. Always wear protective equipment to prevent eye damage.
c. Take aspirin if a headache should occur.
d. Do not do any heavy lifting for a week.
ANS: B
If all tests are negative, restrictions on heavy lifting are not needed. An eye patch does
not have to be worn. Acetaminophen (Tylenol) would be a better choice for a
headache because aspirin promotes bleeding. The client and the family should be
taught about protective equipment while playing sports (helmet and goggles).
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of

Teaching/Learning)
19. An anxious adult client asks why she needs to have intraocular pressure tested
every year. What is the best response from the nurse?
a. Many changes can occur because of aging.

b. If the pressure is too low, you will be blind.
c. If the pressure is too high, blood will not flow through the eye.
d. Loss of vision can occur if the pressure is too high or too low.
ANS: D
Although all responses are somewhat correct, explaining the outcome of abnormal
pressure is to the point and is done at the clients level of understanding, especially if
she is anxious about the test.

20. A client is told that he has 20/10 vision when tested on the Snellen chart. How
does the nurse explain this finding to the client?
a. You can read at 10 feet what others can read at 20 feet.

b. You can read at 20 feet what others can read at 10 feet.
c. This demonstrates normal vision.
d. You are considered legally blind.
ANS: B
The 20 is the point at which the client can see from the chart, and the 10 is the point at
which a healthy eye can see from the chart. Normal vision is 20/20.

Tests) MSC: Integrated Process: Nursing Process (Assessment)
21. The nurse is assessing a clients eyes. Which is the first step for the nurse in this
procedure?
a. Explain the procedure.

b. Wash the hands.
c. Assess for infections.
d. Use the Snellen chart.
ANS: B
Before examining a clients eyes, the examiner should wash his or her hands. This is
done to prevent contamination of the eye and structures. The nurse could then proceed
to explain any procedure, assess infection, or assess visual acuity using the Snellen
chart.
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

22. The nurse is triaging clients in the emergency department. Which clients require
immediate attention by an ophthalmologist?
a. Older client with an intraocular pressure (IOP) of 15

b. Confused client in need of an ophthalmoscopic examination
c. Young client with dry drainage from one eye
d. Middle-aged client with recent onset of eye pain
ANS: D
A client with abrupt onset of eye pain should be the priority because of possible
underlying pathology causing the symptom. An IOP of 15 is within the normal range
(10 to 21); therefore the client does not need to be seen by an eye doctor. If a client is
confused, the ophthalmoscopic examination must be rescheduled because it would not
be safe to perform the examination at this time. Drainage from an eye indicates
possible infection, but this would not be the first client to be seen.
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
CareEstablishing Priorities)
MULTIPLE RESPONSE
1. The nurse is assessing the eye changes in an older adult. Which changes lead the
nurse to consult with the health care provider? (Select all that apply.)
a. Increasing difficulty perceiving greens, blues, and violets

b. Increasing redness in the eyes
c. Acute pain in the eyes
d. Sudden change in acuity
e. Need for additional lighting for reading
f. Need to hold newspaper farther away to read
ANS: B, C, D
Increasing redness, acute pain, and sudden changes in acuity represent manifestations
that might be indicative of a more serious complication and need the providers
evaluation. Delay could cause harm. The other signs are associated with the aging
process and do not require immediate evaluation.
OTHER
1. The nurse is administering ophthalmic drops to a client with an eye infection. Put
the following nursing interventions in order, from first to last. (Separate letters by a
comma and space as follows: a, b, c, d.)
a. Recheck the five Rs and the expiration date of the drug.
b. Put on gloves.
c. Have the client tilt the head backward.
d. Wash your hands.
e. Pull the lower eyelid downward and instill the medication into the conjunctival sac.
f. Instruct the client to close the eyes gently without squeezing the eyelids together.
ANS:
d, b, a, c, e, f
Medication checking of the five Rs the first time is always the first step, followed by
handwashing and gloving because of the risk for secretions. Rechecking the five Rs
right before giving the medication, which is actually the third time that the five Rs are
checked, is critical for maintaining safety. The nurse has the client tilt the head back,
prepare the eye, give the drug, and have the client gently close the eye.

TherapiesMedication Administration)
2. A client is scheduled for a fluorescein angiography. Place the nurses activities in

order, from highest to lowest priority. (Separate letters by a comma and space as
follows: a, b, c, d.)
a. Start an intravenous access.
b. Instill mydriatic eyedrops.
c. Have the consent form signed.
d. Have the client drink fluids.
e. Inject fluorescein dye.
f. Have the client wear dark glasses.
ANS:
c, b, a, e, d, f
Before the invasive procedure is started, an informed consent form must be signed.
The mydriatic drops are then instilled 1 hour before the procedure. An IV is inserted
and the fluorescein dye injected. A series of photographs are taken. After the
procedure, the client is instructed to drink plenty of fluids to aid with excretion of the
dye through the urine. The client is taught to wear dark glasses to prevent pain caused
by the bright light until the mydriatic action of the drops has worn off.

Tests) MSC: Integrated Process: Nursing Process (Implementation)
Chapter 49: Care of Patients with Eye and Vision Problems
Test Bank
MULTIPLE CHOICE
1. A client is using an ophthalmic beta-blocking agent for the treatment of glaucoma.

Which instruction does the nurse give to the client to prevent orthostatic hypotension?
a. Change positions quickly after administering the drops.

b. Take your pulse at least four times daily.
c. Apply pressure to the inside corner of your eye when administering the
drops.
d. Lay down for 10 minutes after administering the drops.
ANS: C
Nasal punctal occlusion during eyedrop instillation keeps the drug in contact with the
eye structures longer and decreases systemic absorption and side effects. Systemic
distribution of the drug is what may cause orthostatic hypotension. The other answers
will not help prevent orthostatic hypotension.

TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

2. Which is the most important information for the nurse to teach a client who is
receiving cycloplegic drug therapy?
a. Do not drive or operate machinery until the drug wears off.

b. Use at least a 30 SPF sunscreen agent when going outdoors.
c. Remain on bedrest for 24 hours in a prone position.
d. Turn up the lights because acuity will be decreased in low-light
environments.
ANS: A
Cycloplegic agents prevent accommodation of the iris, resulting in a widely dilated

pupil. The pupil cannot accommodate to bright light, causing eye discomfort and pain.
Turning up the lights will not assist the client to see more clearly. Bedrest and
sunscreen are not measures needed for this drug.
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
3. An older adult client who has a mature cataract in the right eye states, Now I have
lost the sight in my right eye because I waited too long for treatment. How does the
nurse best respond to the client?
a. Yes, this type of blindness could have been prevented by earlier

treatment.
b. It is fortunate you came for treatment in time to save the sight of your
other eye.
c. Nothing you could have done would have made any difference.
d. Surgery can still save the sight in your eye with removal of the cataract.
ANS: D
Although sight is increasingly impaired as a cataract matures, no other damage is done
to the eye by waiting. Removal of the cataract will result in improved vision,
regardless of how long the cataract has been present. No indication suggests that the
client will develop a cataract in the other eye. The other statements are inaccurate.
TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)
MSC: Integrated Process: Nursing Process (Caring)
4. Which statement indicates that the client understands teaching about the use of
aspirin postcataract surgery?
a. It may increase intraocular pressure after cataract surgery.

b. It changes the ability of the blood to clot and increases the risk of
bleeding.
c. It reduces inflammation and might mask any symptoms of infection.
d. It can cause nausea and vomiting and may increase intraocular pressure.
ANS: B
Aspirin disrupts platelet aggregation and increases the risk for bleeding after surgery.
Aspirin may decrease inflammation but would not mask symptoms of infection.
Aspirin does not cause increased intraocular pressure, nor does it typically cause
nausea and vomiting. Aspirin should not mask signs of infection.

TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Evaluation)
5. Which assessment alerts the nurse to the possible presence of a cataract in a client?
a. Loss of central vision
b. Loss of peripheral vision
c. Dull aching in the eye and brow areas
d. Blurred vision and reduced color perception
ANS: D
As the lens becomes opaque and less able to refract light appropriately, the client
experiences blurred vision and a reduced ability to distinguish among different colors.
The development of a cataract does not typically cause loss of peripheral or central
vision, nor does it result in aching in the brow area.
6. A client is recovering from cataract surgery and needs medication to prevent a

potential eye infection. Which drug does the nurse question administering to the
client?
a. Tobramycin (Tobrex)
b. Apraclonidine (Iopidine)
c. Gentamicin (Genoptic)
d. Ciprofloxacin (Ciloxan)
ANS: B
Apraclonidine is an adrenergic agonist that binds to eye receptors to reduce the

amount of aqueous humor in the eye, resulting in decreased intraocular pressure. This
medication usually is administered to clients with glaucoma. Tobramycin, gentamicin,
and ciprofloxacin are anti-infectives.

TherapiesExpected Actions/Outcomes)
7. Which statement indicates that a client understands why his cataract surgery is
being done first on the eye with the poorest vision?
a. Insurance reimbursement dictates the timing of surgeries.

b. The eye with poorer vision is at greater risk for permanent damage.
c. The pressure in the poorer eye could increase, causing permanent
damage.
d. If a complication arises in that eye, I will still have some vision in the
better eye.
ANS: D
The eye with the better sight is left alone until the outcome of the first surgery is
known to reduce the chance that the client will lose sight in both eyes if complications
arise from the surgery.
Complications from Surgical Procedures and Health Alterations)
8. The nurse is teaching a client about home care after cataract surgery. Which
statement indicates that the client requires further teaching?
a. I am glad that I dont need an eye patch after the surgery.

b. I will try a cool compress to decrease the swelling around the operated
eye.
c. Dark sunglasses will be necessary when I am in the sun.
d. Pain, nausea, and vomiting are normal after this surgery.
ANS: D
Eye pain accompanied by nausea and vomiting is an indication of increased

intraocular pressure and/or hemorrhage. This is an emergent situation and the surgeon
must be contacted by the client. The other responses are correct. The client will not
need an eye patch, cool compresses will decrease the slight swelling, and dark glasses
are necessary outdoors until the pupil responds to sunlight.
9. A client has been educated about activities that can increase intraocular pressure.
Which statement indicates that the client requires further teaching?
a. I will avoid wearing tight shirt collars and ties.

b. I will take stool softeners daily to prevent straining.
c. I will try not to sneeze, cough, or blow my nose.
d. I will not put my arms above my head.
ANS: D
Arm position does not influence intraocular pressure. All other activities listed
decrease the incidence of increased intraocular pressure.

10. The nurse assesses a client postcataract surgery and finds white, dry, crusty
drainage on the clients eyelid and lashes. What does the nurse do next?
a. Obtain a specimen of the drainage for culture.

b. Clean away the drainage and apply the prescribed drops.
c. Contact the physician for an antibiotic order.
d. Arrange for the client to be seen by the ophthalmologist today.
ANS: B
White, dry, crusty drainage on the eyelid and lashes is expected after cataract surgery.
Because the drainage is white and no other symptoms of infection are noted, a culture
does not need to be done and an antibiotic will not be needed. Urgency is not an issue
because this is an expected effect from the trauma of surgery. The physician does not
need to be called.
11. The nurse is assessing a client who wishes to be considered as a potential donor for
corneal transplantation. Which medical diagnosis at the time of death excludes the
client from consideration?
a. Small cell lung cancer

b. Chronic heart failure
c. Profound nearsightedness
d. History of detached retina
ANS: A
Clients of any age may donate corneas as long as the corneas are clear and the client is
free from infectious disease or cancer at the time of death. The other problems would
not keep a client from donating corneas.
12. The nurse assesses several clients. Which one is most likely to have secondary
open-angle glaucoma?
a. Client with gradual onset of blurred vision

b. Client who has recently had eye surgery
c. Client who sees halos around lights
d. Client with reactive pupils and clear sclera
ANS: B
Secondary open-angle glaucoma results from another condition that interferes with
drainage of the aqueous humor such as recent eye surgery. Cataracts usually start with
a slow onset of blurred vision but do not lead to secondary open-angle glaucoma. A
late manifestation of primary open-angle glaucoma is seeing halos around lights; this
is not considered secondary open-angle glaucoma. The client with reactive pupils and
clear sclera has normal assessment findings, not related to secondary open-angle
glaucoma.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 49-3, p. 1063

13. Which statement made by a client after corneal transplantation indicates a need for
further teaching?
a. I will wear an eye shield at night for at least 1 month.

b. I will avoid bending at the waist and straining when moving my bowels.
c. I wont worry if I have increased tearing, because it is normal.
d. Ill notify the ophthalmologist if any signs of rejection occur.
ANS: C
Aqueous humor can leak from the incision site if wound closure is incomplete. Any
fluid coming from the eye in the early postoperative period needs to be checked by the
provider.
14. Which clinical manifestation alerts the nurse to the possibility of a vitreous humor
hemorrhage?
a. Presence of a red reflex

b. Reddened whites of the eye
c. Red haze or floaters in the line of vision
d. Swelling of the upper and lower eyelids
ANS: C
Mild seepage of blood into the vitreous humor causes the clients vision to have an
overall red haze or floaters. With a vitreous humor hemorrhage, the red reflex is
reduced. Reddened whites of the eye and swelling of the eyelids would indicate
irritation and infection of the eye.
15. The nurse is providing discharge teaching for a client with posterior uveitis. Which
is the most important precaution for the nurse to teach the client?
a. Correct technique for eyedrop instillation

b. Clinical manifestations of retinal hemorrhage
c. Correct technique for insertion of contact lenses
d. Proper timing of opioid analgesics
ANS: A
Treatment of posterior uveitis is symptomatic, with eyedrops used to dilate the pupil
and decrease the inflammatory response. The client may have to instill eyedrops as
frequently as every hour. This condition consists of inflammation of the retinanot a
hemorrhage. Opioids are not prescribed to lessen the pain, but cool or warm
compresses may be used for ocular pain.
16. A client with macular degeneration would like to watch television. Where does the
nurse place the television for best visualization of the screen?
a. As close to the clients face as possible

b. As far away as possible, with low lights
c. Directly in front of the client
d. On either side of the client
ANS: D
Macular degeneration decreases central vision but usually does not affect peripheral
vision. Clients looking straight ahead can see people and objects off to the side.
Therefore the television should be placed on either side of the client. The other
options would not help the client with macular degeneration to see the screen.
17. In the emergency department, the nurse is caring for a client diagnosed with a
hyphema. Which statement by the client indicates a need for further teaching?
a. When I get home, I can lie flat in bed and turn from side to side.
b. For a few days, I cannot even read a book or watch television.
c. I will need to protect the eye with a patch and shield.
d. I need to stay on bedrest and will try not to make any sudden movement.
ANS: A
A hyphema is a hemorrhage in the anterior chamber of the eye due to blunt force such
as a motor vehicle accident. For management of this condition, the client must be on
bedrest but must remain in a semi-Fowlers position to prevent accumulation of blood
around the optical center of the cornea. The client cannot lie flat in bed and rotate
from side to side. The client cannot read a book or watch television and must protect
the eye if paralytic eyedrops were used. The client needs to be as still as possible to
prevent further bleeding.
ControlHome Safety) MSC: Integrated Process: Teaching/Learning
18. A client has just returned from having surgery, and sulfahexafluoride gas was used
intraocularly. How does the nurse position the client?
a. Completely supine, with sandbags beside the head

b. On the nonoperative side in the Trendelenburg position
c. On the operative side in the Trendelenburg position
d. On the abdomen, with the affected eye up
ANS: D
Sulfahexafluoride gas has a lower specific gravity than the vitreous humor. It will
float to the highest position. The client should be positioned so that the gas will float
up and against the newly reattached retina. The other positions are incorrect after this
procedure.
19. A client comes to the emergency department with periorbital ecchymosis of the
right eye. Which is the nurses priority action?
a. Apply an ice pack to the affected eye.

b. Patch the eye to prevent eye movement.
c. Assess the clients vision in both eyes.
d. Irrigate the affected eye with normal saline.
ANS: A
Ice will cause capillary vasoconstriction, thereby decreasing swelling and capillary
oozing. Treatment with ice begins at the time of injury. Whenever the eye or
surrounding tissue is injured, visual acuity is assessed next.
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
CareEstablishing Priorities)
20. The nurse is teaching a client how to apply eye medication. Which is the correct
technique for applying ointment into the eye?
a. From the middle out

b. From the inner canthus to the outer canthus
c. From the outer canthus to the inner canthus
d. Against the inner aspect of the eyelid
ANS: B
Ointment should be applied by pulling down the lower lid and forming a pocket.
Application should proceed from the inner canthus toward the outer canthus, with the
client tilting the head backward and looking up at the ceiling.
DIF: Cognitive Level: Knowledge/Remembering REF: Chart 49-1, p. 1053
ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)
21. A client has conjunctivitis in both eyes and is being treated with topical antibiotics.
Which statement by the client indicates a need for further teaching?
a. Ill avoid sharing washcloths or towels with other family members.

b. I will wash my hands after applying the eye ointment to each eye.
c. I will call the ophthalmologist if the drainage continues after the
antibiotics are started.
d. Ill use the same tube of topical ointment for each infected eye.
ANS: D
Bacterial conjunctivitis is highly contagious; therefore the client must avoid sharing
anything with others that has the potential to come in contact with the infected eye,
such as washcloths or towels. The client needs to protect from reinfection by washing
hands frequently during application of the antibiotic ointment and must let the eye
doctor know if drainage continues after treatment is begun. Separate tubes of eye
ointment should be used, with one specifically labeled for each eye.
22. A client is having intraocular pressure measured for both eyes. Which response by
the client best indicates that the client understands why this is necessary every year?
a. Elevated eye pressure can cause high blood pressure.

b. If eye pressure is too high, your eyes will dry out.
c. Elevated eye pressure can press on blood vessels in the eye.
d. Increased eye pressure causes the tear ducts to become blocked.
ANS: C
Intraocular pressure is the pressure generated by the fluids inside the globe of the eye.
As intraocular pressure increases to above normal, it compresses the blood vessels and
the optic nerves. As the blood vessels are compressed, oxygenation to the internal eye
structures, including the nerves and photoreceptors, is diminished. The nerves and
photoreceptors require a constant supply of oxygen and will die if blood flow is
inadequate, leading to blindness. The other statements are inaccurate.

23. A client just underwent a keratoplasty. Which activity does the nurse suggest that
the client begin possibly 1 week after surgery?
a. Continue with salsa dance lessons.

b. Jog only one-half mile versus the usual 2 miles.
c. Return to employment as a receptionist.
d. Help the family move furniture from room to room.
ANS: C
Activities that raise the intraocular pressure (e.g., jogging, dancing, any movement
that can cause jerky head motion) should be discouraged for at least 3 weeks after
surgery. No heavy lifting should be done for 6 to 8 weeks. A sedentary job such as a
receptionist can be tolerated a week after surgery.
MULTIPLE RESPONSE
1. A client with acute-angle glaucoma has several medications ordered. Which

medications does the nurse question? (Select all that apply.)
a. Acetazolamide (Diamox)
b. Pilocarpine (Pilocar)
c. Atropine (Isopto Atropine)
d. Latanoprost (Xalatan)
e. Timolol (Timoptic)
f. Epinephrine
ANS: C, F
Atropine and epinephrine are mydriatics, which decrease the outflow of aqueous
humor, resulting in increased intraocular pressure (IOP). Diamox is a carbonic
anhydrase inhibitor that decreases the formation of aqueous humor. Pilocar is a miotic
that enhances outflow of aqueous humor. Xalatan is a prostaglandin agonist that
improves outflow, and Timoptic is a beta blocker that decreases the formation of
aqueous humor. All these help decrease IOP.

TherapiesExpected Actions/Outcomes)
2. The nurse is teaching a postoperative client who had a keratoplasty. Which

responses by the client require further teaching about safety in the home? (Select all
that apply.)
a. We use throw rugs in the bathroom.

b. Our neighbors will be bringing food for a week.
c. We may have two extension cords in the living room.
d. Most of the furniture is placed against the wall, except for one rocking
chair.
e. Every room has at least one window.
f. The hallway has low lighting.
ANS: A, C, D, F
Throw rugs pose a danger of slipping or tripping. The client cannot see if the rug is
flat or elevated. Extension cords should be placed under or behind the furniture to
decrease the possibility of tripping. Furniture should be out of the normal walking
pathway. Low lighting in the hallway may pose a problem when the client has a patch
and shield over the operated eye. Lighting from a window should not be a problem.
When neighbors bring food, the chance of burns occurring while cooking with limited
vision is reduced.
3. A blind client is admitted to the hospital unit. Orientation to the unit includes which
information? (Select all that apply.)
a. Introduce the staff to the client.

b. Describe the room to the client using one reference point.
c. Walk the client to the bathroom and describe it.
d. Tell the client to use the call light if he or she wants to go to the
bathroom.
e. Explain the routine of the unit and how to operate the bed controls.
f. Assist in putting the clients belongings away.
ANS: B, C, E, F
The client needs to know where everything is located to be independent and safe from
falls. Clients need to be shown where things are and how to do things such as turn on
the call light and raise the head of the bed. The client should be introduced to the staff,
not the reverse, and should first be shown how to use the call light.
ControlAccident/Injury Prevention)

OTHER
1. A client has an eye prosthesis and needs to have it inserted into the eye socket.
Place the following steps of how to insert an eye prosthesis in the correct order.
(Select in order of priority.)
a. Wash your hands.
b. Explain the procedure to the client.
c. Remove the prosthesis from its container and rinse it with tepid water.
d. Cover the work area with a cloth or towel.
e. Don gloves.
f. Place the prosthesis between the thumb and forefinger of your dominant hand with
the notched end of the prosthesis closest to the clients nose.
g. Insert the prosthesis with the top edge slipping under the upper lid.
h. Lift the clients upper lid using your nondominant hand.
i. Retract the lower lid slightly until the bottom edge of the prosthesis slips behind it.
j. Release your hand slowly.
k. Gently release the upper eyelid.
ANS:
b, a, d, e, c, h, f, g, k, i, j
The proper procedure for inserting an eye prosthesis is to explain the procedure, wash
hands, prepare your work area with a cloth or towel, apply gloves, remove the
prosthesis from its container and rinse it, use your nondominant hand to open the
clients upper eyelid, hold the prosthesis properly, insert the prosthesis with the top
edge slipping under the lid, release the lid, retract the lower lid until the prosthesis
slides into place behind the lower lid, and take your hand away slowly.
ControlAccident/Injury Prevention)

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Chapter 48: Assessment of the

Eye and Vision Nursing School

1. Why is the optic disc considered to be a blind spot?

a. This area does not contain photoreceptors.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 1040

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

a. Yellowing or bluing of the sclera

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in

a. The test causes temporary blindness.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

4. The nurse performs an assessment of a clients extraocular movement and notes no

a. No episodes of double vision

DIF: Cognitive Level: Application/Applying or higher REF: N/A

MSC: Integrated Process: Nursing Process (Assessment)

a. Client is unable to turn the eye in toward the nose.

DIF: Cognitive Level: Comprehension/Understanding REF: Table 48.1, p.1042

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

DIF: Cognitive Level: Application/Applying or higher REF: N/A

DIF: Cognitive Level: Application/Applying or higher REF: N/A

a. Postpartum woman with no complications

The hyperglycemia that characterizes diabetes mellitus causes numerous vascular

MSC: Integrated Process: Nursing Process (Assessment)

a. Assess current medications.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic

DIF: Cognitive Level: Application/Applying or higher REF: N/A

MSC: Integrated Process: Nursing Process (Assessment)

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-

a. Both pupils constrict when a light is shined at one eye.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1046

MSC: Integrated Process: Nursing Process (Assessment)

a. Increased intraocular pressure

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1049

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

a. I will wear dark glasses in sunlight to prevent eye pain.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic

a. Closing they eye after the drops are in

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral

a. This type of problem cannot be helped with corrective lenses.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

MSC: Integrated Process: Nursing Process (Implementation)

a. Keep an eye patch on the eye for 48 hours.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of

MSC: Integrated Process: Teaching/Learning

a. Many changes can occur because of aging.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic

a. You can read at 10 feet what others can read at 20 feet.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1046

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic

a. Explain the procedure.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

MSC: Integrated Process: Nursing Process (Implementation)

a. Older client with an intraocular pressure (IOP) of 15