Eye

Published on July 2016 | Categories: Documents | Downloads: 75 | Comments: 0 | Views: 1302
of 12
Download PDF   Embed   Report

Comments

Content

MULTIPLE CHOICE 1. The 60-year-old patient who has had an enucleation asks when he can get his prosthesis fitted. The nurse responds that the prosthesis will be fitted by an optician in approximately: 1. 2 weeks. 2. 4 weeks. 3. 8 weeks. 4. 12 weeks. ANS: 2 After an enucleation, the patient is fitted with a prosthesis in 1 month. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1185 OBJ: 4 TOP: Enucleation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. The patient who has been taking opioid medication for postoperative pain exhibits pinpoint pupils. The anatomic portion of the eye that has been affected by the medication is the: 1. sclera. 2. retina. 3. choroid. 4. bulbar conjunctiva. ANS: 3 The choroid of the eye contains the pupil and iris. PTS: 1 DIF: Cognitive Level: Knowledge REF: 1158 OBJ: 1 TOP: Anatomy and Physiology of the Eye: The Eyeball KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse explains that the portion of your eye that will make it possible for you to see in a darkened environment is the: 1. macula. 2. rods. 3. cones. 4. optic nerve. ANS: 2 The eye uses rods to accommodate to dim light. Cones are the color receptors. The optic nerve transmits to the brain all sensory input from the eye. PTS: 1 DIF: Cognitive Level: Analysis REF: 1158 OBJ: 5 TOP: Anatomy and Physiology: The Eyeball KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. When being interviewed, a 50-year-old patient says that he cannot see the newspaper as well as he used to. You know that vision changes from near to far because: 1. the ciliary muscle changes the pupil size.

2. the lens of the eye changes shape as a muscle contracts and relaxes. 3. of nearsightedness. 4. of clouding of the vitreous humor. ANS: 2 Accommodation or adjustment of the lens by contraction and expansion of the ciliary muscle allows us to see far or near. PTS: 1 DIF: Cognitive Level: Application REF: 1159 OBJ: 1 TOP: Lens Adjustment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. During the initial assessment of a very thin patient at the eye clinic, the nurse notes that the patient has very prominent eyes. The nurse should inquire about a history of: 1. diabetes. 2. glomerulonephritis. 3. Graves’ disease. 4. hypertension. ANS: 3 The appearance of the patient and the prominence of the eye (exophthalmos) would lead the nurse to inquire about a thyroid disorder, most likely Graves’ disease or hyperthyroidism. PTS: 1 DIF: Cognitive Level: Analysis REF: 1160 OBJ: 1 TOP: Past Medical History KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. When you ask your patient about his vision, he says that the last time he had it tested, it was recorded as 20/50. This means that: 1. the patient can read at 20 feet what a person with normal vision can read at 50 feet. 2. the patient can read at 50 feet what a person with normal vision can read at 20 feet. 3. the patient needs to be 50 feet from objects to see them. 4. the patient’s best vision is between 20 feet and 50 feet from objects. ANS: 1 The Snellen eye chart is read at 20 feet. The last line the patient can read with no more than two errors is recorded. In this case, the patient was able to read the 50-foot line at 20 feet. This means that he is reading at 20 feet what a person with normal vision can read at 50 feet. PTS: 1 DIF: Cognitive Level: Application REF: 1161 OBJ: 1 TOP: Physical Examination: Eyes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse recognizes that the patient who is being evaluated for a visual impairment does not have glaucoma because the tonometry reveals an intraocular pressure of:

1. 2. 3. 4.

18 28 45 52

mm mm mm mm

Hg. Hg. Hg. Hg.

ANS: 1 The normal intraocular pressure is between 12 and 21 mm Hg. If the patient had glaucoma, the intraocular pressure would be abnormally high. PTS: 1 DIF: Cognitive Level: Analysis REF: 1162-1163 OBJ: 4 TOP: Tonometry KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 8. The nurse explains to the patient who is to have a pneumotonometry study of the eye that this procedure requires that: 1. his eye may be anesthetized 2. a pneumotonometer will be placed into his eye. 3. there will be a puff of air directed at the surface of the eye. 4. an applanation be done with a slit-lamp microscope. ANS: 1 A pneumotonometer directs a puff of air at the surface of the eye, measuring intraocular pressure by measuring the resistance to the air. The eye is anesthetized prior to the evaluation. PTS: 1 DIF: Cognitive Level: Application REF: 1162-1163 OBJ: 2 TOP: Tonometry KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 9. The nurse performing the eye irrigation would: 1. have the patient tip her head up and run the irrigation fluid over the open eye. 2. direct the irrigating fluid from the inner to the outer canthus. 3. not allow the patient to blink. 4. place the irrigating syringe directly onto the corner of the eye and allow the fluid to move across the eye. ANS: 2 The direction of the flow should be from the inner to the outer canthus. PTS: 1 DIF: Cognitive Level: Application REF: 1165 OBJ: 4 TOP: Eye Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 10. The nurse would include in the information given to a patient who is using topical eye medications to:

1. look upward and drop medication into the inner canthus. 2. pull the lower lid down and drop the medication into the conjunctival sac. 3. hold both lids open and drop medication onto the sclera. 4. tilt the head to the side and drop the medication into the outer canthus. ANS: 2 The eye drops should be dropped into the lower lid and the nurse should press the tear duct to slow absorption. PTS: 1 DIF: Cognitive Level: Application REF: 1165 OBJ: 4 TOP: Topical Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. When the patient asks what electroretinography is supposed to measure, the nurse responds that: 1. a fluorescein dye is injected by IV and the retina is observed as the dye circulates. 2. electrodes are placed on the scalp, each eye is stimulated, and retinal activity is assessed. 3. a small plunger is used to apply pressure on the sclera while the retinal vessels are evaluated. 4. a contact lens is placed on the eye and exposed to flashes of light to evaluate the retinal response. ANS: 4 A contact lens is placed on the eye and retinal activity is assessed as lights are flashed into the eye. The other three options describe fluorescein angiography, visual evoked response, and opthodynamometry, respectively. PTS: 1 DIF: Cognitive Level: Analysis REF: 1163 OBJ: 4 TOP: Electroretinography KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. When doing patient education about protecting vision, you should tell the patient that: 1. after 40 years of age, eye examinations should be done every 2 years. 2. crusted lids on awakening are caused by decreased tear production. 3. floaters are a sign of eye infection. 4. blurred vision without pain is temporary eye strain. ANS: 1 Eye examinations every 2 years are recommended for persons over 40. All the other options are indications that the person should consult a physician for an eye disorder. PTS: 1 DIF: Cognitive Level: Application REF: 1168 OBJ: 3 TOP: Protection of the Eye and Vision

KEY: Nursing Process Step: Implementation MSC: NCLEX: Health 13. The nurse instructs a family member how to guide a visually impaired person when ambulating by: 1. holding the visually impaired person by his or her nondominant arm and walking side by side. 2. holding the nondominant hand, wrapping the arm around his or her waist, and walking side by side. 3. allowing the visually impaired person to hold the helper’s arm, with the helper slightly ahead. 4. allowing the visually impaired person to hold the shoulder of the helper and walk slightly behind the helper. ANS: 3 Allowing the visually impaired person to walk slightly behind the helper and holding the helper’s arm is the most effective way to guide someone who is visually impaired. PTS: 1 DIF: Cognitive Level: Application REF: 1170 OBJ: 4 TOP: Assisting Ambulation with the Visually Impaired KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 14. The newly diagnosed patient with macular degeneration flings her book at the TV set and furiously says, “I can’t read this blasted book and I can’t see what is on the stupid TV!” The nurse recognizes this behavior as: 1. the anger stage of grieving. 2. poor impulse control. 3. ineffective management of therapeutic regimen. 4. psychotic reaction to loss. ANS: 1 There is frequently a grieving process that accompanies the realization that there will be deteriorating vision and ultimate blindness. PTS: 1 DIF: Cognitive Level: Analysis REF: 1169 OBJ: 6 TOP: Impact of Visual Impairment KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 15. The nurse explains that the correct term to use for a patient with a vision disorder is: 1. blind. 2. handicapped. 3. partially blind. 4. visually impaired. ANS: 4 The term visual impairment is a medically accepted term to use for patients with a vision loss. PTS: 1 DIF: Cognitive Level: Application REF: 1169

OBJ: 6 TOP: Nursing Care of the Visually Handicapped Patient KEY: Nursing Process Step: N/A MSC: NCLEX: Psychosocial Integrity 16. A nursing diagnosis for a visually impaired patient might include all of the following except: 1. Impaired sensory perception. 2. Risk for delayed development. 3. Self-care deficit. 4. Ineffective coping. ANS: 2 Patients with a visual impairment are not at risk for delayed development. They will have a nursing diagnosis of Impaired sensory perception, Ineffective coping, and Self-care deficit. PTS: 1 DIF: Cognitive Level: Application REF: 1169-1170 OBJ: 6 TOP: Nursing Diagnosis, Goals, Outcomes KEY: Nursing Process Step: Planning MSC: NCLEX: Psychological Integrity 17. Implementations that are appropriate in the care plan for a visually impaired person include: 1. leaving the bed in the highest position. 2. keeping the door closed. 3. announcing your presence when you enter and leave the room. 4. leaving the radio on all the time to help the patient know the time of day. ANS: 3 The nurse should announce her or his presence in the room and address the patient before touching him or her. The bed should be in the lowest position and the door should be open to avoid social isolation. PTS: 1 DIF: Cognitive Level: Synthesis REF: 1170 OBJ: 6 TOP: Implementations KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 18. The patient with glaucoma who is using a beta-adrenergic blocking agent, timolol (Timoptic) should be monitored for: 1. wheezing. 2. hypertension. 3. sudden eye pain. 4. blurred vision. ANS: 1 Beta-adrenergic blocking agents cause bronchospasm and tachycardia. PTS: 1 DIF: Cognitive Level: Application REF: 1180, Drug Therapy table OBJ: 4 TOP: Beta-Adrenergic Blocking Agents KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

19. The patient tells you that he has to hold his paper farther and farther away from his face to read it. It has become a joke in his family about how far away he needs to hold reading material. You tell the patient: 1. “You have myopia. Glasses will help you read.” 2. “You may have astigmatism, and your eyes will get used to the problem.” 3. “You have presbyopia, which is a normal age-related change. Reading glasses will help you.” 4. “You may have an eye infection that is affecting your vision. You will need an antibiotic ointment to instill into your eyes.” ANS: 3 Presbyopia is a normal age-related change. It is caused by changes in the ciliary muscles. Corrective lenses such as bifocals are used to correct this visual change. PTS: 1 DIF: Cognitive Level: Analysis REF: 1175 OBJ: 5 TOP: Error of Refraction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. The nurse explains that LASIK surgery and PRK are new methods to correct refractive errors surgically. These procedures are used to reshape the: 1. cornea. 2. lens. 3. iris. 4. pupil. ANS: 1 Both surgical procedures are used to reshape the cornea. The test taker will need to determine which structure of the eye will need surgery to correct vision. PTS: 1 DIF: Cognitive Level: Application REF: 1175 OBJ: 5 TOP: Surgical Treatment for Refractive Errors KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The patient reports to the home health nurse that she is having cloudy vision and seeing spots and halos around lights. Based on these complaints, the nurse makes arrangement to have a medical evaluation for: 1. cataracts. 2. glaucoma. 3. detached retina. 4. macular degeneration. ANS: 1 Cataracts are the cause of cloudy vision and seeing spots or halos. PTS: 1 DIF: Cognitive Level: Application REF: 1176 OBJ: 5 TOP: Internal Eye Disorders KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

22. The nurse explains that the difference between open-angle and closed-angle glaucoma is that, with c2losed-angle glaucoma: 1. the onset is acute. 2. trabeculectomy is the initial treatment. 3. can be treated conservatively. 4. intraocular pressure drops suddenly. ANS: 1 Closed-angle glaucoma has an acute onset with eye pain and other systemic symptoms, such as nausea and vomiting. It is an ocular emergency to get the intraocular pressure reduced. PTS: 1 DIF: Cognitive Level: Application REF: 1179 OBJ: 4 TOP: Open-Angle versus Closed-Angle Glaucoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse considers in planning care for a patient with glaucoma that this disorder is caused by: 1. cloudiness in the lens. 2. an increase in intraocular pressure. 3. failed eye surgery. 4. retinal tears. ANS: 2 Glaucoma is caused by an increase in intraocular pressure. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1179 OBJ: 6 TOP: Glaucoma KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 24. A patient presents in the emergency room complaining of severe pain in his eye, and is seeing halos around lights and feeling nauseous. You suspect that he may be experiencing: 1. open-angle glaucoma. 2. angle-closure glaucoma. 3. cataracts. 4. retinal detachment. ANS: 2 Sudden onset of acute eye pain with nausea and vomiting and halos around lights are all symptoms of angle-closure glaucoma. The acute pain is caused by sudden blockage of the fluid channels in the eye. PTS: 1 DIF: Cognitive Level: Analysis REF: 1179 OBJ: 5 TOP: Glaucoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 25. The nurse explains to a patient with retinal detachment that the surgical implementation that is most effective is: 1. removing the lens.

2. macular bonding. 3. LASIK surgery. 4. scleral buckling. ANS: 4 Scleral buckling is used to hold the retinal repair in place. The band is left in place to keep the layers of the eye tissue together. PTS: 1 DIF: Cognitive Level: Analysis REF: 1183 OBJ: 5 TOP: Retinal Detachment KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse assesses an 80-year-old for agerelated changes to the eye, which are (select all that apply): 1. decreased tear production. 2. eyeball sunk deep in orbit. 3. hyperopia. 4. eye lashes diminished. 5. arcus senilis. ANS: 1, 2, 3, 5 Eyelash diminution is not a consistent finding in older adults. All the other options are common eye changes related to advancing age. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1159 OBJ: 1 TOP: Age-Related Changes in the Eye KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. The nurse is aware that the refractive media of the eye is made up of the (select all that apply): 1. aqueous humor. 2. retina. 3. vitreous humor. 4. cornea. 5. lens. ANS: 1, 3, 4, 5 The retina is not part of the refractive media. All the other options are components of the refractive media. PTS: 1 DIF: Cognitive Level: Knowledge REF: 1158-1159 OBJ: 2 TOP: Refractive Media KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. The nurse assesses the patient’s accommodation by (select all that apply): 1. holding his or her finger approximately 20 inches in front of the patient’s eyes. 2. observing for pupillary constriction. 3. assessing for convergence. 4. noting blinking. 5. moving his or her finger slowly toward the patient’s nose.

ANS: 1, 2, 4, 5 Assessment for blinking is not part of the accommodation assessment. All the others are part of the accommodation assessment. The nurse holds his or her finger approximately 20 inches in front of the patient’s eyes, slowly moved the finger toward the patient’s nose, assessing for pupillary constriction and convergence. PTS: 1 DIF: Cognitive Level: Application REF: 1161 OBJ: 2 TOP: Testing for Accommodation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. The patient who has had surgery this morning for cataracts is now going home. Discharge instructions include that the patient should (select all that apply): 1. sleep on the operated side. 2. use stool softeners. 3. avoid bending over. 4. not lift anything heavier than 5 pounds. 5. not wear an eye shield at night. ANS: 2, 3, 4 The postcataract surgery patient should sleep on the unoperated side with the eye shield in place, avoid heavy lifting, and use stool softeners to prevent straining. PTS: 1 DIF: Cognitive Level: Analysis REF: 1177 OBJ: 4 TOP: Discharge Instructions for Cataract Surgery KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance ______________________________________Situation: Mang Tomas is a 60 year old man who has just had cataract surgery performed on his right eye. 1. The physician has prescribed Cyclogel preoperatively to: a) prevent dryness of the cornea and conjunctiva b) reduce the inflammation of the iris and choroids c) paralyze the ciliary muscle d) promote drainage of aqueous humor from the chamber of the eye 2. After discharge, Mang Tomas attends the eye clinic for follow-up visits. When he receives his cataract glasses, it is important that the nurse advise him that: a) his peripheral vision will be increased b) objects will appear closer than they really are c) magnification by the lens is only about 10% d) daily eye drops are required with these lenses

3. The nurse should instruct a client preparing for eye surgery that which of these activities will be restricted post-operatively? a) bending with the knees flexed b) bending from the waist c) keeping the head in a neutral position d) lying flat 4. Nursing care for Mang Tomas during the first 48 hours after surgery will include: a) maintain bed rest b) changing the dressing daily c) encouraging coughing and deep breathing d) lie on the unoperated side

afflicted with arthritis, Parkinson's disease and Alzheimer's. Intraocular lenses are implants that provide the best visual correction. However, it is associated with more postoperative complications. 3) B - during the postoperative period of eye surgery, activities that increase intraocular pressure should be avoided: instruct patient to avoid bending over avoid vomiting - give antiemetics avoid coughing - give antitussives, avoid conditions that stimulate coughing avoid sneezing - avoid allergens that stimulate sneezing such as powders, dusts etc. avoid straining - use stool softener avoid lifting heavy objects 4) D - Cataract is clouding or opacity of the lens which prevents light rays from reaching the retina. Cataract is not due to trauma tends to occur bilaterally but they do not mature at the same time.

Situation: Mang Ben is diagnosed with glaucoma and is scheduled for surgery. 5. Which symptoms are associated with acute closed-angle glaucoma? a) diplopia and photophobia b) episodic blindness and no pain c) blurred vision and colored rings around lights d) sensation of curtain drawn across the visual field 6. Which order for Mang Ben before surgery will the nurse question: a) demerol (meperidine) 50 mg IM b) atropine sulfate 0.4 mg IM c) valium (diazepam) 2 mg IM d) phenergan (promethazine) 25 mg IM

5) C - Glaucoma is due to increased ocular pressure (normal is 10-20 mm/Hg) from accumulation of aqueous humor in the eye that damages the optic nerve resulting in irreversible blindness. Aqueous humor is produced by the ciliary body, nourishes the cornea and lens and flows out of the eye through the trabecular meshwork via the canal of Schlemm. appearance early in the disease of scotoma or 6) B - drugs which cause pupils to dilate should be avoided by persons having angle closure glaucoma as they increase flow of fluid, and thus, the intraocular pressure. This includes: atropine anticholinergics patient should also avoid caffeine Drugs used in Glaucoma are: 1. Betablockers: Timolol/Betaxolol action: decreases production of aqueous humor side effects: bradycardia, hypotension contraindication: asthma, heart block, COPD 2. Carbonic Anhydrase: Acetazolamide/Mannitol action: decreases production of aqueous humor side effects: allergy (do not give if with sulfa allergy), weight loss, electrolyte imbalance, depression, impotence 3. Cholinergics: Pilocarpine/Carbachol action: increases outflow of aqueous humor side effects: pain, blurry vision, diminished vision at dark 4. Adrenergics: Epinephrine/Dipivefrin

1) C - another preoperative eye drop that is usually prescribed to patient awaiting cataract surgery is tropicamide (mydriacyl) which is a dilating agent. 2) B - cataract surgery is performed to remove the opacified lens. After surgery, a new artificial lens will be inserted at the posterior chamber or the client will be left without a lens. Aphakia or the absence of lens can be corrected to restore normal vision by eye glasses, contact lenses or intraocular lenses. Eye glasses are the safest and least expensive alternative. The nurse should inform the patient that the eyeglasses will be thick and will cause objects to appear closer than they really are and vertical lines will also appear curved. Contact lenses provide better visual correction than eye glasses but the patient must learn how to insert, clean and replace the lenses correctly. This can be difficult for elderly clients

action: decreases production of aqueous humor side effects: tremors, headache, redness and itching 7. A physician prescribes "patching" for a child with strabismus of the right eye. A nurse instructs the mother regarding this procedure. Which of the following statements when made by the mother indicates that she understands the instruction? a) I will place the patch on the right eye b) I will place the patch on both eyes c) I will place the patch on the left eye d) I will alternate the patch from right to left eye hourly 8. The client comments, "I frequently change my eye glasses, none of which is satisfactory and I have difficulty focusing on my work." Which of the following disorders may the client be experiencing? a) cataract b) glaucoma c) detached retina d) myopia 9. An 85-year old woman complains of pain in her operated eye after cataract removal surgery. The nurse knows that this symptoms is a) expected, and she should offer analgesic b) unexpected and may signify a detached retina c) unexpected and may indicate hemorrhage d) expected and she should advise the client to be on bed rest 10. The client had just undergone repair of detached retina. Which of the following should be included in the nursing care plan of the client? a) encourage self-care activities b) limit movement of his eyes c) restrict excessive talking d) limit fluid intake

a) this seasonal allergy should no be a problem b) the medications instilled into my eyes make my vision blurred c) I feel nervous with my operation tomorrow d) I have allergy to certain medications 13. Which of the following is done when performing Weber test? a) place vibrating tuning fork in front of the opening of the ear b) place the vibrating tuning fork in the middle of the head c) place the vibrating tuning fork behind the ear d) irrigate the ear with cold water and observe movement of the eyes 14. The client has been diagnosed to have Meniere's disease. Which of the following should be included when giving health teachings? a) limit carbohydrates and proteins in the diet b) limit salt intake c) limit fats in the diet d) drink a lot of fluids 15. The nurse plans care for a client with acute glaucoma who reports severe pain in the eyes and rainbow colors (halos) around lights. Which action should the nurse take first? a) administer pain medication b) explain to the client that with reduction in intraocular pressure, pain and other symptoms will subside c) provide preoperative teachings to the client d) assess the client's visual status 16. A nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? a) I will not sleep on my left side b) I will not sleep on my right side c) I will not sleep with my head elevated d) I will not wear my glasses until my physician says it is okay 17. A day care nurse is observing a 2-year old child and suspects that the child may have strabismus. Which observation made by the nurse might indicate this condition? a) the child has difficulty b) the child consistently tills the head to see c) the child consistently turns the head to see d) the child does not respond when spoken to

11. Which of the following is an effective technique of communicating with a hearing impaired client? a) speak slowly in a low tone of voice b) speak slowly in a loud voice c) speak slowly and try to overemphasize words d) speak slowly and directly in front of the client 12. Which of the following client statements indicates the need to postpone cataract surgery in the morning?

18. The mother of a 6-year old child arrives at a clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. Based on this diagnosis, the nurse determines that which of the following requires further investigation? a) possible trauma b) possible sexual abuse c) presence of an allergy d) presence of a respiratory infection 19. A nurse prepares a teaching plan for a mother of a child diagnosed with bacterial conjunctivitis. Which of the following, if stated by the mother, indicates a need for further teaching? a) I need to wash my hands frequently b) I need to clean the eye as prescribed c) it is okay to share towels and washcloths d) I need to give the eye drops as prescribed 20. A nurse provides discharge instructions to the mother of a child after myringotomy with insertion of tympanostomy tubes. The nurse determines that the mother needs additional instructions if the mother states that: a) swimming in deep water is prohibited b) swimming in lake water needs to be avoided c) she will place earplugs in the child's ears during baths and showers d) she will be sure to give her child soft tissues to blow his nose 1. Shortly after a neonate is delivered, erythromycin is instilled into the neonate’s eyes. This drug is given to prevent: a. Ophthalmia neonatorum b. Retrolental fibroplasias c. Corneal keratitis d. Acute uveitis 22. An older female client confides to the visiting nurse that she is afraid she will fall while going to the bathroom at night. Which suggestion, if made by the nurse, indicates that the nurse understands the visual changes affecting the older client? a) limit your fluid intake during the day b) use a commode in your bedroom at night c) keep a red light on the bathroom at night d) us ea bell to call your daughter if you need to get up

23. The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which most appropriate nursing diagnosis in the plan of care? a) anxiety b) self-care deficit c) nutrition, imbalanced d0 sensory perception, disturbed 24. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is: a) diplopia b) eye pain c) floating spots d) blurred vision 25. In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physician's orders, expecting which type of eye drops to be prescribed? a) a miotic agent b) a thiazide diuretic c) an osmotic diuretic d) an mydriatic medication

26. During the early postoperative period, the client who has had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: a) call the physician b) reassure the client that this is normal c) turn the client on his or her operative side d) administer the ordered pain medication and anti-emetic 27. The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions? a) I will take aspirin if I have any discomfort b) I will sleep on the side that I was operated on c) I will not lift anything if weighs more than 10 pounds d) I will wear my eye shield at night and my glasses during the day

28. The client with glaucoma asks the nurse if complete vision will return. The most appropriate response is: a) your vision will never return to normal b) your vision will return soon as the medication begins to work c) your vision loss is temporary and will return in about 3 to 4 weeks d) although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan 29. The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care? a) avoid overuse of the eyes b) decrease the amount of salt in the diet c) eye medications will need to be administered for the client's entire life d) decrease fluid intake to control the intraocular pressure 30. The nurse is preforming an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder? a) total loss of vision' b) pain in the affected eye c) a yellow discoloration of hte sclera d) a sense of a curtain falling across the field of vision 1. The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment? a) total loss of vision b) a reddened conjunctiva c) a sudden sharp pain in the eye d) complaints of a burst of black spots or floaters 32. The client arrives in the emergency room following an automobile accident. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse places the client in which position? a) flat on bed rest b) semi-fowler's on bed rest c) lateral on the affected side d) lateral on the unaffected side

object. Which intervention is initiated immediately? a) notify the physician b) apply ice to the affected eye c) irrigate the eye with cool water d) accompany the client to the emergency room 34. The client arrives in the emergency room with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding form the eye. What is the initial nursing action? a) apply an eye patch b) perform visual acuity tests c) irrigate the eye with sterile saline d) remove the piece of wood using a sterile eye clamp 35. The client arrives in the emergency room after sustaining a chemical eye injury from a splash of battery acid. The initial nursing action is to: a) begin visual acuity testing b) cover the eye with a pressure patch c) swab the eye with antibiotic ointment d) irrigate the eye with sterile normal saline 31) D - Complaints of a sudden burst of black spots or floaters indicates that bleeding has occurred as a result of the detachment. Options A, B, and C are not signs of bleeding. 32) B - A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler’s position to assist gravity in keeping the hyphema away from the optical center of the cornea. 33) B - Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries. 34) B - If the laceration is the result of a penetrating injury, an object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the

33. The client sustains a contusion of the eyeball following a traumatic injury with a blunt

eye may disrupt the foreign body and cause further tearing of the cornea. 35) D - Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the emergency department, the irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed. Options B and C are not a component of initial care. NCLEX Review About The Aging Eye 36. The nurse is caring for a client following enucleation. The nurse notes the presence of bright red drainage on the dressing. Which nursing action is appropriate? a) notify the physician b) document the finding c) continue to monitor the drainage d) mark the drainage on the dressing and monitor for any increase in bleeding 37. A 55-year old woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency room frantic and screaming for help. The nurse should instruct the woman to take which immediate action? a) call the physician b) irrigate the eyes with water c) come to the emergency room d) irrigate the eyes with diluted hydrogen peroxide

c) the client can read at distance of 60 feet what a client with normal vision can read at 20 feet d) the client can read only at distance of 20 feet what a client with normal vision can read at 60 feet 40. The clinic nurse notes that following several eye examinations, the physician has documented a diagnosis of legal blindness in the client's chart. The nurse reviews the results of the Snellen chart test expecting note which finding? a) 20/20 vision b) 20/40 vision c) 20/60 vision d) 20/200 vision

36) A - If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician, because this indicates hemorrhage. Options B, C, and D are inappropriate. 37) B - In this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes or until the emergency medical service personnel arrive. In the emergency department, the cleansing agent of choice is normal saline. Calling the physician and going to the emergency room delays necessary intervention. Hydrogen peroxide is never placed in the eyes. 38) A - Visual acuity is assessed in one eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 feet from the chart. 39) D - Vision that is 20/20 is normal—that is, the client is able to read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet. 40) D - Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses) or visual acuity of less than 20 degrees of the visual field in the better eye.

38. The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test? a) the right eye is tested, followed by the left eye, and then both eyes are tested b) both eyes are assessed together, followed by the assessment of the right and the left eyes c) the client is asked to stand at a distance of 40 feet from the chart and asked to read the largest line in the chart d) the client is asked to stand at a distance of 40 feet from the chart and read the line that can be read 200 feet away by an individual with unimpaired vision 39. The client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. The nurse interprets this as: a) the client is legally blind b) the client's vision is normal

1. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client's chart and understands that the normal intraocular pressure is: a) 2 to 7 mm Hg b) 10 to 21 mm Hg c) 22 to 30 mm Hg d) 31 to 35 mm Hg 42. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implantation. Which home care measures will the nurse include in the plan? Select all that apply a) avoid activities that require bending over b) contact the surgeon if eye scratchiness occurs c) place an eye shield on the surgical eye at bedtime d) episodes of sudden severe pain in the eye are expected e) contact the surgeon if a decrease in visual acuity occurs f) take acetaminophen (Tylenol) for minor eye discomfort

d) the medication will help block the responses that are sent to the muscles in the eye

41) B - Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mm Hg are considered within the normal range. 42) A, C, E, F - Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure, such as bending over. 43) A - When an eye drop and an eye ointment are scheduled to be administered at the same time, the eye drop is administered first. Options B, C, and D are incorrect. 44) B - Options A, C, and D are miotic agents used to treat glaucoma. Option B is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye. 45) C - Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options A, B, and D are incorrect. 46. Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which of the following medications does the nurse plan to have available in case of systemic toxicity? a) atropine sulfate b) pindolol (Visken) c) protamine sulfate d) naloxone hydrochloride (Narcan)

43. The client is receiving an eye drop and eye ointment to the right eye. The nurse should: a) administer the eye drop first, followed by the eye ointment b) administer the eye ointment first, followed by the eye drop c) administer the eye drop, wait 10 minutes, and administer the eye ointment d) administer the eye ointment, wait 10 minutes, and administer the eye drop 44. The nurse is caring for a client with glaucoma. Which of the following medications, if prescribed for the client, would the nurse question? a) carbachol (Carboptic) b) atropine sulfate (Isopto Atropine) c) pilocarpine (Ocusert Pilo-20, Ocusert Pilo-40) d) pilocarpine hydrochloride (Isopto Carpine) 45. A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse tells the client that: a) the medication will help dilate the eye to prevent pressure from occurring b) the medication will relax the muscles of the eyes and prevent blurred vision c) the medication causes the pupil to constrict and will lower the pressure in the eye

47. Betaxolol hydrochloride (Betoptic) eye drops have been prescribed for the client with glaucoma. Which of the following nursing actions is most appropriate related to monitoring for the side effects of this medication? a) monitoring temperature b) monitoring blood pressure c) assessing peripheral pulses d) assessing blood glucose level

toxicity. Pindolol is a β blocker. Naloxone hydrochloride is an opioid antagonist used to reverse narcotic-induced respiratory depression. Protamine sulfate is the antidote for heparin. 47) B - Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options A, C, and D are not specifically associated with this medication. 48) B - Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis. 49) A - The client can lie down or sit with the head tilted back. The lower lid should be pulled downward with the thumb or fingers. The client holds the bottle like a pencil, with the tip downward, and squeezes the bottle gently, allowing one drop to fall into the sac. The client gently closes the eye. Options B, C, and D identify correct methods for administering eye drops. 50) D - Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options A, B, and C will not prevent systemic absorption.

48. In preparation for cataract surgery, the nurse to administer cyclopentolate (Cyclogyl) eye drops. The nurse a is to administer the eye drops, knowing that the purpose of this medication is to: a) produce miosis of the operative eye b) dilate the pupil of the operative eye c) provide lubrication to the operative eye d) constrict the pupil of the operative eye 49. The home health nurse visits a client at home and instructs the client on the administration of the prescribed eye drops. Which of the following statements by the client indicates a need for further education? a) I can lie down, pull up the upper lid, and place the drop in the lower lid b) I can lie down, pull down on the lower lid, and place the drop in the lower lid c) I can sit and tilt my head back, pull down on the lower lid, and place the drop in the lower lid d) I can lie on my side opposite to the eye I am going to place the drop, put the drop in the corner of the lid nearest my nose, and then slowly turn to my other side while blinking 50. The nurse is providing instructions to a client who will be self-administering eye drops. To minimize the systemic effects that eye drops can produce, the nurse instructs the client to: a) eat before instilling the drops b) swallow several times after instilling the drops c) blink vigorously to encourage tearing after instilling the drops d) occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops 6) A - Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Atropine sulfate must be available in the event of systemic

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close