Deck 11: Assessing the Eyes

Question 1

Which of the following cranial nerves are responsible for the activity of the eye? Select all that apply.

A) Cranial nerve III
B) Cranial nerve IV
C) Cranial nerve I
D) Cranial nerve VI
E) Cranial nerve X

Answer 1

Cranial nerve III
Cranial nerve IV
Cranial nerve VI

Question 2

The nursing instructor is teaching a group of students about the Healthy People 2020 goals related to improving vision health. Which objectives should the nursing student be prepared to include in future patient education? Select all that apply.

A) Have routine eye examinations performed.
B) Rest your eyes.
C) Wear protective eyewear.
D) Increase protein in diet.
E) Take B₁₂ vitamins daily.

Answer 2

Have routine eye examinations performed.
Rest your eyes.
Wear protective eyewear.

Question 3

The extraocular structures of the eye include which of the following? Select all that apply.

A) Sclera
B) Conjunctiva
C) Optic nerve
D) Lacrimal glands
E) Iris

Answer 3

Conjunctiva
Lacrimal glands

Question 4

A patient is diagnosed with glaucoma. The nurse reviews the patient's medical record, expecting to note which of the following? Select all that apply.

A) Medications for intraocular pressure
B) Decreased visual acuity
C) Loss of peripheral vision
D) Redness of the conjunctiva
E) Swelling of the eyes

Question 5

An older patient is diagnosed with macular degeneration and asks the nurse to explain this condition. The nurse includes which information in her response to the patient? Select all that apply.

A) "It may be an age-related problem."
B) "It is a breakdown of cells in the macula of the retina."
C) "It is caused by a gradual blockage of the arteries and veins in your eye."
D) "It is a result of deterioration of the area that controls peripheral vision."
E) "Treatment aims to help maximize remaining vision."

Question 6

You are assessing a patient's eyes. You start by inspecting the anterior eye structures. Normal findings would include which of the following? Select all that apply.

A) Eyelashes equally distributed
B) Yellow drainage from lacrimal ducts
C) Eyes symmetrical
D) Cornea with white opacities
E) Sclera white
F) No abnormal involuntary movement

Question 7

You are assessing a patient's eye using the Confrontation Test for Visual Field Testing. At what angles should the field of vision be assessed? Select all that apply.

A) Temporal
B) Nasal
C) Posteriorly
D) Superiorly
E) Inferiorly

Question 8

You are performing an eye assessment on a patient in the intensive care unit who suffered a head injury. Which of the following are normal findings? Select all that apply.

A) The left pupil measures 7 mm and the right pupil measures 6 mm.
B) The eyes are symmetrical.
C) There is a drooping eyelid and constricted right pupil.
D) The pupils dilate in response to light.

Question 9

You are assessing the internal structures of the eye. Normal findings of the optic disc include which of the following? Select all that apply.

A) Color is red or dark orange
B) Shape is round or oval
C) Disc outline is sharp or cloudy
D) Central physiologic cup (if present) is a dark gray color

Question 10

You are assessing for color blindness. What are the most common colors affected when you have color blindness? Select all that apply.

A) White
B) Red
C) Blue
D) Brown
E) Green

Question 11

A patient has fallen off a small cliff and hit his head. He reports blurry vision. What is the purpose of inspecting this patient's pupil size and consensual pupil response? Select all that apply.

A) To assess the integrity of the optic pathways
B) To assess the accommodation reflex
C) To assess the pupillary light reflex
D) To assess the functioning of the ocular muscles

Question 12

You are assessing a patient's eyes and note that the left eyelid is drooping. What assessment should you perform next?

A) Assess the nasolacrimal folds.
B) Assess the conjunctiva for drainage.
C) Assess the palpebral fissures.
D) Assess the pupil reaction.

Question 13

The nurse is preparing a patient for a dilated eye examination using mydriatic eye drops. Which areas of the eye will be examined?

A) Eyebrows, conjunctiva, and optic disc
B) Conjunctiva, optic disc, and eyelids
C) Pupils, sclera, and lacrimal glands
D) Fundus, macula, and optic disc

Question 14

The nurse is preparing a patient for a dilated eye examination using mydriatic eye drops. What post-procedure education should be provided to the patient?

A) "You should not drive for 1 to 2 hours."
B) "You will need to remain on bedrest today."
C) "You should follow up with the doctor in a week."
D) "You may feel a numbing sensation for several hours."

Question 15

An elderly African American man reports that he has been diagnosed with open-angle glaucoma. He has a past medical history of being a type 2 diabetic and states that he takes pills for his diabetes. He does not know what he did wrong to have this eye condition and asks if you can help him to understand why he has glaucoma. How should the nurse respond?

A) "Open-angle glaucoma is more common in diabetics and African Americans."
B) "You should not have glaucoma at your age, but sometimes it just develops."
C) "Open-angle glaucoma occurs more often when you do not get regular eye examinations."
D) "Open-angle glaucoma occurs most often among all family members."

Question 16

A patient comes to the community health clinic complaining of blurry vision. She reports that her vision has been blurry for the last couple of months. Which statement by the patient may require further evaluation?

A) "My mother has diabetes and takes insulin every day."
B) "My father had decreased circulation in his legs."
C) "I wear dark sunglasses when I'm outside."
D) "I had my last eye examination 2 years ago."

Question 17

You are starting to perform an internal eye assessment. Using the ophthalmoscope, you have tried several times to find the red reflex but are unable to see it. What should be your next action?

A) Ask the patient if he or she has any eye pain.
B) Call the health-care provider immediately.
C) Ask the patient if he or she has an artificial eye or cataracts.
D) Continue on with your internal eye examination.

Question 18

The patient's daughter reports that her mother has red, crusty, and greasy eyelid lashes every morning and throughout the day. The nurse knows that this condition is called:

A) Conjunctivitis.
B) Hordeolum.
C) Blocked lacrimal duct.
D) Blepharitis.

Question 19

You are assessing the vision of a patient who wears glasses. What instructions will you give this patient?

A) "Read each line from right to left on the Snellen chart until you cannot read one letter correctly."
B) "Read each line on the Snellen chart until you cannot read all the letters."
C) "You may keep your glasses on, cover your left eye, and start reading each line from left to right."
D) "Remove your glasses, cover your right eye, and start reading the lines from top to bottom."

Question 20

The nurse is conducting the Snellen test on a patient in a clinic. The findings are recorded as 20/40 in both eyes. Which is the correct interpretation of this finding?

A) The patient can read from 20 feet what someone with 20/20 vision can read at 40 feet.
B) The patient is farsighted and needs correction to see more clearly.
C) The patient can read from 40 feet what someone with 20/40 vision can read at 20 feet.
D) The patient is suffering from presbyopia and needs to be rescreened.

Question 21

You are assessing the eyes for PERRLA. What equipment will the nurse need?

A) Blood pressure cuff
B) Stethoscope
C) Reflex hammer
D) Penlight

Question 22

You are assessing consensual pupil reaction. What is a normal finding?

A) Shine light into the left eye pupil and assess the left eye; left eye should constrict.
B) Shine light into the left eye pupil and assess the right eye; right eye should constrict.
C) Both eyes should dilate in response to bright light.
D) Both eyes should constrict when the lights are turned on.

Question 23

A patient presents to the clinic complaining of blurred vision and feeling like he needs to clean his glasses all the time, which does not improve his blurry vision. The patient denies eye pain. Based on this patient's report, which eye disorder would the nurse suspect?

A) Ectropion
B) Conjunctivitis
C) Diabetic retinopathy
D) Cataracts

Question 24

The patient reports that he is legally blind. The definition of legal blindness is:

A) Visual acuity of 20/40 or more.
B) Visual acuity of 20/50 or more.
C) Visual acuity of 20/100 or more.
D) Visual acuity of 20/200 or more.

Question 25

Which statement illustrates proper use of the standard ophthalmoscope?

A) Hold the instrument in your right hand to examine the patient's right eye.
B) Focus the lens from a position of about 12 to 15 inches away from the patient.
C) Ask the patient to look directly into the light beam.
D) No adjustments to the diopter are needed to see the red reflex.

Question 26

A patient comes to the urgent care center stating that while mowing his lawn, his eyes brushed against a hanging tree limb. He reports that his "eyes hurt and feel gritty." Which external structures should the nurse inspect?

A) Conjunctiva
B) Macula
C) Retina
D) Pupil size

Question 27

A patient comes to the emergency room complaining that he has sudden left eye pain with blurry vision. He states, "I am also seeing flashing lights in my left eye." What eye condition does the nurse suspect?

A) Cataract blindness
B) Acute glaucoma
C) Detached retina
D) Macular degeneration

Question 28

The 60-year-old patient is complaining of seeing tiny floating spots in his line of vision, especially when he wakes up in the morning. The nurse knows that these symptoms are the result of which pathological process?

A) Clouding of the lens
B) Myopia
C) Hyperopia
D) Vitreous floaters

Question 29

The nurse asks a patient to read a paragraph in a newspaper. He is able to read the paragraph without difficulty. She asks the patient to read the bottom line of a Snellen chart and he is unable to read all the letters correctly. Which visual disorder would the nurse suspect?

A) Hyperopia
B) Legal blindness
C) Myopia
D) Presbyopia

Question 30

The nurse is preparing to assess a patient's central vision. Which chart will the nurse use to assess central vision?

A) Snellen
B) Tumbling 5
C) Amsler grid
D) Ishihara plate

Question 31

The nurse is testing the patient's peripheral vision. Which test will the nurse perform or use?

A) Amsler grid
B) PERRLA
C) Confrontation
D) Snellen chart

Question 32

The nurse is examining a 48-year-old patient's eyes and notices the patient moving the handheld vision card to arm's length. Which visual disorder would the nurse suspect?

A) Hyperopia
B) Blindness
C) Myopia
D) Presbyopia

Question 33

You are performing an eye assessment and inspecting the conjunctiva. What instructions should you give to the patient?

A) Ask the patient to look up.
B) Ask the patient to look down.
C) Ask the patient to look at a focal point on the wall.
D) Ask the patient to look straight ahead.

Question 34

The patient covers one eye. You place your hand with extended fingers behind the patient's field of vision and move your fingers toward the patient's field of vision. What assessment technique are you performing?

A) Consensual response
B) Confrontation test
C) Test for accommodation
D) Ocular mobility test

Question 35

You are assessing the accommodation reflex of the eye. How far away should you hold the object from the eye for the patient to focus on it?

A) 6 inches
B) 12 inches
C) 14 inches
D) 16 inches

Question 36

You are assessing the accommodation reflex of the eye. Which is a normal finding?

A) Pupils constrict and both eyes converge simultaneously.
B) Pupils constrict and both eyes diverge simultaneously.
C) Pupils dilate and both eyes converge simultaneously.
D) The right eye dilates and the left eye constricts with accommodation.

Question 37

You are assessing the six cardinal positions of gaze. While performing this assessment, what should the nurse do to make sure involuntary movements of the eye are not missed?

A) Slowly move the object to six different positions.
B) Tell the patient to move his or her head to follow the pattern.
C) Pause before changing each of the six different positions.
D) Hold the patient's head in place and look directly into the eyes.

Question 38

A patient arrives in the emergency room after falling down a cliff. He is lethargic. You are assessing his pupils and note the right pupil measurement is 10 mm and the left pupil measurement is 6 mm. This is called:

A) Diplopia.
B) Anisocoria.
C) Miosis.
D) Mydriasis.

Question 39

A diabetic patient has come in for his annual physical examination. He reports that he has been a diabetic for more than 40 years and takes insulin. You take his vital signs: blood pressure 170/92, pulse 82, respiratory rate 18, and temperature 97.8°F (tympanic). The patient reports that his blood pressure is always high. You assess the eyes with an ophthalmoscope and see puffy, white patches on the retina. What are you seeing?

A) Drusen bodies
B) Diabetic retinopathy
C) Papilledema
D) Cotton wool spots

Question 40

You are performing an eye assessment. The part(s) of the eye you are palpating in this picture is/are the ___________ _____________.