TESTBANK For ATI Medical Surgical Nursing Assessment of the Eye and Vision

TESTBANK For ATI Medical Surgical Nursing Assessment of the Eye and Vision TESTBANK For ATI Medical Surgical Nursing Assessment of the Eye and Vision 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 Adaptation—Pathophysiology) 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 TESTBANK For ATI Medical Surgical Nursing Assessment of the Eye and Vision TESTBANK For ATI Medical Surgical Nursing Assessment of the Eye and Vision 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 Adaptation—Alterations 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. TESTBANK For ATI Medical Surgical Nursing Assessment of the Eye and Vision TESTBANK For ATI Medical Surgical Nursing Assessment of the Eye and Vision DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Teaching/Learning 4. The nurse performs an assessment of a client’s 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)