1 . During an assessment, the nurse covers the client’s right eye and then observes a shift in
the client’s gaze after the eye is uncovered. Which conclusion should the nurse make about
the results of the test?
A. The client has opacity of the lens-
B. The client has absence of the blink reflex.
C. The client has increased intraocular pressure.
D. The client has weakness in the extraocular muscles.
ANSWER: D
A. Lens opacity is detected by direct observation.
B. Stroking the eyelashes will evoke the blink reflex.
C. The intraocular pressure is measured by tonometry.
D. Covering and then uncovering the client’s eye and then observing for a shift in the
client’s gaze is the cover—uncover test used to detect weakness in the extraocular
muscles.
2. The nurse completes an assessment of the older adult client. Which disorder should the
nurse associate with the finding illustrated?
A. Glaucoma
B. Arcus senilis
C. Cataract
D. Mydriasis
,ANSWER: C
A. Glaucoma causes increased pressure within the eye and is not visible.
B. Arcus senilis is a bluish-white ring within the outer edge of the cornea, which is not
present in this illustration.
C. The illustration shows opacity of the lens of the eye. The nurse should associate this
finding with a cataract.
D. Mydriasis is constriction of the pupil, which is not present in the illustration.
3. The 60-year-old client notices a gradual decline in visual acuity and asks if it could be from
a cataract. Which question will help determine whether a cataract is developing?
A. “Has your ability to perceive colors changed?”
B. “Does your vision appear distorted or wavy?”
C. “Does the center of your visual field appear dark?”
D. “Do you see random flashes of bright light?”
ANSWER: A
A. Asking about a change in the ability to perceive colors will help in determining cataract
development. Cataract formation involves the lens of the eye becoming more opaque,
thus decreasing the vibrancy of colors.
B. Distorted central vision is a sign of macular degeneration.
C. A darkened area in the center of the visual field is associated with macular degeneration.
D. Seeing flashes of bright lights is associated with retinal detachment.
4. The nurse telephones the client 1 day post—cataract surgery. Which client statement
necessitates an evaluation by an ophthalmologist?
A. “My eye starts hurting about 4 hours after a pain pill.”
B. “The redness in my eye is a little less than yesterday.”
C. “There has never been any swelling around my eye.”
D. “I can’t see as well as I could yesterday after surgery.”
ANSWER: D
A. Pain relieved by prescribed pain medication is within normal assessment parameters.
B. Decreasing redness is within normal assessment parameters.
, C. No swelling is within normal assessment parameters.
D. A significant reduction in vision may indicate a complication such as infection or retinal
detachment.
5. The client is one day post—surgical repair of a retinal detachment. Which assessment
finding is most important for the nurse to report immediately to the HCP because it indicates
a significant complication?
A. Surgical eye pain rated 2 on a 10-point scale
B. Increased tearing from the surgical eye
C. Blurred vision and floaters in the surgical eye
D. Dryness and injection of the sclera in the surgical eye
ANSWER: C
A. A low level of postoperative pain does not indicate a significant complication.
B. Watery drainage is not a specific sign for concern and is less serious than changes in
visual acuity.
C. Blurred vision and floaters in the surgical eye may occur with redetachment of the retina
and would warrant additional surgery.
D. Dryness and injection of the sclera may or may not resolve without treatment. However,
a more important sign of complication that should be reported immediately is loss of
visual acuity.
6. The client’s eyes, tested with the use of a Snellen chart, show 20/40 vision in the right eye
and 20/30 in the left eye. How should the nurse interpret these results?
A. The client has elevated intraocular pressure in both eyes.
B. The client needs testing for glaucoma with a tonometer.
C. The left eye is closer to normal vision than the right eye.
D. The client has errors of refraction indicating astigmatism.
ANSWER: C
A. The Snellen chart is not used to measure intraocular pressure.
B. There is no information suggesting that the client needs glaucoma testing.
C. The Snellen chart is used to test distance vision. The numbers recorded indicate that at
20 feet (the first number) the client is able to read what a person with normal vision can
the client’s gaze after the eye is uncovered. Which conclusion should the nurse make about
the results of the test?
A. The client has opacity of the lens-
B. The client has absence of the blink reflex.
C. The client has increased intraocular pressure.
D. The client has weakness in the extraocular muscles.
ANSWER: D
A. Lens opacity is detected by direct observation.
B. Stroking the eyelashes will evoke the blink reflex.
C. The intraocular pressure is measured by tonometry.
D. Covering and then uncovering the client’s eye and then observing for a shift in the
client’s gaze is the cover—uncover test used to detect weakness in the extraocular
muscles.
2. The nurse completes an assessment of the older adult client. Which disorder should the
nurse associate with the finding illustrated?
A. Glaucoma
B. Arcus senilis
C. Cataract
D. Mydriasis
,ANSWER: C
A. Glaucoma causes increased pressure within the eye and is not visible.
B. Arcus senilis is a bluish-white ring within the outer edge of the cornea, which is not
present in this illustration.
C. The illustration shows opacity of the lens of the eye. The nurse should associate this
finding with a cataract.
D. Mydriasis is constriction of the pupil, which is not present in the illustration.
3. The 60-year-old client notices a gradual decline in visual acuity and asks if it could be from
a cataract. Which question will help determine whether a cataract is developing?
A. “Has your ability to perceive colors changed?”
B. “Does your vision appear distorted or wavy?”
C. “Does the center of your visual field appear dark?”
D. “Do you see random flashes of bright light?”
ANSWER: A
A. Asking about a change in the ability to perceive colors will help in determining cataract
development. Cataract formation involves the lens of the eye becoming more opaque,
thus decreasing the vibrancy of colors.
B. Distorted central vision is a sign of macular degeneration.
C. A darkened area in the center of the visual field is associated with macular degeneration.
D. Seeing flashes of bright lights is associated with retinal detachment.
4. The nurse telephones the client 1 day post—cataract surgery. Which client statement
necessitates an evaluation by an ophthalmologist?
A. “My eye starts hurting about 4 hours after a pain pill.”
B. “The redness in my eye is a little less than yesterday.”
C. “There has never been any swelling around my eye.”
D. “I can’t see as well as I could yesterday after surgery.”
ANSWER: D
A. Pain relieved by prescribed pain medication is within normal assessment parameters.
B. Decreasing redness is within normal assessment parameters.
, C. No swelling is within normal assessment parameters.
D. A significant reduction in vision may indicate a complication such as infection or retinal
detachment.
5. The client is one day post—surgical repair of a retinal detachment. Which assessment
finding is most important for the nurse to report immediately to the HCP because it indicates
a significant complication?
A. Surgical eye pain rated 2 on a 10-point scale
B. Increased tearing from the surgical eye
C. Blurred vision and floaters in the surgical eye
D. Dryness and injection of the sclera in the surgical eye
ANSWER: C
A. A low level of postoperative pain does not indicate a significant complication.
B. Watery drainage is not a specific sign for concern and is less serious than changes in
visual acuity.
C. Blurred vision and floaters in the surgical eye may occur with redetachment of the retina
and would warrant additional surgery.
D. Dryness and injection of the sclera may or may not resolve without treatment. However,
a more important sign of complication that should be reported immediately is loss of
visual acuity.
6. The client’s eyes, tested with the use of a Snellen chart, show 20/40 vision in the right eye
and 20/30 in the left eye. How should the nurse interpret these results?
A. The client has elevated intraocular pressure in both eyes.
B. The client needs testing for glaucoma with a tonometer.
C. The left eye is closer to normal vision than the right eye.
D. The client has errors of refraction indicating astigmatism.
ANSWER: C
A. The Snellen chart is not used to measure intraocular pressure.
B. There is no information suggesting that the client needs glaucoma testing.
C. The Snellen chart is used to test distance vision. The numbers recorded indicate that at
20 feet (the first number) the client is able to read what a person with normal vision can
