(ANSWERS and RATIONALE) – NCLEX Review for Eyes

VIEW QUESTIONS

1. ANSWER B. 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 then are tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20ft. from the chart.

2. ANSWER 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.

3. ANSWER 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 only can read at a distance of 20 feet of what a person with normal vision can read at 60 feet.

4. ANSWER 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 mmHg are considered within normal range.

5. ANSWER C. The most appropriate nursing diagnosis for the client scheduled for cataract surgery is Disturbed sensory perception (visual) related to lens extraction and replacement. Although the other options identify nursing diagnoses that may be appropriate, they are not related specifically to cataract surgery.

6. ANSWER C. A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception.

7. ANSWER C. A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medication act by dilating the pupils. They also constrict blood vessels. An osmotic diuretic may be used to decrease intraocular pressure. A miotic medication constricts the pupil. A thiazide diuretic is not likely to be prescribed for a client with a cataract.

8. ANSWER A. Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately. The other options are inappropriate.

9. ANSWER C. The client is instructed to wear a metal or plastic shield to protect the eye from accidental and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the side of the body on which the operation occurred. The client is not to lift more than 5 pounds.

10. ANSWER A. Vision loss to glaucoma is irreparable. The client should be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Option C does not provide reassurance to the client.

11. ANSWER D. The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life.

12. ANSWER C. A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options B and D are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

13. ANSWER A. Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment.

14. ANSWER C. Treatment for 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.

15. ANSWER C. 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 eye may disrupt the foreign body and cause further tearing of the sclera. (The only option that will prevent further disruption is to assess visual acuity.)

16. ANSWER B. 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.

17. ANSWER A. If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician because this indicated hemorrhage.

18. ANSWER B. The numerator refers to the client’s vision while comparing the normal vision in the denominator.

19. ANSWER D. A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye, especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye.

20. ANSWER D. Atropine, an anticholinergic drug, has mydriatic effects causing pupil dilation. This allows more light onto the retina and may cause photophobia and blurred vision. Atropine doesn’t paralyze the blink reflex or cause miosis (pupil constriction). Driving may be contraindicated to blurred vision.

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