[Osborn] chapter 71

Learning Outcomes [Number and Title]

Learning Outcome 1
Identify the normal basic anatomy and physiology of the eye.
Learning Outcome 2
Perform basic assessment, tests, and examination of the eye to
obtain meaningful data for management and treatment.
Learning Outcome 3
Describe different types of visual and ocular conditions and
problems.
Learning Outcome 4
Apply nursing diagnosis, nursing process, and patient teaching
associated with visual and ocular problems of the adult.
Learning Outcome 5
Discuss and provide meaningful resources for patients with
visual and ocular problems.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

1. The function of the lens of the eye is accommodation. This allows the individual to:
1. See objects at close and at far range.
2. See at night.
3. Prevent too much light from entering the eye.
4. Distinguish color.
Correct Answer: See objects at close and at far range.
Rationale: The lens is the focusing structure of accommodation that allows seeing objects at
close and at far range. Night vision and color vision are a function of rods and cone receptors in
the retina. The pupil controls the amount of light entering the eye.
Cognitive Level: Comprehension
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

2. An examination of a client indicates there is limited central vision. This would indicate a
problem with the:
1. Macula.
2. Lens.
3. Sclera.
4. Extraocular muscles.
Correct Answer: Macula.
Rationale: The center of the retina, called the macula, is where the greatest numbers of cone
receptors are located for central and color vision. The sclera is the outer protective layer of the
eyeball that helps maintain its shape. The lens is the focusing structure of accommodation. The
extraocular muscles move the eyeball.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

3. A client complains that sometimes there appears to be gnats in his field of vision. The nurse
realizes the client is talking about:
1. Floaters.
2. Conjunctivitis.
3. Nystagmus.
4. Strabismus.
Correct Answer: Floaters.
Rationale: The vitreous gel is made up mainly of water with a collagen framework. The collagen
network can be aggregated by vitreous collapse due to aging and form opacities, which cast
shadows on the retina. These shadows are referred to as floaters. The client often describes this
as seeing gnats or a fine filament floating in the line of sight. Conjunctivitis is an inflammation
of the conjunctiva. The main symptom is a discharge from the eyes. Nystagmus is an involuntary
tremor or jerky movement of the eyeball. Strabismus is a functional misalignment of the
extraocular muscles that causes the eyes not to focus together.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

4. During an initial examination of the eye, the intraocular pressure should be measured. The
nurse would use a _______________ to determine to pressure.
1. Tonometer
2. Ophthalmoscope
3. Pen light
4. Snellen acuity chart
Correct Answer: Tonometer
Rationale: A tonometer is used to measure the intraocular pressure. An ophthalmoscope is used
to view the fundus of the eye by viewing through the pupil. A pen light is used for external
examination of the eye. The Snellen acuity chart is used to measure visual acuity.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

5. During an assessment of the eye, the optic nerve can be evaluated by:
1. Direct ophthalmoscope examination.
2. Using dilation eyedrops.
3. Shining a pen light into the eye.
4. A tonometer.
Correct Answer: Direct ophthalmoscope examination.
Rationale: Direct ophthalmoscope examination is used to check the fundus of the eye, viewing
through the pupil. The optic nerve can be visualized and should be checked for color, shape, and
vessels. Dilation eyedrops are used for many diagnostic tests, but are not required to see the optic
nerve with an ophthalmoscope. The optic nerve cannot be seen by shining a pen light into the
eye. A tonometer is used to measure intraocular pressure.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

6. A visual field test is performed on a client to test peripheral visual acuity. The nurse finds that
the clients angle of recognition of the test object is decreased in two of the four quadrants. The
appropriate response of the nurse should be to:
1. Refer for further testing.
2. Document it is a normal test result.
3. Repeat the test.
4. Repeat the test with the clients glasses on.
Correct Answer: Refer for further testing.
Rationale: If any visual field defects are noted, the client should be sent for sophisticated visual
field testing. The degree of angle recognition must approximate normal degrees for all four
quadrants to be documented as normal results. The test does not need to be repeated if
administered correctly. The clients glasses should be off because the glasses frame may interfere
with the field of vision.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

7. A client has been diagnosed with primary glaucoma. Primary glaucoma refers to form of
glaucoma that:
1. Has no relation to other ocular conditions.
2. Is the result of another preexisting ocular condition.
3. Is caused by a congenital anomaly.
4. Is not as serious as other forms of glaucoma.
Correct Answer: Has no relation to other ocular conditions.
Rationale: Primary glaucoma infers that it has no relation to other ocular conditions, and
secondary glaucoma is the result of another preexisting ocular condition. A congenital anomaly is
a cause of secondary glaucoma. Glaucoma is always serious and can cause blindness because the
increased intraocular pressure can cause optic nerve changes.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

8. The nurse performed a cover-uncover test on a client to test for atropia. When the left eye was
covered, the right eye moved inward. The finding indicated that the client had:
1. Exotropia.
2. Esotropia.
3. No strabismus.
4. Vertical phoria.
Correct Answer: Exotropia.
Rationale: Tropia is a functional defect that results from a break in visual fusion due to an
imbalance or misalignment of the extraocular muscles when both eyes are not covered. If the
uncovered eye moves inward, then it was fixed outward. This is exotropia. If the uncovered eye
moves outward, then it was fixed inward. This is esotropia. If the uncovered eye does not move,
it indicates the client does not have strabismus, which is a functional misalignment of the
extraocular muscles that causes the eyes not to focus together. If the uncovered eye moved up or
down, it would indicate vertical phoria.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

9. A client is admitted with orbital cellulitis of the right eye. The most common cause of orbital
cellulitis in adults is an infection caused by staphylococci and streptococci as a result of:
Bacterial sinusitis.
Traumatic induction of bacteria.
Intraocular surgery.
Conjunctivitis.
Correct Answer: Bacterial sinusitis.
Rationale: Orbital cellulitis is inflammation of the postseptal orbital tissue from the spread of
bacteria from elsewhere, usually from the nasal and sinus system. The most common causative
organisms in adults are staphylococci and streptococci from bacterial sinusitis. It can be caused
by traumatic induction of bacteria, but it is not the most common cause. Infection is a risk of any
surgery, but an infection from intraocular surgery generally does not cause orbital cellulitis.
Conjunctivitis is an inflammation of the conjunctiva caused by a bacteria, virus, or allergen.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

10. The nurse is caring for a client newly diagnosed with glaucoma. The client is asymptomatic
except for the increased intraocular pressure detected during a routine eye examination. When
developing a plan of care for this client, which of the following goals should have the highest
priority?
1. Stress importance of compliance with glaucoma eyedrops.
2. Assess for fall injuries.
3. Consider home maintenance issues.
4. Discuss risk factors.
Correct Answer: Stress importance of compliance with glaucoma eyedrops.
Rationale: All of the goals should be part of a nursing care plan for a client with glaucoma.
However, this client is asymptomatic and has not suffered any vision loss. To prevent vision loss,
the importance of client compliance with glaucoma eyedrops to decrease the intraocular pressure
should be given the highest priority. Discussion of risk factors is important, but the eyedrops are
the most effective method of decreasing the chance of vision loss. Assessing for fall injuries and
home maintenance issues are more relevant to clients who already have vision loss.
Cognitive Level: Analysis
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

11. Following a severe eyelid laceration, the most important aspect of client education is:
1. Prescribed medication regimen.
2. Care of the eye patch.
3. Surgical reconstruction.
4. Use of ice packs.
Correct Answer: Prescribed medication regimen.
Rationale: Client education about the prescribed medication regimen is a must to prevent the risk
of noncompliance. When discussing the medications, it is important to stress good hand hygiene
before applying eyedrops or ointments to prevent the risk of infection. A patch is contraindicated
if an intraocular foreign body is present. Surgical reconstruction may not be necessary depending
on the severity of the injury. Ice packs may be used to control bleeding, reduce swelling, and
may provide some comfort. Ice packs must be used correctly, but client education in this area is a
lower priority.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

12. Phenylephrine (Neo-Synephrine) is administered to a client before a diagnostic procedure.

The client education about this medication should include:
1. Driving may be difficult.
2. Tears will be yellow.
3. May cause burning.
4. Sunlight will improve vision.
Correct Answer: Driving may be difficult.
Rationale: Phenylephrine causes pupillary dilation. The nurse should inform the client that
driving with eyes dilated may cause difficulty, especially on a sunny day. Patients should be
instructed to wear sunglasses to block ultraviolet (UV) exposure. The pupils are unable to react
to or decrease the amount of light entering the eye. Burning is an adverse reaction to
phenylephrine. Medications that numb the eye, such as Proparacaine, will cause the tears to be
yellow.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

13. A client recovering from a head injury has adult strabismus. This client would probably be
referred for the most common treatment of adult strabismus, which is/are:
1. Eye muscle surgery.
2. Eye muscle exercises.
3. Botox injections.
4. Glasses.
Correct Answer: Eye muscle surgery.
Rationale: Eye muscle surgery is the most common treatment. It is used to loosen or tighten the
muscles around the eye in order to correct the misalignment. Eye muscle exercise is used when
treating a form of adult strabismus called convergence insufficiency. Botox injections are an
effective treatment when overactive eye muscles are causing strabismus. Prism eyeglasses can be
used to correct mild double vision associated with adult strabismus.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

14. A pregnant woman with retinitis pigmentosa is concerned about the possibility that the baby
will also develop the disorder. An appropriate referral source would be:
1. Genetic counseling.
2. An ophthalmologist.
3. A gynecologist.
4. A nutritionist.
Correct Answer: Genetic counseling.
Rationale: Retinitis pigmentosa is a hereditary disorder. Genetic counseling would give the client
information regarding hereditary traits. An ophthalmologist, gynecologist, and nutritionist are all
important resources for this patient, but are not the best resource for discussing hereditary traits.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

15. A client with blindness resulting from diabetic retinopathy is being cared by a family
member. When developing a plan of care for this client, the highest priority in this situation
would be an assessment to determine if a referral is needed for:
1. Respite services.
2. A low-vision rehabilitation specialist.
3. Assistive devices.
4. Housekeeping assistance.
Correct Answer: Respite services.
Rationale: An individual who is the sole caregiver may need respite services if he or she is the
only support system for the family. It is difficult for a single individual to be a sole caregiver, and
the individual would likely need some type of respite service. A client who is blind would
probably not benefit from a referral to a low-vision specialist. Assistive devices and
housekeeping assistance may be necessary, but assessment for the need for respite services
would be a higher priority.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.