advanced assessment 3rd edition goolsby test bank
Chapter 5. The Eye
Identify the choice that best completes the statement or answers the question.
____ 1. The most common type of eye disorder is:
____ 2. Which of the following findings should trigger an urgent referral to a cardiologist or neurologist?
|A.||History of bright flash of light followed by significantly blurred vision|
|B.||History of transient and painless monocular loss of vision|
|C.||History of monocular severe eye pain, blurred vision, and ciliary flush|
|D.||All of the above|
____ 3. The first assessment to complete related to the eyes is:
____ 4. It is important to not dilate the eye if ____ is suspected.
|C.||Acute closed-angle glaucoma|
|D.||Chronic open-angle glaucoma|
____ 5. Which of the following is true concerning adjustment of diopters during funduscopic exam?
|A.||Moving towards more positive diopters shifts examiner’s focus posteriorly|
|B.||Moving towards more negative diopters shifts examiner’s focus anteriorly|
|C.||Moving towards more positive diopters broadens the examiner’s field of view|
|D.||Moving towards more negative diopters broadens the examiner’s field of view|
____ 6. A clinician can assess the alignment of the eyes by all except:
|A.||Checking for a symmetric light reflex|
|B.||Observing eye movements|
|C.||Performing cover/uncover exam|
|D.||Measuring the palpebral gap|
____ 7. The fundoscopic examination allows the clinician to directly observe:
|A.||Cranial nerve I|
|B.||Cranial nerve II|
|C.||Cranial nerve III|
|D.||Cranial nerve IV|
____ 8. Shining a light directly on one pupil should make the other pupil constrict. This is called the:
|C.||Corneal light reflex|
|D.||Consensual pupil response|
____ 9. Your patient describes blurry vision as well as halos and glares in response to bright lights or when driving in the dark. There is no pain. These are symptoms of:
____ 10. While assessing visual acuity, you notice that the patient is turning his head “side-to-side” for an oblique, or peripheral, view of the Snellen chart, raising your suspicion that the patient may suffer from:
____ 11. When examining the six cardinal fields of gaze, the clinician is assessing function of:
|D.||All of the above|
____ 12. Your patient has been treated for glaucoma for 5 years. Which of the following will provide indication of the level of progression during the funduscopic examination for this patient?
|A.||Checking the macula|
|B.||Estimating cup-to-disk ratio|
|C.||Verifying a red reflex|
____ 13. A patient describes a brief episode of visual impairment where it was as if a dark shade was gradually coming down over one eye. The vision returned a moment later. This is most commonly described in which condition?
____ 14. A Marcus-Gunn effect involves:
|A.||Abnormal pupillary responses|
|B.||Abnormal visual acuity|
|C.||Abnormal funduscopic findings|
|D.||All of the above|
____ 15. In the following condition, patients often describe a sudden, large flash of light with gradual loss of vision in one eye.
____ 16. Macular degeneration is a visual disturbance due to:
|A.||Sudden head trauma|
|B.||Ischemia of the central retinal artery|
|C.||Elevated intraocular pressure|
____ 17. An Amsler grid is used to evaluate which of the following conditions?
____ 18. The most common cause of eye redness is:
____ 19. A patient presents with eye redness, scant discharge, and a gritty sensation. Your examination reveals the palpable preauricular nodes, which are most likely with:
____ 20. Your patient with Crohn’s Disease complains of eye pain and photophobia. This is likely related to:
|A.||Symptoms of temporal arteritis|
|B.||Altered pupil response due to uveitis|
|C.||Blurry vision due to bilateral cataracts|
____ 21. Your patient is suffering from herpes zoster along the trigeminal nerve distribution of the face. You should carefully assess for the presence of:
____ 22. A 4-day-old newborn presents with redness and tearing of one eye. Slight pressure over the lacrimal sac produces white discharge. The clinician should be aware that the following condition is common in newborns:
____ 23. Ptosis is commonly the first sign of:
____ 24. A 9-month-old patient presents with fever and large areas of redness and bullae over the trunk, palms, legs, and sole of the feet. There is redness and swelling of the conjunctiva and lips. The clinician should recognize this condition as:
|A.||Giant cell arteritis|
____ 25. In assessing the eyes, which of the following is considered a “red flag” finding when associated with eye redness?
|A.||History of prior red-eye episodes|
|B.||Grossly visible corneal defect|
Chapter 5. The Eye
The most common forms of visual impairment are refractive errors. In fact, over 150 million Americans are reported to use corrective lenses for refractive errors.
Amaurosis fugax is a monocular, transient loss of vision. It stems from transient ischemia of the retina and presents an important warning sign for impending stroke. Depending on the circumstances reported, the patient should be immediately referred to either a cardiovascular or neurological specialist.
The eye examination begins with determination of the patient’s visual acuity. Next, the examiner typically inspects the external and accessory structures before concentrating inward to include the eye.
If the patient has experienced sudden onset of eye pain, it is important not to dilate the eyes before determining whether acute closed-angle glaucoma is present because dilating the eye may increase the intraocular pressure.
As the dial on the ophthalmoscope is moved counterclockwise, the diopters shift from positive to negative. Because the more negative diopters direct the focus posteriorly, by moving from the positive to negative diopters, your focus will shift from the anterior eye to the posterior eye, retina, and optic disk.
Alignment is evaluated by observing eye motion, performing the cover/uncover test, and assessing the light reflex.
The optic nerve (CN II) is directly observed during the fundoscopic examination.
The pupillary reflex is elicited by holding the light source in front of the patient so that it is directed toward one eye. At this point, observe both pupils, noting the direct response of the eye receiving the direct light and the consensual response in the opposite eye.
Patients with cataracts generally describe progressive and painless decreased visual acuity. The altered vision includes general blurring, dimming, and haziness of vision as well as the development of halos and glares in response to bright lights or when driving in the dark. The opacities may be visible as gray or whitening areas over the pupil.
Visual loss associated with macular degeneration can be progressive, unilateral or bilateral, and starts centrally.
The six cardinal fields of gaze are testing the extraocular muscles, which are innervated by the oculomotor nerve (CN III), trochlear nerve (CN IV), and abducens nerve (CN VI).
In glaucoma, inspection may identify cup/disk ratio change; late afferent effect is possible.
In amaurosis fugax, the patient often describes an episode as if a shade had been pulled over one eye in a descending fashion and then, a short time later, the shade was raised and vision restored.
Note whether the pupil response is a slight constriction, slightly more pronounced with direct light, which is normal, or the pupil slightly relaxes so that the response is slightly less pronounced with direct light, which is an abnormal, Marcus-Gunn effect.
With retinal detachment, the patient usually provides a history of a contributing condition or trauma, followed by a sudden visual disturbance, such as flashing light, floaters, or scotoma. The visual defect may advance or progress as the retinal detachment enlarges, but central vision will be retained unless the macula is involved.
Most commonly, macular degeneration is associated with aging and results either from atrophy of the macula or exudation and hemorrhage of the vessels in the macular region.
With macular degeneration, a commonly used test, the Amsler grid, assesses the patient’s ability to accurately see a set of grids.
The most common cause of eye redness is conjunctivitis (see Plate 38), which involves an inflammation of one or more areas of the conjunctiva. It is important to discriminate between allergic, viral, bacterial, and other causes of conjunctivitis in order to provide definitive treatment. Infectious conjunctivitis is usually caused by viral organisms, although bacterial infections are also common and can be secondary to viral infections. Allergies are the most frequent cause of noninfectious conjunctivitis. Other causes include chemical reactions.
Preauricular nodes are nonpalpable and nontender in allergic conjunctivitis, usually nonpalpable in bacterial conjunctivitis, and palpable in viral conjunctivitis.
Uveitis involves inflammation of the uveal tract, including the iris. The inflammation may be caused either by infection or as part of a reaction associated with a systemic disorder. For instance, an increased incidence of uveitis is associated with autoimmune disorders, such as Crohn’s disease, ankylosing spondylitis, and HIV infection. The vision changes associated with uveitis stem from altered responsiveness of the pupil and lens. Patients commonly experience both photophobia and eye pain. There is a ciliary flush and, usually, a constricted pupil.
Keratitis is inflammation of the cornea that can lead to blindness in the affected eye. Keratitis is commonly caused by herpetic and other infections, ischemia, chemical exposures, foreign bodies, or corneal abrasions. Keratitis is noteworthy because it can lead to ulcerations, opacities, and blindness of the affected eye; thus, patients suspected of this disorder should be immediately referred to an ophthalmologist.
Dacryocystitis is an infection of the lacrimal sac and is most common in infants, secondary to congenital stenosis of the lacrimal duct. If the duct is occluded, constant tearing may occur. The lacrimal sac may be edematous, red, and tender. Pressure over the sac produces purulent discharge.
Ptosis, or drooping of an eyelid, can be related to simple aging, with natural loss of elasticity and lid drooping, or it can result from a variety of other causes. The causes of ptosis are often categorized as congenital and acquired. Causes occurring after birth include trauma, conditions adding mass to the eyelid, and conditions that affect the nerves or muscles controlling the lid’s position. In 75% of the cases, the first manifestation of myasthenia gravis is ptosis.
Stevens-Johnson syndrome, also called erythema multiforme, involves inflammation of the mucous membranes and skin. It is often related to an infection or can be due to almost any medication. Often, no specific cause is identified. The condition can be fatal. It is important to immediately recognize and treat. The patient appears acutely ill and has systemic symptoms, including malaise, fever, and arthralgias, so that the eye findings are not isolated. Conjunctival bullae and ulcerations may develop. Patients develop erythematous lesions and bullae over the skin and hemorrhagic lesions of the mucous membranes. In addition to the eye tissue, the palms, soles, anus, vagina, nose, and mouth are commonly affected.
Red flag warnings for eye redness include pain (not discomfort or irritation), decreased vision, profuse discharge, and corneal defect grossly visible.
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