Ch. 16 Eyes
While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's A) Esotropia B) Strabismus C) Phoria D) Exotropia
A) Esotropia Rationale: Esotropia is an inward turn of the eye.
What is a characteristic symptom of Graves hyperthyroidism? A) Exophthalmos B) Episcleritis C) Pterygium D) Pinguecula
A) Exophthalmos Rationale: In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.
The optic nerves from each eyeball cross at the A) Optic chiasma B) Visual cortex C) Optic disc D) Vitreous humor
A) Optic chiasma Rationale: At the point where the optic nerves from each eyeball cross—the optic chiasma—the nerve fibers from the nasal quadrant of each retina (from both temporal visual fields) cross over to the opposite side.
The meibomian glands secrete
An oily substance to lubricate the eyes Explanation: meibomian glands secrete an oily substance that lubricates the eyelid.
Which of the following statements most accurately describes the maintenance of normal intraocular pressure?
Aqueous humor is continuously circulating through the eye with production equaling drainage Explanation: aqueous humor, produced by the ciliary body, maintains intraocular pressure with production equaling drainage. It is not a closed system, and pressure is not adjusted through muscular control of eye volume.
Which technique by the nurse demonstrates proper use of the ophthalmoscope?
Ask the client to fix the gaze upon an object and look straight ahead Explanation: after turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye and left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10 to 15 inches from the client at a 15° angle. The nurse should keep the ophthalmoscope still and ask the client to look into the light to view the fovea and macula.
An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. Which the following should the nurse mention to the client as potential risk factors? Select all that apply. A) Lack of vitamin C in the diet B) Ultraviolet light exposure C) Use of antibiotics D) Obesity
B) Ultraviolet light exposure D) Obesity Explanation: exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lens of the eyes). Obesity also increases risk of cataracts. Consistent use of sunglasses during exposure and healthy weight management techniques minimize the client's risk.
A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment?
Blunt force trauma often results in fracture of the orbit Explanation: high velocity injuries are typically penetrating. Blunt force trauma often results in fracture of the eye orbit. Optic atrophy is atrophy of the optic nerve. Strabismus is the medical term for cross eye.
A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition? A) Iris nevus B) Blepharitis C) Hyphema D) Chalazion
C) Hyphema Rationale: Hyphema is blood in the anterior chamber of the eye, usually caused by blunt trauma. Blepharitis is inflammation of the margin of the eyelid. Chalazion is a cyst in the eyelid. Iris nevus is a rare condition affecting one eye. The latter 3 conditions are not commonly attributed to blunt force trauma to the head as hyphema is.
A client complains of feeling like he is slowly losing his central vision. The nurse knows the symptom could represent A) Hemianopsia B) Open-angle glaucoma C) Macular degeneration D) Retinal detachment
C) Macular degeneration Explanation: macular degeneration causes deterioration in the center of the retina, which leads to a gradual loss of central vision.
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? A) Upward toward the forehead B) Downward toward the chin C) Medially toward the nose D) Laterally toward the ear
C) Medially toward the nose Rationale: Follow the blood vessels as they get wider. Follow the vessels medially toward the nose and look for the round yellowish orange structure which is the optic disc.
The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what? A) Conjunctiva B) Limbus C) Lacrimal apparatus D) Eyelid
Conjunctiva Explanation: the conjunctiva is a thin mucous membrane that lines the inner eyelid (palpebral conjunctivae) and also covers the sclera (bulbar conjunctiva). The border between the cornea and the sclera is the limbus. The lacrimal apparatus protects and lubricates the cornea and the conjunctiva by producing and draining tears. The eyelid is a loose fold of the skin that covers and protects the eye.
While the nurse examines a client's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse? A) Consensual reaction B) Myopia C) Presbyopia D) Direct reaction
Consensual reaction Explanation: the consensual reaction is when the pupil constricts in the opposite eye. Myopia is impaired far vision. Presbyopia is impaired near vision often seen in middle-ages and older clients. The direct reaction is when the pupil constricts in the same eye.
A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?
Consensual reaction Explanation: the constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the people one focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object.
The nurse selects the chart shown here to assess a client's vision. Which client characteristic caused the nurse to select this chart?
Does not speak English Explanation: the Snellen E chart can be used for clients who do not speak English. The chart is not used for clients being treated for glaucoma, color blindness, or recovering from cataract surgery.
A client shares that a first-degree relative has an eye problem, but they are not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for? A) Glaucoma B) Retinoblastoma C) Retinitis pigmentosa D) Strabismus
Glaucoma Explanation: glaucoma and a first-degree relative increases the clients risk for the same problem 2 to 3 times. Retinoblastoma can be inherited from either parent but does not have increased incidence if a first-degree relative has the disease. Retinitis pigmentosa is also a genetic disease, but a client's risk of the disease is not increased if a first-degree relative is affected. Strabismus is not genetic in nature.
An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible
Glaucoma Explanation: a scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.
A nurse begins the eye examination on a client who presents to the healthcare clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?
Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time Explanation: near vision is tested with a Jaeger card, Snellen card, or comparable card, held 14 inches from the face. Have the client cover one eye with an opaque card before reading from top to bottom. Sitting the client front of the examiner, extending one arm, and slowly move one finger upward until it is seen by both the client and the examiner is a test for gross peripheral vision. If the client wears glasses, they should be left on for the test. Placing the client 20 feet from the chart and record the smallest line the client can read is the test for distant acuity.
The nurse is planning to assess a clients near vision. Which technique should be used?
Have the client read newspaper print held 14 inches from the eyes Explanation: near vision is tested by asking the client to read newspaper print held 14 inches from the eyes. Shining a light on the bridge of the nose tests the corneal light reflects. Moving the eyes in the direction of a moving finger tests for extraocular movements. Having a client read letters on a wall chart test for central and distance vision.
A client presents to the clinic reporting sudden visual loss in the left eye. What is the nurses priority action?
Notify the healthcare provider immediately Explanation: sudden vision loss is an emergency and should be immediately reported to the healthcare provider. Wearing protective eyewear is not a priority, though whether the client wears protective eyewear is relevant information. Assessing cranial nerve function and vision testing are not realistically possible when the client suffers sudden visual loss.
On a health history, a client reports no visual disturbances, last exam been two years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment for man holds the paper close to the face. What should the nurse do next?
Perform both the distant and visual acuity test Explanation: the first thing the nurse should do is perform both distant and near visual acuity exams to assess for loss of far and near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the client's record. If abnormalities are found upon assessment, the client should be referred for a complete eye examination.
The nurse observes a middle-age colleague fully extending her arm to read the label on a vial of medication. Which of the following age related changes as a nurse likely to have observed?
Presbyopia Explanation: Presbyopia denotes an age related deficit in close vision. It is less likely that cataracts, macular degeneration, or loss of convergence underline the colleague's visual changes.
The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess the clients vision?
Snellen E chart Explanation: the Snellen E chart can be used for people who cannot read or speak English.
How can a nurse accurately assess the distant visual acuity of a client who is non-English-speaking?
Use a Snellen E chart to perform the examination Explanation: if a client does not speak English, is unable to read, or has a verbal communication problem, the Snellen E chart can be used to test the client's distant visual acuity. With this test, the client is asked to indicate by pointing which way the E is open on the chart. The six cardinal positions of gaze tests eye muscle function and cranial nerve function. The Jaeger chart tests near visual acuity. Confrontation test is used to test visual fields for a peripheral vision.
A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?
Use of safety equipment Explanation: the nurse should assess with each client the use of safety equipment when playing sports. Proper eye protection can prevent many sports related eye injuries. All options are points for client teaching for this client; however, the most important opportunity involves the use of safety equipment.
A client in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what? A) 20/200 or less B) 20/300 or less C) 20/400 or less D) 20/100 or less
A) 20/200 or less Rationale: In the United States, a person is usually considered legally blind when vision in the better eye, corrected by glasses, is 20/200 or less.
The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the clients eye. The nurse recognizes this condition, common in older adults, as which of the following? A) Arcus senilis B) Ectropion C) Myopia D) Presbyopia
A) Arcus senilis Explanation: Arcus senilis , a normal condition and older clients, appears as a white arc around the limbis. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused my decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision.
A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client? A) Brain tumor B) Viral infection C) Allergies D) Vitamin A deficiency
A) Brain tumor Rationale: Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor. Vitamin A deficiency is a cause of night blindness. Allergies are usually indicated by burning or itching pain in the eye. Viral infection is usually indicated by redness or swelling of the eye.
When performing a cover test, a nurse notices that the clients left eye turns outward. How should the nurse document is finding in the clients record? A) Exotropia B) Esotropia C) Strabismus D) Presbyopia
A) Exotropia Explanation: with the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant misalignment of the eyes. Presbyopia is impaired near vision.
A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition? A) "Do you see floaters in front of your eyes?" B) "Are the blind spots constant or intermittent?" C) "Is night blindness a problem for you?" D) "How often do you have redness or tearing?"
B) "Are the blind spots constant or intermittent?" Rationale: A scotoma is the presence of blind spots that can be constant or intermittent. If they are constant it may indicate retinal detachment. Intermittent blind spots may be due to vascular spasm or pressure on the optic nerve. Floaters are a common finding in individuals with myopia or in person over the age of 40 years and are a sign of normal aging. Redness or tearing is associated with allergies or inflammation of the eye. Night blindness is associated with optic nerve atrophy, glaucoma, or vitamin A deficiency.
A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye? A) "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." Correct response: B) "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."
B) "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." Rationale: Conjunctivitis usually has an infectious etiology. Severe pain and vision damage are not common consequences.
Which of the following assessment findings suggest a problem with the clients cranial nerves? A) Fundoscopic examination reveals intraocular bleeding B) A client's extraocular movements are asymmetrical and she complains of diplopia C) A client states that he has recently begun seeing lights flashing in his field of vision D) A client's lens appears cloudy and she claims that her visual acuity has recently declined
B) A client's extraocular movements are asymmetrical and she complains of diplopia Explanation: deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology.
The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to A) Congenital cataracts B) Decreased accommodation C) Muscle weakness D) Constant misalignment of the eyes
B) Decreased accommodation Rationale: Presbyopia (impaired near vision) is indicated when the client moves the chart away from the eyes to focus on the print. It is caused by decreased accommodation.
The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should A) Ask the client if there is a genetic history of blindness B) Document the findings in the client's records C) Refer the client for further evaluation D) Examine the client for other signs of glaucoma
B) Document the findings in the client's records Rationale: Validate the eye assessment data that you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.
A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? A) She can accurately name 20% of the letters at 20 feet B) She can see at 100 feet what a normal person could see at 20 feet C) She can see at 20 feet what a normal person could see at 100 feet D) She obtains a 20% correct score at 100 feet
C) She can see at 20 feet what a normal person could see at 100 feet Rationale: The denominator of an acuity score represents the line on the chart the client can read. In the example above, the client could read the larger letters corresponding with what a normal person could see at 100 feet.
A 52-year-old client with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse? A) "Please come into the clinic right away so we can see what is wrong." B) "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." C) "I have an opening tomorrow at 2 in the afternoon. Can you come in then?" D) "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."
D) "It is not an uncommon finding and people older than 40 years for this to happen. They are called floaters." Explanation: floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted clients. No additional follow-up is needed.
An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse assesses the client's eye for A) Double vision B) Allergic reactions C) Viral infection D) Lacrimal obstruction
D) Lacrimal obstruction Explanation: excessive tearing (epiphora) is caused by exposure to irritants or obstruction of the lacrimal apparatus. Unilateral epiphora is often associated with foreign body or obstruction.
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the clients eyes A) Pupils dilate in response to a light shone in the eyes B) Eyes do not converge to focus on a shining light C) Light reflection appears at different spots on both eyes D) There is no reaction in the opposite pupil to light
D) There is no reaction in the opposite pupil to light Explanation: when a light is shone into the eyes, both the pupils that receives direct light and the consensual (opposite) pupils constrict. An abnormal response to this test is if either or both pupils do not constrict in response to light. Pupils do not dilate in response to light shone into them. Convergence of the eyes is called accommodation and occurs when the focus of vision is moved from a far object to a close object. Light reflection appearing at different spots on both eyes is an abnormal result of the corneal light reflex test, not of the consensual pupillary reaction to light test.
A nurse begins the eye examination on a client who presents to healthcare clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?
Have the client hold a Jaeger card 14 inches from the face and read with one eye at a time Explanation: near vision is tested with the Jaeger card, sound card, or comparable card, held 14 inches from the face. Have the client cover one I with no pay card before reading from top to bottom. Sitting in the car in front of the examiner, extending one arm, and slowly move one finger upward until it has seen by both the client and examiner is a test for grass peripheral vision. The client wears glasses, they should be left on for the test. Place in the client 20 feet from the chart and record the small sign the client can read is the test for visual distant acuity.
A 12 year old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on the description, what is the most likely diagnosis?
Stye Explanation: a hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.