Chapter 11 The Eyes
The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following? Ectropion Myopia Presbyopia Arcus senilis
Arcus senilis Explanation: Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by 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 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? This could be a sign of strabismus The client could have optic atrophy Blunt-force trauma often results in fracture of the orbit High-velocity injuries are typically non-penetrating
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 orbit. Optic atrophy is atrophy of the optic nerve. Strabismus is the medical term for cross-eye.
A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, "Do you wear sunglasses during exposure to the sun?" the nurse is addressing a known risk factor for what health problem? Presbyopia Nystagmus Cataracts Glaucoma
Cataracts Explanation: Sun exposure is a risk factor for cataracts but is not noted to influence the development of presbyopia, nystagmus, or glaucoma.
A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process? Retinal detachment Renal insufficiency Diabetes Anemia
Diabetes Explanation: Exudates appear as light-colored spots on the retinal background and occur in individuals with diabetes or hypertension. Anemia, renal insufficiency, and retinal detachment do not cause this appearance on the retina.
What is vital in maintaining vision and a healthy outlook for clients? Health education Emotional support Monthly eye exams Physical exercise
Health education Explanation: Nursing education is vital in maintaining vision and a healthy outlook for clients.
A nurse is presenting a class to a local community group about vision and eye health. As part of the presentation, the nurse explains how visual perception occurs. What would the nurse include in the explanation? It allows the eyes to focus on near objects. It begins with light rays striking the retina. It refers to a client's subjective appraisal of his or her vision. It primarily involves the lens of the eye.
It begins with light rays striking the retina. Explanation: Visual perception occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted. The lens does not contribute directly to visual perception. Accommodation is the process that allows the eyes to focus on near objects.
Signs of macular degeneration seen during the ophthalmoscopic examination include which of the following? Clouded lens Hemorrhage around optic disc Altered size and color of optic disc Subretinal exudate
Subretinal exudate Explanation: Ophthalmoscopy of a client with a macular degeneration may reveal variations in retinal pigmentation and subretinal hemorrhage or exudates.
A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina? Refracts light rays onto the posterior surface of the eye Permits the entrance of light to the eye Controls the amount of light entering the eye Transforms light rays into nerve impulses that are conducted to the brain
Transforms light rays into nerve impulses that are conducted to the brain Explanation: Visual perception occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted. The lens functions to refract (bend) light rays onto the retina. Muscles in the iris adjust to control the pupils size, which controls the amount of light entering the eye. The cornea permits the entrance of light, which passes through the lens to the retina.
An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should ask about the client's diet. ask the client if he has any known allergies. determine whether there is a history of glaucoma. check the client's blood pressure.
check the client's blood pressure. Explanation: Hypertension narrows blood vessels in the retina affecting vision.
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 exotropia. esotropia. phoria. strabismus.
esotropia. Explanation: Esotropia is an inward turn of the eye.
A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition? "Is night blindness a problem for you?" "How often do you have redness or tearing?" "Are the blind spots constant or intermittent?" "Do you see floaters in front of your eyes?"
"Are the blind spots constant or intermittent?" Explanation: 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 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? "I have an opening tomorrow at 2 in the afternoon. Can you come in then?" "Please come into the clinic right away so we can see what is wrong." "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."
"It is not an uncommon finding in 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.
Which vision acuity reading indicates blindness? 20/20 20/200 20/100 20/40
20/200 Explanation: The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision. This means that the client being tested can distinguish what a person with normal vision can distinguish from 20 feet away. The top or first number is always 20, indicating the distance from the client to the chart. The bottom or second number refers to the last full line the client could read. The higher the second number, the poorer the vision. 20/40 and 20/100 also denote poor vision.
The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal? 4 mm 8 mm 2 mm 6 mm
4 mm Explanation: Pupils are normally equal in size and range from 3 to 5 mm. Size outside this range are considered abnormal.
The nurse practitioner is assessing the eyes of a client with long-standing uncontrolled hypertension. What might the nurse practitioner visualize during an assessment with an ophthalmoscope? AV nicking Dilated arteries Dilated veins Brass wiring
AV nicking Explanation: AV nicking results from high blood pressure and retinal hemorrhages in the form of dot-blot spots or flame hemorrhages. Dilated arterioles and venules may be seen, not dilated arteries and veins. Brass wiring is not an assessment finding.
When using the ophthalmoscope, which of the following would the nurse do? Use the small round beam of white light Approach the client at a 15-degree angle to the client's side Use the right eye to examine the client's left eye Move the ophthalmoscope around to get the best view
Approach the client at a 15-degree angle to the client's side Explanation: The nurse should begin about 10 to 15 inches from the client at a 15-degree angle to the client's side, and select the aperture with the large round beam of white light. The small round beam is used if the client has smaller pupils. The nurse should not use his or her right eye to examine the client's left eye, or his or her left eye to examine the client's right eye. The nurse should not move the ophthalmoscope around.
A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next? Arrange for worker to be promptly assessed by an eye specialist. Irrigate the eye with dilute hydrogen peroxide. Encourage the worker to see an optometrist as soon as possible. Attempt to remove the splinter using sterile forceps.
Arrange for worker to be promptly assessed by an eye specialist. Explanation: The nurse should refer the client to an eye doctor immediately if a foreign body cannot be removed with gentle washing. Optometrists are specialists in primary vision care and do not normally treat eye trauma. Irrigation with hydrogen peroxide or attempted removal using instruments would be contraindicated and potentially dangerous.
A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate? Test the client's near visual acuity instead. Have the client keep the glasses on but occlude one eye. Ask the client to remove the glasses before testing. Use the E chart rather than the Snellen chart for testing.
Ask the client to remove the glasses before testing. Explanation: When testing distant visual acuity, the nurse should have the client remove the reading glasses, because they blur distant vision. The client would wear his or her glasses during the test if they were not reading glasses. The nurse would still test the client's distant visual acuity. The E chart would be appropriate if the client could not read or has a handicap that prevents verbal communication.
A client complains of excessive tearing of the eyes. Which assessment would the nurse do next? Perform the eye positions test Inspect the palpebral conjunctiva Assess the nasolacrimal sac Test pupillary reaction to light
Assess the nasolacrimal sac Explanation: Excessive tearing is caused by exposure to irritants or obstruction of the lacrimal apparatus. Therefore the nurse should assess the nasolacrimal sac. Inspecting the palpebral conjunctiva would be done if the client complains of pain or a feeling of something in the eye. The client is not exhibiting signs of problems with muscle strength such as drooping, so performing the eye position test, which assesses eye muscle strength and cranial nerve function, is not necessary. Testing the pupillary reaction to light evaluates pupillary response and function of the oculomotor nerve.
The nurse is preparing to assess a client's visual fields to evaluate her gross peripheral vision. Which test would the nurse perform? Confrontation test Cover test Corneal light reflex test Eye position test
Confrontation test Explanation: The confrontation test evaluates peripheral vision. The cover test, corneal light reflex test, and eye position test would be used to evaluate extraocular muscle function.
The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what? Limbus Lacrimal apparatus Conjunctiva Eyelid
Conjunctiva Explanation: The conjunctiva is a thin mucous membrane that lines the inner eyelid (palpebral conjunctivae) and also covers the sclera (bulbar conjunctivae). 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 skin that covers and protects the 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? Direct reaction Near reaction Consensual reaction Accommodation
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 pupil when 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.
A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following? Direct reflex Consensual response Accommodation Optic chiasm
Consensual response Explanation: When a light is shone in one eye, that eye will constrict and the opposite (consensual) eye will also constrict. Shining a light on one eye with the resulting constriction of that eye demonstrates the direct reflex. The optic chiasm is the point where the optic nerves from each eyeball cross. Accommodation occurs when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict.
The nurse selects the chart shown here to assess a client's vision. Which client characteristic caused the nurse to select this chart? Recovering from cataract surgery Does not speak English Has blue-green color blindness Being treated for glaucoma
Does not speak English Explanation: The Snellen E chart can be used for clients who do not speak English. This chart is not used for clients being treated for glaucoma, color blindness, or recovering from cataract surgery.
A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? Ectropion Epicanthus Ptosis Exophthalmos
Exophthalmos Explanation: In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumor and inflammation in the orbit.
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record? Presbyopia Esotropia Exotropia Strabismus
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 malalignment of the eyes. Presbyopia is impaired near vision.
The nurse is assessing a client whose electronic health record notes a diagnosis of esotropia. When examining this client, the nurse should expect what finding? Eye malalignment Eye turning outward Eye turning inward Eye oscillating
Eye turning inward Explanation: Esotropia is a term used to describe eyes that turn inward. Exotropia refers to an outward turning of the eyes. Strabismus refers to a constant malalignment of the eyes. Nystagmus refers to an oscillating or a shaking movement of the eye.
The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? Lateral, then far Lateral, then near Near, then far Far, then near
Far, then near Explanation: When testing accommodation, the nurse would ask the client to focus on a distant object such as a finger or pencil and to remain focused on that object as the nurse moves it closer to the eyes.
A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for? Strabismus Retinitis pigmentosa Retinoblastoma Glaucoma
Glaucome Explanation: Glaucoma in a first-degree relative increases the client's risk for the same problem two to three 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.
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Sinus Lacrimal apparatus Aqueous chamber Vitreous chamber
Lacrimal apparatus Explanation: The lacrimal apparatus (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears.
A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following? Recent eye trauma Macular degeneration Recent peripheral nervous system injury Narcotic use
Narcotic use Explanation: Pinpoint pupils suggest narcotic use or brain damage. Hyphema would suggest recent eye trauma. Dilated and fixed pupils typically result from central nervous system injury, circulatory collapse, or deep anesthesia.
The nurse asks the client to perform the action pictured. What is the nurse assessing? Distance vision Near vision Color discrimination Intraocular pressure
Near vision Explanation: The client is using the Jaeger chart which is used to assess near vision. The Snellen chart is used to assess distant vision. The nurse would not assess intraocular pressure. Ishihara cards are used to assess color discrimination.
During adolescence, what vision change is common? Presbyopia Nearsightedness Color blindness Amblyopia
Nearsightedness Explanation: Vision changes, such as nearsightedness, are common in adolescents. Amblyopia is also known as "lazy eye". This is more common in young children. Presbyopia is the decreased ability for one to focus on near objects and is more common in the adult as they age. Color blindness is a genetic condition and not impacted by the age of the client.
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? Light reflection appears at different spots on both eyes Eyes do not converge to focus on a shining light Nonreaction of the opposite pupil to light Pupils dilate in response to a light shone in the eyes
Nonreaction of the opposite pupil to light Explanation: When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict. An abnormal response to this test is if wither 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 & occurs when a person moves his focus of vision from a far object to a close object.
A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which action? Comparing the difference between the client's dilated pupil and a constricted pupil Observing the eye's reaction when a light is shone into the opposite eye Shining a light into one eye while covering the other eye with an opaque card Have the client state when they see the nurse's finger enter their peripheral vision field.
Observing the eye's reaction when a light is shone into the opposite eye Explanation: The nurse assesses consensual response at the same time as direct response by shining a light obliquely into one eye and observing the pupillary reaction in the opposite eye. This does not involve a comparison between maximum and minimum pupil size, however. Neither eye is covered, and peripheral vision is not relevant to this assessment.
When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. How would the nurse document this finding? Retinal vessels Fovea Physiologic cup Optic disc
Optic disc Explanation: The optic disc is round to oval with sharp, well-defined borders. The physiologic cup appears on the optic disc as slightly depressed and a lighter color than the disc. Arteriole retinal vessels appear bright red, and venules appear darker red and larger, with both progressively narrowing as they move away from the optic disc. The fovea is a small area of the retina that provides acute vision.
On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? Perform both the distant and near visual acuity tests Test the pupils for direct and consensual reaction to light Obtain a referral to the ophthalmologist for a complete eye exam Document the findings in the client's record
Perform both the distant and near visual acuity tests Explanation: The first thing the nurse should do is perform both the 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.
A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client? Strabismus Esotropia Exotropia Presbyopia
Presbyopia Explanation: Presbyopia, which is impaired near vision, is indicated when the client moves a reading chart or other reading material away from the eyes to focus on the print. It is caused by decreased accommodation and is a common condition in clients over 45 years of age. 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 malalignment of the eyes.
When testing the near reaction, an expected finding includes which of the following? Pupillary dilation on near gaze; constriction on distant gaze Pupillary constriction on near gaze; constriction on distant gaze Pupillary dilation on near gaze; dilation on distant gaze Pupillary constriction on near gaze; dilation on distant gaze
Pupillary constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far gaze.
A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? She obtains a 20% correct score at 100 feet. She can see at 100 feet what a normal person could see at 20 feet. She can see at 20 feet what a normal person could see at 100 feet. She can accurately name 20% of the letters at 20 feet.
She can see at 20 feet what a normal person could see at 100 feet. Explanation: 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.
As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? Client's consensual pupil constricts in response to indirect light Direct light shown into the client's pupils results in constriction Eyes converge on an object as it is moved towards the nose The client and the examiner see the examiner's finger at the same time
The client and the examiner see the examiner's finger at the same time Explanation: The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger and a delay in seeing indicates reduced peripheral vision. Client's consensual pupils constrict in response to indirect light as well as direct light shown into the client's pupils resulting in constriction is observed when testing the pupils for reaction to light. Eyes converge on an object as it is moved towards the nose tests for accommodation.
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? Light reflection appears at different spots on both eyes. Pupils dilate in response to a light shone in the eyes. There is no reaction in the opposite pupil to light. Eyes do not converge to focus on a shining light.
There is no reaction in the opposite pupil to light. Explanation: When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should 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 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.
An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for double vision. allergic reactions. viral infection. lacrimal obstruction.
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.
An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing? cataracts detached retina glaucoma macular degeneration
macular degeneration Explanation: Macular degeneration causes a loss of central vision. Risk factors for macular degeneration are age, smoking history, obesity, family history, and female gender. Cataracts are characterized by cloudiness of the eye lenses. Glaucoma is an increase in intraocular pressure that places pressure on eye structures and affecting vision. A detached retina is the sudden loss of vision in one eye. This health problem may be precipitated by the appearance of blind spots.
A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent hemianopsia retinal detachment macular degeneration open-angle glaucoma
macular degeneration Explanation: Macular degeneration causes deterioration in the center of the retina, which leads to a gradual loss of central vision.
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should instruct the client to begin reading from the bottom of the chart. ask the client to read each line with both eyes open. ask the client to remove his glasses. position the client 609.6 cm (20 ft) away from the chart.
position the client 609.6 cm (20 ft) away from the chart. Explanation: Used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked one above the other. The letters are large at the top and decrease in size from top to bottom. The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20 feet from the chart and covers one eye with an opaque card (which prevents the client from peeking through the fingers). Then the client reads each line of letters until he or she can no longer distinguish them.