Chapter 13: Eye assessment

A review of a client's history reveals cranial nerve IV paralysis. What finding would the nurse expect to assess? A. The eye cannot look to the outside side. B. Ptosis will be evident. C. The eye cannot look down when turned inward. D. The eye will look straight ahead.

C. The eye cannot look down when turned inward. Rationale: With paralysis of the fourth cranial nerve, the eye cannot look down when turned inward. With paralysis of cranial nerve VI, the eye cannot look to the outer side. Ptosis and looking straight ahead reflects cranial nerve III paralysis.

What is vital in maintaining vision and a healthy outlook for clients? Health education A. Monthly eye exams B. Emotional support C. Physical exercise D. Health education

D. Health education Rationale: Nursing education is vital in maintaining vision and a healthy outlook for clients.

A parent is very upset because she is told her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in children. TRUE or FALSE?

TRUE

The nurse tests the six cardinal directions to test extraocular movement of the eye. TRUE or FALSE?

TRUE

A client is concerned about a bright red area on the sclera. What should the nurse say to the client about this finding? A. "This can occur with sneezing or coughing and is harmless." B. "You are in the process of having a detached retina." C. "You need to see an ophthalmologist immediately." D. "This can mean the pressure in your eye is too high."

A. "This can occur with sneezing or coughing and is harmless." Rationale: A bright red area on the sclera indicates a subconjunctival hemorrhage that can occur by sneezing, coughing, or vomiting which may break a blood vessel. The trapped blood accumulates and is not quickly absorbed. This finding is harmless and disappears in 1 to 2 weeks. The client does not need to see an ophthalmologist immediately. This finding does not indicate an increase in eye pressure or developing a detached retina.

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? A. Aqueous chamber B. Vitreous chamber C. Sinus D. Lacrimal apparatus

D. Lacrimal apparatus Rationale: 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.

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 this client's vision? A. Ishihara B. PERRLA C. Allen D. Snellen E

D. Snellen E Rationale: The Snellen E chart can be used for people who cannot read or speak English.

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? A. Arcus senilis B. Presbyopia C. Ectropion D. Myopia

A. Arcus Senilis Rationale: 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.

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.

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking? A. Use a Snellen E chart to perform the examination B. Perform the confrontation test C. Have the client read from a Jaeger reading card D. Move an object through the six cardinal positions of gaze

A. Use a Snellen E chart to perform the examination Rationale: 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 test eye muscle function and cranial nerve function. The Jaeger chart tests near visual acuity. Confrontation test is used to test visual fields for peripheral vision.

The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal? A. 2 mm B. 4 mm C. 6 mm D. 8 mm

B. 4 mm Rationale: Pupils are normally equal in size and range from 3 to 5 mm. Size outside this range are considered abnormal.

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? A. Use the E chart rather than the Snellen chart for testing. B. Ask the client to remove the glasses before testing. C. Test the client's near visual acuity instead. D. Have the client keep the glasses on but occlude one eye.

B. Ask the client to remove the glasses before testing.

A client complains of excessive tearing of the eyes. Which assessment would the nurse do next? A. Inspect the palpebral conjunctiva B. Assess the nasolacrimal sac C. Perform the eye positions test D. Test pupillary reaction to light

B. Assess the nasolacrimal sac Rationale: 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.

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? A. Direct reflex B. Optic chiasm C. Consensual response D. Accommodation

C. Consensual response Rationale: 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.

A 67-year-old lawyer comes to the clinic for an annual examination. He denies any history of eye trauma or recent visual changes. Inspection of his eyes reveals a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis? A. Corneal scar B. Corneal arcus C. Cataracts D. Pterygium

D. Pterygium Rationale: A pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side. Reddening may occur, and it may interfere with vision as it encroaches on the pupil. Otherwise treatment is unnecessary.

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? A. Corrective lenses B. Surgery C. No night driving D. Daily use of eye drops

A. Corrective lenses Rationale: Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition.

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? A. Exotropia B. Esotropia C. Strabismus D. Presbyopia

A. Exotropia Rationale: 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.

Which of the following would a nurse expect to assess in a client with esotropia? A. Eye turning inward B. Eye turning outward C. Eye malalignment S. Eye oscillating

A. Eye turning inward Rationale: 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 oscillating or 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? A. Far, then near B. Lateral, then near C. Near, then far D. Lateral, then far

A. Far, then near Rationale: 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 nurse assesses the pupillary reaction to light for a client who has lost vision in one eye. Which precaution should the nurse follow to get an accurate result of consensual response? A. Place an opaque card in between the eyes of the client B. Observe the response in the eye focused with light C. Shine a bright light directly into the eye to be tested D. Instruct the client to close the eye not focused with light

A. Place an opaque card in between the eyes of the client Rationale: The nurse should place an opaque card in between the eyes of the client when assessing the client for consensual response to avoid inaccurate results. The light should not be focused directly into the eye to be tested; it should be focused obliquely into one eye, and the response should be checked in the other eye. The client should not be instructed to close the other eye not focused with light because the response is checked in the other eye.

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed? A. Presbyopia B. Cataract formation C. Loss of convergence D. Macular degeneration

A. Presbyopia Rationale: Presbyopia denotes an age-related deficit in close vision. It is less likely that cataracts, macular degeneration, or loss of convergence underlie the colleague's visual changes.

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction? A. Up B. Down C. To the right D. To the left

A. Up Rationale: The correct technique to use when examining a client's sclera and conjunctiva during an eye examination is to instruct the client to look up. Having the client look down, to the right, or to the left will not provide visualization of the sclera or conjunctiva during the examination.

A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis A. has a watery, mucoid discharge. B. usually follows trauma. C. is not painful. D. can result from a cough.

A. has a watery, mucoid discharge.

Which of the following assessment findings suggests a problem with the client's 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. Rationale: 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.

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? A. Ptosis B. Exophthalmos C. Ectropion D. Epicanthus

B. Exophthalmos Rationale: 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.

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? A. Comparing the difference between the client's dilated pupil and a constricted pupil B. Observing the eye's reaction when a light is shone into the opposite eye C. Have the client state when they see the nurse's finger enter their peripheral vision field. D. Shining a light into one eye while covering the other eye with an opaque card

B. Observing the eye's reaction when a light is shone into the opposite eye Rationale: 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 an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following? A. Retinal vessels B. Optic disc C. Fovea D. Physiologic cup

B. Optic disc Rationale: 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? A. Document the findings in the client's record B. Perform both the distant and near visual acuity tests C. Test the pupils for direct and consensual reaction to light D. Obtain a referral to the ophthalmologist for a complete eye exam

B. Perform both the distant and near visual acuity tests Rationale: 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.

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? A. Eyes converge on an object as it is moved towards the nose B. The client and the examiner see the examiner's finger at the same time C. Client's consensual pupil constricts in response to indirect light D. Direct light shown into the client's pupils results in constriction

B. The client and the examiner see the examiner's finger at the same time Rationale: 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 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. "I have an opening tomorrow at 2 in the afternoon. Can you come in then?" B. "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." C. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." D. "Please come into the clinic right away so we can see what is wrong."

C. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." Rationale: 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.

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 this description, what is the most likely diagnosis? A. Dacryocystitis B. Chalazion C. Stye D. Xanthelasma

C. Stye Rationale: A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.

Which technique by the nurse demonstrates proper use of the ophthalmoscope? A. Uses right eye to examine the client's left eye B. Approaches the client directly in front of the pupil C. Moves the scope around so the entire optic disk may be seen D. Asks the client to fix the gaze upon an object and look straight ahead

D. Asks the client to fix the gaze upon an object and look straight ahead Rationale: 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 & 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 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula.

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? A. Client did not wear his glasses for this test and therefore it is not accurate B. When 50 feet from the chart, the client can see better than a person standing at 20 feet C. Client can read the 20/50 line correctly and two other letters on the line above D. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet

D. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet Rationale: The Snellen chart tests distant visual acuity by seeing how far the client can read the letters standing 20 feet from the chart. The top number is how far the client is from the chart and the bottom number refers to the last line the client can read. A reading of 20/50 means the client sees at 20 feet what a person with normal vision can see at 50 feet. The minus number is the number of letters missed on the last line the client can distinguish.

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. Myopia B. Presbyopia C. Direct reaction D. Consensual reaction

D. Consensual reaction Rationale: 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-aged and older clients. The direct reaction is when the pupil constricts in the same eye.

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test the near visual acuity using a Jaeger reading card? A. Place the chart on a table 17 inches away from the client B. Instruct the client to hold the chart away from the body at arm's length C. Place the chart 20 feet away from the client on the wall D. Instruct the client hold the chart 14 inches from the eyes

D. Instruct the client hold the chart 14 inches from the eyes Rationale: To test the near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arm's length is an arbitrary length depending on the size of the client & is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client.

During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect? A. Myopia B. Tropia C. Cataracts D. Presbyopia

D. Presbyopia Rationale: Presbyopia is indicated when the client moves an object away from the eyes to focus. It is a common condition in clients over age 45. Myopia is impaired far vision. Cataracts typically are associated with painless blurring, light sensitivity, poor night vision, and a need for a brighter light to read. Tropia refers to a misalignment of the eyes.

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data? A. Ineffective Individual Coping B. Disturbed Self-Concept C. Self-Care Deficit D. Risk for Injury

D. Risk for injury Rationale: The only nursing diagnosis that can be confirmed with this data is Risk for Injury. The client is aware of the dangers of driving due to changes in his vision. There is not enough data to support the other diagnosis.

A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis? A. Corneal abrasion B. Acute iritis C. Conjunctivitis D. Subconjunctival hemorrhage

D. Subconjunctival hemorrhage Rationale: A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turns yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rare for a serious condition to cause it, so reassurance is usually the only treatment necessary.