Chapter 16 Assessing Eye Prep U

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

The functional reflex that allows the eyes to focus on near objects is termed

accommodation

What do retinal abnormalities include?

age-related macular degeneration

A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?

ask the client about previous trauma to the eyes

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

corrective lenses

The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents

entropion

A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder?

glaucoma

A nurse is testing a client's pupillary reaction to light, noting that the pupil constricts when shining light obliquely into it. The nurse understands that muscles in which of the following structures adjust to control the amount of light entering the eye through the aperture of the pupil?

iris

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

lacrimal obstruction

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?

presbyopia

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

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?

"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

Which vision acuity reading indicates blindness?

20/200

Which technique by the nurse demonstrates proper use of the ophthalmoscope?

Asks the client to fix the gaze upon an object and look straight ahead

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

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

She can see at 20 feet what a normal person could see at 100 feet.

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?

Snellen E

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

There is no reaction in the opposite pupil to light

The nurse should make it a priority to assess which client for papilledema?

a 45-year-old suspected of experiencing a subarachnoid hemorrhage

A client asks a nurse if any foods promote eye health. What food would the nurse include as a response?

deep water fish

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?

exophthalmos

The nurse is planning to assess a client's near vision. Which technique should be used?

have the client read newspaper print held 14 inches from the eyes

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

lacrima apparatus

Photoreceptors of the eye are located in the eye's

retina

Which of the following is a symptom of the eye?

scotomas

What is the largest chamber of the eye?

vitreous

A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition?

"Are the blind spots constant or intermittent?"

Which data collected in a health history interview of a client should the nurse document as risk factors for the development of cataracts? Select all that apply.

- Cigarette smoking - Works in lawn maintenance - Eats very few fruits or vegetables

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?

20/200 or less

Which of the following assessment findings suggests a problem with the client's cranial nerves?

A client's extraocular movements are asymmetrical and she complains of diplopia.

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

Conjunctiva

A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?

Focused on the bridge of the nose

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?

Instruct the client hold the chart 14 inches from the eyes

What are the glands that are located on the tarsal plates and open on the lid margins?

Meibomian glands

When testing the near reaction, an expected finding includes which of the following?

Pupillary constriction on near gaze; dilation on distant gaze

On visual confrontation testing, a client with a recent stroke cannot see the examiner's fingers on the entire right side with either eye covered. Which of the terms would describe this finding?

Right homonymous hemianopsia

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?

Transforms light rays into nerve impulses that are conducted to the brain

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?

Up

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

The meibomian glands secrete

an oily substance to lubricate the eyes

The conjunctiva of the eye is divided into the palpebral portion and the

bulbar portion

An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should

check client's BP

The middle layer of the eye is known as the

choroid layer

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

decreased accommodation

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?

diabetes

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

esotropia

What is a characteristic symptom of Graves hyperthyroidism?

exophthalmos

When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals?

fundus is grayish brown with a purplish cast

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?

macular degeneration

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?

medially toward the nose

The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from?

myopia

The nurse asks the client to perform the action pictured. What is the nurse assessing?

near vision

The nurse performs the action shown when assessing a client's eyes. What is the nurse assessing?

ocular alignment

The optic nerves from each eyeball cross at the

optic chiasma

What is the open space between the eyelids called?

palpebral fissure

You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document?

papilledema

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

position the client 609.6 cm (20 ft) away from the chart.

What is the primary purpose of the health history in relation to the eyes?

to identify changes

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?

hyphema

A client notices that the newspaper print is not as clear to read as it used to be. What health problem should the nurse consider is occurring with this client?

hyperopia

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?

presbyopia

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

document the findings in the client's records.

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?

consensual reaction

The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope

in the right hand for the right eye and in the left hand for the left eye

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?

The client and the examiner see the examiner's finger at the same time.

A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?

The larger the bottom number, the worse the visual acuity.

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

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

An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible

increased intracranial pressure.

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that 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?

risk for injury

An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for

allergies

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?

arcus senilis

A client is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the client's medical record supports this diagnosis?

increased intraocular pressure

A nurse begins the eye examination on a client who presents to the health care 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

An adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. The nurse should assess the client for

a foreign body in the eye.

You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what?

a left temporal hemianopsia

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?

brain tumor

The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding?

consensual light response present in left eye

On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing 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

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?

stye