Chapter 16: Assessing 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. Esotropia is an inward turn of 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. Myopia b. Presbyopia c. Direct reaction d. Consensual reaction

d. Consensual reaction 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.

The nurse is teaching about the importance of regular eye examinations and should include information about which conditions that place clients at highest risk for blindness? (Select all that apply.) a. Diabetes b. Hypothyroidism c. Hyperlipidemia d. Hypertension e. Osteoarthritis

a. Diabetes d. Hypertension Diabetic retinopathy is the most common cause of blindness in the United States. Hypertensive retinopathy is another high risk factor for blindness over hypothyroidism, hyperlipidemia, and osteoarthritis.

The meibomian glands secrete a. an oily substance to lubricate the eyes. b. sweat. c. hormones. d. clear liquid tears.

a. an oily substance to lubricate the eyes. Meibomian glands secrete an oily substance that lubricates the eyelid.

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to a. retinal damage. b. cataracts. c. myopia. d. corneal damage.

d. corneal damage. Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage.

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? a. Blunt-force trauma often results in fracture of the orbit b. High-velocity injuries are typically non-penetrating c. The client could have optic atrophy d. This could be a sign of strabismus

a. Blunt-force trauma often results in fracture of the orbit 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 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? a. Use of safety equipment b. Prevention of knee injuries c. Prevention of head injuries d. Use of correct foot gear

a. Use of safety equipment 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.

The nurse should make it a priority to assess which client for papilledema? a. a 45-year-old suspected of experiencing a subarachnoid hemorrhage b. an 80-year-old diagnosed with chronic open-angle glaucoma c. a 12-year-old demonstrating a deviated left eye d. a 56-year-old reporting double vision

a. a 45-year-old suspected of experiencing a subarachnoid hemorrhage Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup. Increased intracranial pressure is transmitted to the optic nerve, causing edema of the optic nerve. Papilledema often signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions. An enlarged physiological cup suggests chronic open-angle glaucoma. If cranial nerve IV is paralyzed, the left eye will deviate from its normal position in that direction of gaze, and the eyes will no longer appear conjugate, or parallel. Diplopia in adults may arise from a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of cranial nerve (CN) III or VI, or vertical diplopia from palsy of CN III or IV.

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. 20/100 or less b. 20/200 or less c. 20/300 or less d. 20/400 or less

b. 20/200 or less 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.

Photoreceptors of the eye are located in the eye's a. ciliary body. b. lens. c. retina. d. pupil.

c. retina. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends it to the brain. The retina consists of numerous layers of nerve cells, including the cells commonly called rods and cones. These specialized nerve cells are often referred to as "photoreceptors" because they are responsive to light

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. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." b. "Please come into the clinic right away so we can see what is wrong." c. "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." d. "I have an opening tomorrow at 2 in the afternoon. Can you come in then?"

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

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 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.

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 a. glaucoma. b. increased intracranial pressure. c. bacterial infection. d. migraine headaches.

a. glaucoma. A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent a. macular degeneration b. open-angle glaucoma c. hemianopsia d. retinal detachment

a. macular degeneration 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 a. position the client 609.6 cm (20 ft) away from the chart. b. ask the client to remove his glasses. c. ask the client to read each line with both eyes open. d. instruct the client to begin reading from the bottom of the chart.

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

Which of the following assessment findings suggests a problem with the client's cranial nerves? a. A client states that he has recently begun seeing lights flashing in his field of vision. b. A client's extraocular movements are asymmetrical and she complains of diplopia. c. Fundoscopic examination reveals intraocular bleeding. 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. 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.

What is a characteristic symptom of Graves hyperthyroidism? a. Pterygium b. Exophthalmos c. Pinguecula d. Episcleritis

b. Exophthalmos In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.

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? 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 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 client comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse? a. "It is probably just allergies. If it still hurts in the morning call me." b. "A painful eye happens sometimes with allergies. Do you have allergies?" c. "You will need to see the doctor to have your eye checked." d. "Did you do anything different yesterday? You may have eye strain."

c. "You will need to see the doctor to have your eye checked." Pain in the eye is never normal and should always be further explored.

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? a. She obtains a 20% correct score at 100 feet. b. She can accurately name 20% of the letters at 20 feet. c. She can see at 20 feet what a normal person could see at 100 feet. d. 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. 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.

Which technique by the nurse demonstrates proper use of the ophthalmoscope? a. Uses right eye to examine the client's left eye b. Moves the scope around so the entire optic disk may be seen c. Approaches the client directly in front of the pupil 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 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. 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.

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? a. Retinoblastoma b. Strabismus c. Retinitis pigmentosa d. Glaucoma

d. Glaucoma 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.