chapter 16: assessing the eyes

________ is a functional reflex allowing the eyes to focus on near objects

accommodation

Iris nevus

benign tumor on the iris surface

Hyphemia

blood in the anterior chamber of the eye

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. 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.

ectropion

outward turning of the rim of the eyelid

use the chart with all of the E's when

patient does not speak English

detached retina

separation of the retina from the choroid in the back of the eye; can be caused by injury, tumor, or hemorrhage

Xanthelasma

soft, raised yellow plaques occurring on the skin at the inner corners of the eyes

A nurse assesses the vision of an older adult client with a long history of uncontrolled type 2 diabetes. The nurse determines the client's vision with corrective lenses is 20/200. How should the nurse interpret these findings?

these findings indicate the client is legally blind

true or false: a visual field refers to what one eye can see

true

what vision is considered legally blind?

20/200 or less

chalazion

a nodule or cyst, usually on the upper eyelid, caused by obstruction in a sebaceous gland

epicanthus

a vertical fold of skin on either side of the nose

exophthalmos

abnormal protrusion of the eyeball

Cataracts

clouding of the lens

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 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.

presbyopia

impaired vision as a result of aging (farsightedness)

Glaucoma

increased intraocular pressure results in damage to the retina and optic nerve with loss of vision

Blepharitis

inflammation of the eyelid

dacryocystitis

inflammation of the tear sac

Aniscoria

unequal pupil size

Pinguecula

yellowish nodules on the bulbar conjunctiva

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

accommodation.

scotoma

blind spot in vision

macular degeneration

loss of central vision

true or false: darker skinned people may have sclera with yellow or pigmented freckles

true

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 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.

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 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 is performing a focused visual assessment on a client. The nurse assesses the pupillary response with a pen light. Both of the client's pupils immediately constrict when the light is shone into the right pupil. How should the nurse document this finding?

consensual reflexes observed When exposed either directly or indirectly to light, pupils will constrict; the term consensual means that constriction occurs in both eyes when light is only shown into one eye. Oscillating or shaking of an eye is referred to as nystagmus. Accommodation is tested by having the client focus their vision on something distant and then a near object, which causes the pupils to constrict. A wisp of cotton is used to test corneal reflex, which stimulates a blink in both eyes when the cotton touches the eye.

diplopia

double vision

Ptosis

drooping

A 48-year-old client reports a recent loss of peripheral vision and eye pain. Based on these findings, the nurse determines these signs and symptoms may be the result of which of the following eye disorders?

glaucoma Acute angle closure glaucoma is the only eye disorder that causes pain. The pain is the result of increased ocular pressure (greater than 22 mm Hg). Acute angle closure glaucoma is an emergency; if not treated promptly, the client could lose their vision. Macular degeneration causes a loss of central vision. 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. Opacities of the lens are seen with cataracts, causing hazy vision.

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. 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?

macular degeneration