HA Chapter 11- PREPU- eyes
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? Anemia Renal insufficiency Diabetes Retinal detachment
Correct response: 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.
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Vitreous chamber Aqueous chamber Lacrimal apparatus Sinus
Correct response: 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.
The tarsal plates of the upper eyelid contain meibomian glands. sebaceous glands. tear ducts. ocular muscles.
Correct response: meibomian glands. Explanation: The upper eyelid is larger, more mobile, and contains tarsal plates made up of connective tissue. These plates contain the meibomian glands, which secrete an oily substance that lubricates the eyelid.
A patient 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? 20/100 or less 20/200 or less 20/300 or less 20/400 or less
Correct response: 20/200 or less Explanation: 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.
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.) Diabetes Hypothyroidism Hyperlipidemia Hypertension Osteoarthritis
Correct response: Diabetes Hypertension Explanation: 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 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 Cataract formation Loss of convergence Macular degeneration
Correct response: Presbyopia Explanation: Prebyopia 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.
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 refer the client for further evaluation. examine the client for other signs of glaucoma. ask the client if there is a genetic history of blindness. document the findings in the client's records.
Correct response: document the findings in the client's records. Explanation: 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.
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 glaucoma detached retina macular degeneration
Correct response: 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 nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate? Ask the client to remove the glasses before testing. Have the client keep the glasses on but occlude one eye. Test the client's near visual acuity instead. Use the E chart rather than the Snellen chart for testing.
Correct response: 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 is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition? "Do you see floaters in front of your eyes?" "Are the blind spots constant or intermittent?" "How often do you have redness or tearing?" "Is night blindness a problem for you?"
Correct response: "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 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? Report this to the health care provider Ask the client about previous trauma to the eyes Document this finding in the client's record Continue with the examination
Correct response: Ask the client about previous trauma to the eyes Explanation: Unequal pupil size is termed anisocoria. Often it is a normal finding but it can indicate trauma to the parasympathetic nerve supply to the iris. The nurse should ask the client about previous trauma to the eye to determine if this is a new finding or this is new onset. All other options the nurse can do after this is determined.
Which technique by the nurse demonstrates proper use of the ophthalmoscope? Uses right eye to examine the client's left eye Moves the scope around so the entire optic disk may be seen Approaches the client directly in front of the pupil Asks the client to fix the gaze upon an object and look straight ahead
Correct response: Asks the client to fix the gaze upon an object and look straight ahead Explanation: 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 complains of excessive tearing of the eyes. Which assessment would the nurse do next? Inspect the palpebral conjunctiva Assess the nasolacrimal sac Perform the eye positions test Test pupillary reaction to light
Correct response: 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. Reference:
A diabetes educator is teaching a group of adults about the risks to vision that result from poorly controlled blood glucose levels. Which of the following pathophysiologic processes underlies the vision loss associated with diabetes mellitus? Diabetes contributes to increased intraocular pressure. Increased blood glucose levels cause osmotic changes in the aqueous humour. Blood vessels supplying the retina become weak and bleeding occurs. Diabetes is associated with recurrent corneal infections and consequent scarring.
Correct response: Blood vessels supplying the retina become weak and bleeding occurs. Explanation: In diabetic retinopathy, the vessels that feed the retina change and weaken. Eventually, they may become blocked and cause bleeding into the eye, which blocks vision. Diabetes does not directly cause an increase in pressure in the eye, osmotic changes in the aqueous humor or corneal infection.
A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following? Retina Sclera Cornea Conjunctiva
Correct response: Conjunctiva Explanation: The conjunctiva is a thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion. The palpebral conjunctiva lines the inside of the eyelids, and the bulbar conjunctiva covers most of the anterior eye, merging with the cornea at the limbus. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends them to the brain. The sclera is a dense, protective, white covering that physically supports the internal structures of the eye. The transparent cornea permits the entrance of light, which passes through the lens to the retina.
A client presents to the clinic reporting sudden visual loss in the left eye. What is the nurse's priority action? Assess cranial nerve function. Notify the healthcare provider immediately. Ask the client if protective eyewear was worn. Perform the Allen test and report the findings urgently.
Correct response: Notify the healthcare provider immediately. Explanation: Sudden visual loss is an emergency and should be immediately reported to the healthcare provider. Wearing protective eyewear is not a priority, though whether the client wore protective eyewear is relevant information. Assessing cranial nerve function and vision testing are not realistically possible when the client suffers sudden visual loss.
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? Exotropia Esotropia Strabismus Presbyopia
Correct response: 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.
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 Prevention of knee injuries Prevention of head injuries Use of correct foot gear
Correct response: Use of safety equipment Explanation: 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.
