ch 16 assessing eyes, Cranial nerves nursing assessment, RANGE OF MOTION FOR DIARTHRODIAL JOINTS

Which vision actually reading indicates blindness

20/200 20/20 is considered normal vision. Top number always indicates the distance from the client to the chart. The bottom second number refers to the last full one chart the client could read. Th higher the bottom the number the poorer the vision.

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 Arcus seniles, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia is impaired near vision common in clients over 45. Ectropion is when the lower eyelids evert, causing more exposure & drying of the conductive

Radial flexion wrist

Bend wrist medially toward thumb.

Flexion of head

Bring chin to rest on chest.

Hyperextension of wrist

Bring dorsal surface to hand back as far as possible.

A nurse is inspecting the bulbar conductive and sclera of a 67- year old client and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nursing action at this time?

Document the finding and proceed with the examination Yellowish nodules on the bulbar conjunctiva are called pinguecula. These harmless nodules are common in older clients & appear first on the medial side of the iris & then on the lateral side. Therefore the nurse should document this finding & proceed w/ the examination. There is no need to notify the physician of the finding. Having trouble focusing when reading up close is a sign of presbyopia, impaired near vision which is not associated w/ the finding of pinguecula. A foreign body or lesion may cause irritation, during, pain & swelling of the upper eyelid but would not cause yellowish nodules

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

Glaucoma Rings around lights or halos is associated with narrow angle glaucoma. Diabetes produces change in the retina that can cause blurred vision. Cataracts are caused by the clouding of the lens of the eyes. Hypertension affects the blood vessels of the eyes which may not cause any eye symptoms until the damage is severe

A nurse assess the distant vision acuity of a client using the Snellen chart. Which action should the nurse implement to perform the test with accuracy?

Instruct the client to read without reading glasses Reading glasses blur the vision when reading in distance, so it can interfere w/ the assessment. The nurse should position the client 20 feet not 12 feet away from the Snellen chart.

III Oculomotor

Motor, ask patient to follow pen light in six directions from center outward. Assess pupil reaction to light with pen light

XII Hypoglossal

Motor, ask patient to stick out tongue, move it side to side

XI accessory

Motor, head movement, shrugging of shoulders. Sk pt to move head from side to side, touch chin to chest, ear to shoulders or shrug shoulders.

VI Abducens

Motor, lateral eyeball movement, assess directions of gaze.

IV Trochlear

Motor, moves eyeball down and laterally, ask patient to follow movement of pen light in six directions.

Plantar flexion of ankle

Move foot so toes are pointed downward.

Dorsiflexion of ankle

Move foot so toes are pointed upward.

Extension of hip

Move leg back beside other leg.

Adduction of hip

Move leg back toward medial position and beyond if possible.

Hyperextension of hip

Move leg behind body.

Extension of thumb

Move thumb straight away from hand.

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 Presbyopia which is impaired near vision, is indicated when the client moves a reading chart or other reading material away from eyes to focus on the print. It is caused by decreased accommodation & 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 client is admitted to the health care facility after sustaining a crushing injury to the right eye. The nurse should anticipate abnormal results for which vision test?

Six cardinal posisitions of gaze 6 cardinal positions of gaze test muscle strength and cranial nerve function. Accommodation tests the ability of the eyes to focus from far to near. Pupillary reaction to light test the pupil reaction and not muscle function. Positions of the eyeballs should not be affected by an injury.

Extension of toes

Straighten toes.

Rotation of head

Turn head as far as possible to right and left.

External rotation of hip

Turn knee toward the outside.

Supination of forearm

Turn lower arm and hand so palm is up.

Pronation of forearm

Turn lower arm so palm is down.

Eversion of foot

Turn sole of foot laterally.

Inversion of foot

Turn sole of foot medially.

V Trigeminal

both Sensory and motor, sensation of cornea, nasal mucosa and skin of face. Use cotton ball to lightly touch different places on face when patients eyes are closed. Ask patient to identify location of touch. Use alternating ends of safety pin to test blunt and sharp sensation. Use corner of four by four to lightly touch cornea, patient should blink. Ask patient to clench teeth.

VII Facial

both motor and sensory, ask patient to smile, raise eyebrows, frown, puff out cheeks, close eyes tightly. Ask pt to identify various tasts on tongue, such as sugar, salt, lemon juice, quinine.

IX glossopharyngeal

both motor and sensory, ask pt to move tongue from side to side and up and down, ask pt to swallow.

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?

transform light rays into nerve impulses that are conducted the brain Visual perception occur as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve & interpreted. The lens functions to refract (bend) light rays onto the retina. Muscles is the iris adjust to control the pupils size, which controls the amount of light entering the eye. The cornea permits the entrance of light, which passes through the lens to the retina.

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

six cardinal fields of gaze

A test to evaluate extraocular muscle function; performed by having the patient visually track an object in six visual fields in an H pattern.

Flexion of elbow

Bend elbow so lower arm moves toward its shoulder joint and hand is level with shoulder

Flexion of toes

Curl toes downward.

An elderly client presents to the health care clinic with reports of decreased tearing in both eyes. The nurse observes the presence of ectropion. What is an appropriate action by the nurse?

Document the finding as a normal sign of aging Ectropion is when the lower eyelids evert, causing exposure & drying of the conjunctiva. This is a normal finding in the older client.

Extension of head

Return head to erect position

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 OD = right eye, OS= left eye. Therefore, the client has worse vision in the right eye because the larger the number on the bottom, the worse the visual acuity. A client is considered legally blind when the vision in the better eye with corrective lens is 20/200 or less. Snellen test is to test for distant vision (far) not near vision

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 If the client does not speak English, 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 indicated by pointing which way the E is open on the chart. The 6 cardinal positions of gaze test eye muscle function & cranial nerve function. The jaguar chart test near visual acuity. Confrontation test is used to test visual fields for peripheral vision.

The Rinne test

hearing test using a tuning fork; checks for differences in bone conduction and air conduction

PERRLA

pupils equal, round, reactive to light and accommodation

A client performs the test for distant visual acuity & scores 20/50. How should the nurse most accurately interpret this finding?

At 20 feet from the chart, the client see what a person with good vision can see at 50 feet

Adduction of shoulder

Lower arm sideways and across body as far as possible.

Hyperextension of shoulder

Move arm behind body, keeping elbow straight

Circumduction of arm

Move arm in full circle. Circumduction is combination of all movements of ball-and-socket joint.

Extension of wrist

Move fingers so fingers, hands, and forearm are in same plane.

II Optic

Sensory , test vision, ask patient to read Snellen chart

Abduction of fingers

Spread fingers apart.

Lateral flexion of head

Tilt head as far as possible toward each shoulder

Opposition of thumb

Touch thumb to each finger of same hand.

External rotation of shoulder

With elbow flexed, move arm until thumb is upward and lateral to head .

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

"Are the blind spots constant or intermittent?" If they are contanst it may be retinal detachment. Intermittent blind spots may be due to vascular spasm or pressure on the optic nerve. Floaters are a common finding in people w/ myopia or in ppl over 40 & is 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 assess 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 client about previous trauma to the eyes Unequal pupil size is termed anisocoria. Often it is a normal finding but it can indicate trauma to the eye to determine whether this is a new finding or new onset. All other options the nurse can do after this is determined.

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 Ask client to remove glasses but keep contact lens in place. The nurse should use the right eye to exam the left & vice versa. This allows the nurse to get as close as possible. Begin at 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 & macula

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?

At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

Hyperextension of fingers

Bend fingers back as far as possible.

Hyperextension of head

Bend head back as far as possible.

Hyperextension of elbow

Bend lower arm back as far as possible. Not all elbows hyperextend.

Ulnar flexion wrist

Bend wrist laterally toward fifth finger; referred to as radial/ulnar deviation.

X Vagus

Both motor and sensory, sensation of pharynx and larynx, swallowing, vocal cord movement. Same tests as glossopharyngeal, plus assess voice for hoarseness"

Adduction of fingers

Bring fingers together.

Flexion knee

Bring heel back toward back of thigh.

Adduction of toes

Bring toes together

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 membranes as which of the following?

Conjunctiva Conjunctiva is a thin,transparent, continuous membrane that is divided into 2 parts; a palpebral (lies inside the eyelids) & bulbar portion (covers most of the anterior eye). The Retina is the innermost layer extends only to the ciliary body anteriorly. The sclera is a dense, protective, white covering that physically supports the internal structure of the eye The transparent cornea permits the entrance of light, which passes through the lens to the retina.

A client visits the health care clinic with reports of itchy and watery eyes for 3 days. The nurse observes a generalzied redness to the conjunctiva. The nurse recognizes this as what condition?

Conjunctivitis Can also be to to an allergic reaction, viral or bacterial infection. Blepharitis is an infection of the eyelid by the staphylococcus bacteria. A hordeolum is also called a stye & is caused by infection in the lower eyelashes. A chalazion is an infected meibomian gland in the lower lid.

A nurse performs the cover test to assess for proper alignment of the eyes. When uncovering the previously covered eye, the nurse should observe for which response to indicate normal finding ?

Covered eye remains fixed straight ahead The eye moving to any side to reestablish focus indicates a deviation in alignment of the eyes and muscle weakness The eyes should to turn toward the object to establish focus. The eyes moving upward or downward are abnormal responses

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 Exudates appear as light-colored spots on the retinal background & occur in individuals with diabetes or hypertension. Anemia, renal insufficiency, and retinal detachment do not cause this appearance on the retina

Which action by the nurse indicates the appropriate use of an ophthalmoscope?

Employ the right eye to examine the client's right eye The nurse should employ the right eye to examine the client's right eye; this action of the nurse indicates the correct use of the ophthalmoscope. The nurse should hold the ophthalmoscope with the index finger on the lens wheel. The nurse should ask the client to gaze at an object straight ahead & slightly upward, not downward. The nurse should approach the client from the side not from the front

A client is diagnosed with glaucoma. When performing the ophthalmic exam, what changes should the nurse anticipate finding?

Enlarged physiologic cup that occupies more than half of disc's diameter Glaucoma is a condition of increased pressure within the eye. This causes the physiologic cup to enlarge to more than half of the disc's diameter. Widening of the light reflex with a coppery color to the arterioles and the opaque or silver appearance of the arterioles wall are seen with hypertension. Hyperemia of the optic disc due to accumulation of blood is called papilledema

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?

Exotropia 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 eyes turns outward it is called exotropia. If the uncovered eye turns inward it is call esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired vision

Abduction of thumb

Extend thumb laterally (usually done when placing fingers in abduction and adduction)

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 When testing the corneal light reflex the nurse should shine the light toward the bridge of the nose. At the same time the client is instructed to stare straight ahead. This facilitiates a parallel image on the cornea. The eye response upon shining the light toward the eye may interfere with the assessment. The light should not be shined toward the forehead or an object on the wall.

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 Jaeger card 14 inches from the face & read with one eye at a time Near vision is tested with Jaguar card. Sitting the client in front of the examiner, extending one arm, and slowly move one finger upward until it is seen by both the client & examiner is a test for gross peripheral vision. If a client wears glasses, they should be left on for the test. Placing the client 20 feet from the chart & record the smallest line the client can read is the test for distant acuity.

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?

Instruct the client hold the chart 14 inches from the eyes To test near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The Snellen chart should be kept at eye level, 20 feet way on the wall when testing for distant vision. An arms 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.

Flexion of fingers

Make fist.

Flexion of hip

Move leg forward and up.

Circumduction of hip

Move leg in circle.

Abduction of hip

Move leg laterally away from body.

Flexion of wrist

Move palm toward inner aspect of the forearm.

Flexion of thumb

Move thumb across palmar surface of hand.

Adduction of thumb

Move thumb back toward hand.

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

Perform both the distant and near visual acuity tests The first thing the nurse should do is perform both the distant & near visual acuity exams to assess for loss of far & near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the clients record. If abnormalities are found upon assessment the client should be referred for a complete eye examination

A nurse assess the pupillary reaction to light for a client. Which precaution should the nurse follow to get an accurate result of consensual response?

Place an opaque card in between the eyes of the client 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, & the response should be checked in the other eye. The client should not be instructed to close the other eye not focused w/ light because the response is checked in the other eye

Flexion of shoulder

Raise arm from side position forward to position above head.

Abduction of shoulder

Raise arm to side to position above head with palm away from head.

Extension of shoulder

Return arm to position at side of the body.

Extension of knee

Return heel to floor.

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 The only nursing diagnosis that can be confirmed with these 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.

I Olfactory

Sensory -ask patient if can smell a vial of coffee

VIII auditory, MRS. R calls Acoustic

Sensory, Romberg test for balance, equilibrium, tuning fork, whisper to test hearing

Abduction of toes

Spread toes apart.

Extension of elbow

Straighten elbow by lowering hand.

Extension of fingers

Straighten fingers.

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 The observation that the client & examiner see the examiner's finger at the same time indicates normal peripheral vision. Clients consensual pupils constricting in response to indirect light as well as direct light shown into the clients pupils resulting in constriction are observed when testing the pupils for reaction to light. Eyes converging on an object as it is moved towards the nose is a normal result for accommodation.

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

The is no reaction in the opposite pupil to light When light is shone into the eyes both the pupil the receives direct light & the consensual (opposite ) pupil should constrict (smaller). An abnormal response to this test is if either or both pupils do not constrict in repose to light. Pupils do not dilate in repose to light. Convergence of the eyes is called accommodation and occurs when focus of vision is moved from a far object to a close object. Light reflection appearing at different spots on both eyes is an abnormal result of the corneal light reflex treat, NOT of the consensual pupillary reaction to light.

Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination?

Touch the cornea with a wisp of cotton The nurse should asses the corneal reflex by lightly touching the corneal surface w/ a wisp of cotton. Shinning a penlight may help to test the pupillary respond & accommodation. A Snellen chart test the visual vision acuity. An ophthalmoscope is used to asses the internal; structures of eye.

Internal rotation of hip

Turn knee toward the inside.

A nurse is examining the eyes of a 7-year-old boy. The boy asks the nurse, "What's inside my eyeball?" The nurse explains that the biggest space inside the eyeball contains a clear, gelatinous substance that light passes through. Which of the following is the technical name for this gelatinous substance?

Vitreous humor Vitreous humor is the clear & gelatinous substance that fills the vitreous chamber, the largest chamber of the eye which is located in the area behind the lens to the retina. Aqueous humor is a clear liquid substance produced by the ciliary body that fills the anterior & posterior chambers of the eye. It helps to cleanse & nourish the cornea & lens as well as maintain intraocular pressure. Lacrimal & meibomian refer to glands that produce tears & a lubricating substance of the eyelids, respectively, & not to types of humor

Internal rotation of shoulder

With elbow flexed, rotate shoulder by moving arm until thumb is turned inward and toward back

Snellen test

a distance visual acuity test which determines the smallest letters that can be read on a chart from a distance of 20 feet away

Cover test

an examination of how the two eyes work together and is used to assess binocular vision. one eye at a time is covered while the patient focuses on an object across the room. determines the present or type of misalignment of the eye

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 underlying condition should the nurse most suspect in this client?

brain tumor Double vision (diplopia) may indicate increased intracranial pressure due to injury or 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 nurse inspects the eyes of a young child and notices the inward turning of the eyes. What test should the nurse perform to assess whether this finding is normal or abnormal?

corneal light reflex In young children the pupils will often appear at the inner canthus due to the epicanthic fold. To test for corneal light reflex the nurse shines a penlight about 12 inches from the face, directing it towards the bridge of the nose. The reflection of light on the cornea should be in the exact same spot on each eye. If not, this is considered abnormal & requires further assessment. The cover test does not test extroacular muscle function. The confrontation test examples peripheral vision. Pupillary reaction to light test constriction of pupil, not alignment

Weber test

hearing test using a tuning fork; distinguishes between conductive and sensorineural hearing loss

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

iris Iris is circular disc that determines eye color. Central aperture of the iris is called the pupil. The lens is a biconvex,transparent,avascular encapsulated structure located immediately posterior to the iris the refracts (bends) light rays onto the retina. The optic disc is a cream-colored circular area located on the retina. Retina (innermost layer) extends only to the ciliary body anteriorly. It receives visual stimuli & sends it to the brain

A client presents to the health care clinic with red, watery eyes and constant tearing. The nurse understands that which of the following is the organ that produces tears ?

lacrimal gland Lacrimal gland, located in the upper outer corner of the orbital cavity just above the ye produces tears. The meibomian glands, which are located in the tarsal plates of the upper eyelid, secrete an oily substance that lubricates the eyelid. Eccrine glands produce sweat & are located in the skin all over the body. Sebaceous glands are glands located in the dermis of the skin that open to wait follicles & that secrete an oily substance known as sebum

A nurse cares for a client with optic atrophy. The nurse recognizes that an ophthalmoscopic examination of the eye should reveal which characteristic finding in the optic disc?

white-colored White-colored optic disc is the characteristic finding in optic atrophy due to a lack of disc vessels. This condition is caused by the death of optic nerve fibers, An oval-shaped,orange-colored optic disc that is 1.5 mm wide is normal. Blurred margins indicate papilledema, or swelling