Chap. 16: eye assessment

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1.The right eye is tested, followed by the left eye, and then both eyes are tested. 2.Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3.The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. 4.The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

1.The right eye is tested, followed by the left eye, and then both eyes are tested.

normal size of pupils

2-4 cm

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? 1.Focus on a close object. 2.Focus on a distant object. 3.Close 1 eye and read letters on a chart. 4.Raise 1 finger when the sound is heard

2.Focus on a distant object. this dilates the pupil and then move object in to see if pupil constricts bilaterally

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1.Provide the client with materials on legal blindness. 2.Instruct the client that he or she may need glasses when driving. 3.Inform the client of where he or she can purchase a white cane with a red tip. 4.Inform the client that it is best to sit near the back of the room when attending lectures.

2.Instruct the client that he or she may need glasses when driving

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? 1.Flashlight 2.Snellen chart 3.Reflex hammer 4.Ophthalmoscope

2.Snellen chart

what snellen chart level would be blindness?

20/200. normal person can see at 200 feet what it take a person to see at 20 feet.

The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client? 1."You have normal vision." 2."You have some degree of blindness." 3."You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters)." 4."You can read at a distance of 30 ft (9 meters) what a person with normal vision can read at 20 ft (6 meters)."

3."You can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 30 ft (9 meters).

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

A left temporal hemianopsia

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? When 50 feet from the chart, the client can see better than a person standing at 20 feet. Client did not wear his glasses for this test and therefore it is not accurate. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet. Client can read the 20/50 line correctly and two other letters on the line above.

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

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 a normal finding? A. both eyes may return either downward or upward B. uncover eyes moves to establish focus C. covered eye remains fixed straight ahead uncovered eye turns inward to establish focus

C. covered eye remains fixed straight ahead

A client tells the nurse that his eyes "are not working right." When the nurse asks what the client means, the client states, "It is like one eye is moving faster than the other." What test would be most appropriate for the nurse to use to assess this client? Static confrontation Cover Kinetic confrontation Cardinal fields

Cardinal fields the cardinal fields of gaze allow the nurse to detect muscle defects that cause misalignment or uncoordinated movement of the eyes. Kinetic and static confrontation tests are used to test peripheral vision. The cover test is for accommodation.

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 Accommodation Direct reaction Near reaction

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.

tympanic membrane function

Convey vibrations created by sound waves from the external ear to the auditory ossicles

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? Daily use of eye drops Corrective lenses No night driving Surgery

Corrective lenses Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition.

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 Esotropia Strabismus Presbyopia

Exotropia

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 Pointed at a fixed object on the wall Directly on the eye being examined Shined on the forehead

Focused on the bridge of the nose

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? Obtain a referral to the ophthalmologist for a complete eye exam Test the pupils for direct and consensual reaction to light Perform both the distant and near visual acuity tests Document the findings in the client's record

Perform both the distant and near visual acuity tests

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? Loss of convergence Macular degeneration Presbyopia Cataract formation

Presbyopia

When testing the near reaction, an expected finding includes which of the following? Pupillary constriction on near gaze; constriction on distant gaze Pupillary constriction on near gaze; dilation on distant gaze Pupillary dilation on near gaze; constriction on distant gaze Pupillary dilation on near gaze; dilation on distant gaze

Pupillary constriction on near gaze; dilation on distant gaze

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 patient's vision? Ishihara PERRLA Allen Snellen E

Snellen E

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? Pupils dilate in response to a light shone in the eyes. Eyes do not converge to focus on a shining light. There is no reaction in the opposite pupil to light. Light reflection appears at different spots on both eyes.

There is no reaction in the opposite pupil to light.

When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction? Down Up To the right To the left

Up

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? Vision is worse in the left eye than the right eye. The larger the bottom number, the worse the visual acuity. Glasses are needed by the client for near vision. Client is legally blind in the left eye.

Vision is worse in the left eye than the right eye.

The functional reflex that allows the eyes to focus on near objects is termed refraction. indirect reflex. accommodation. pupillary reflex.

accommodation Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens.

In the cover test, what would indicate an abnormal finding?

as the patient stares ahead, either after covering the eye or uncovering of the eye, there is a shift to the left or right side. this indicates muscle weakness or "lazy eye"

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? glaucoma macular degeneration cataracts detached retina

cataracts

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 consensual light response present in right eye direct light response present in left eye pupils equal and react to accommodation

consensual light response present in right eye

what is this testing

corneal reflex; tests trigeminal and facial nerve (not eye nerves)

strabismus

cross-eyed. (stray eye)

risk factors for glaucoma

diabetes, AA, anglo >60 years old, corticosteriods long term use, hypothyroidism

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 ask the client if there is a genetic history of blindness. document the findings in the client's records. refer the client for further evaluation. examine the client for other signs of glaucoma.

document the findings in the client's records.

The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents exophthalmos ptosis ectropion entropion

entropion

A nurse assesses the distant vision ccuity of a client using the Snellen chart. Which action should the nurse Implement to perform the test accurately? A. position the client 12 feet away from the Snellen chart B. instruct the client to lean forward and read the chart C. ask the client to cover one eye with the hand instruct the client to read without reading glasses

instruct the client to read without reading glasses

causes of tinnitis

medications-vancomysin, hypertension, loud noises,

Straight movements of the eye are controlled by the corneal muscles. oblique muscles. rectus muscles. lacrimal muscles

rectus muscles. The extraocular muscles are the six muscles attached to the outer surface of each eyeball. These muscles control six different directions of eye movement. Four rectus muscles are responsible for straight movement, and two oblique muscles are responsible for diagonal movement.

Correct order of administering Snellen test?

right eye, left eye, than both.

The nurse tests the six cardinal directions to test extraocular movement of the eye. True False

true