Chapter 11: The Eyes
The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?
4 mm
Which of the following assessment findings suggests a problem with the client's cranial nerves?
A client's extraocular movements are asymmetrical and she complains of diplopia.
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
A client complains of excessive tearing of the eyes. Which assessment would the nurse do next?
Assess the nasolacrimal sac
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.
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?
Blunt-force trauma often results in fracture of the orbit
A client visits the health care clinic with reports of itchy and watery eyes for three days. The nurse observes a generalized redness to the conjunctiva. The nurse recognizes this as what condition?
Conjunctivitis
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
A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?
Exophthalmos
What is a characteristic symptom of Graves hyperthyroidism?
Exophthalmos
The nurse is assessing a client whose electronic health record notes a diagnosis of esotropia. When examining this client, the nurse should expect what finding?
Eye turning inward
Which of the following would a nurse expect to assess in a client with esotropia?
Eye turning inward
What is vital in maintaining vision and a healthy outlook for clients?
Health education
A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?
Instruct the client hold the chart 14 inches from the eyes
When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. How would the nurse document this finding?
Optic disc
A nurse has taught a group of older adults about the high incidence and prevalence of macular degeneration. What health promotion and prevention activity should the nurse encourage these clients to perform?
Post an Amsler grid in their home and perform the test on a regular basis
The functional reflex that allows the eyes to focus on near objects is termed
accommodation.
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
glaucoma.
Photoreceptors of the eye are located in the eye's
retina
