Chapter 16: Assessing Eyes
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? Document this finding in the client's record Continue with the examination Report this to the health care provider Ask the client about previous trauma to the eyes
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 whether this is a new finding or new onset. All other options the nurse can do after this is determined.
What is the open space between the eyelids called? The lacrimal apparatus The limbus The palpebral fissure The eyeball
The palpebral fissure. Explanation: The palpebral fissure is the almond-shaped open space between the eyelids. The limbus is the border of the cornea and the sclera. The eyeball is the round part of the eye within the eyelids and socket. The lacrimal apparatus protects and lubricates the cornea and conjunctiva by producing and draining tears.
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? direct light response present in left eye pupils equal and react to accommodation consensual light response present in left eye consensual light response present in right eye
consensual light response present in left eye Explanation: The consensual light response occurs when one eye is exposed to light and the pupil of the other eye constricts. Since the light was shined in the right eye, the left pupil constricted. The left eye was not exposed to direct light. There is not enough information to determine if the pupils are equal or reacting to accommodation.
The optic nerves from each eyeball cross at the: optic chiasma. visual cortex. vitreous humor. optic disc.
optic chiasma. Explanation: At the point where the optic nerves from each eyeball cross—the optic chiasma—the nerve fibers from the nasal quadrant of each retina (from both temporal visual fields) cross over to the opposite side.
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? Presbyopia Arcus senilis Myopia Ectropion
Arcus senilis Explanation: Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision.
Which data collected in a health history interview of a client should the nurse document as risk factors for the development of cataracts? Select all that apply. Hit on the back of the head with a hammer Works in lawn maintenance Thyroid disease Eats very few fruits or vegetables Cigarette smoking Blood pressure medications
Cigarette smoking Works in lawn maintenance Eats very few fruits or vegetables. Explanation: Risk factors for the development of cataracts include age over 50, exposure to ultraviolet B light, diabetes mellitus, alcohol use, cigarette smoking, a diet low in antioxidants, high blood pressure, eye injuries, and steroid use.
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? Conjunctiva Retina Cornea Sclera
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 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? Renal insufficiency Retinal detachment Anemia Diabetes
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.
Normal movement of the eye involves what cranial nerves? (Mark all that apply.) II III IV V VI
II III IV VI Explanation: As the nurse inspects and palpates the eye, he or she assesses for the sensory and motor functions of four cranial nerves: Cranial nerve II, optic nerve, visual acuity, visual fields, fundoscopic examination; cranial nerve III, oculomotor, cardinal fields of gaze, eyelid inspection, pupil reaction (direct/consensual/ accommodation); cranial nerve IV, trochlear, cardinal fields of gaze; and cranial nerve VI, abducens, cardinal fields of gaze. Cranial nerve V, known as the trigeminal nerve, is a nerve responsible for sensation in the face and certain motor functions such as biting and chewing.
A client is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the client's medical record supports this diagnosis? Sluggish pupillary reaction Displaced optic nerve Increased intraocular pressure Opaque lens
Increased intraocular pressure Explanation: Aqueous humor is produced by the ciliary body, circulates from the posterior chamber through the pupil into the anterior chamber, and drains out through the canal of Schlemm. This system controls the pressure within the eye. If there is an obstruction of the canal of Schlemm, aqueous humor will not drain, increasing pressure within the eye. An obstruction of the canal of Schlemm will not displace the optic nerve because the optic nerve is located within the posterior portion of the eye. An opaque lens is a cataract, which is not caused by an obstruction of the canal of Schlemm. Pupil reaction is a neurological function not affected by intraocular pressure
What are the glands that are located on the tarsal plates and open on the lid margins? Pterygium glands Levator glands Meibomian glands Chalazion glands
Meibomian glands Explanation: Within the eyelids lie firm strips of connective tissue called tarsal plates. Each plate contains a parallel row of meibomian glands, which open on the lid margin.
You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document? Hyperopia Papilledema Arteriovenous crossings Positive axoplasmic sign
Papilledema Explanation: Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup.
A 67-year-old lawyer comes to the clinic for an annual examination. He denies any history of eye trauma or recent visual changes. Inspection of his eyes reveals a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis? Cataracts Corneal arcus Corneal scar Pterygium
Pterygium Explanation: A pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side. Reddening may occur, and it may interfere with vision as it encroaches on the pupil. Otherwise treatment is unnecessary.
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? Eyes do not converge to focus on a shining light. Pupils dilate in response to a light shone in the eyes. 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. Explanation: When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict. An abnormal response to this test is if either or both pupils do not constrict in response to light. Pupils do not dilate in response to light shone into them. 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 test, not of the consensual pupillary reaction to light test.
What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client? Thick, purulent drainage is noted at inner corner of OS. Thick, purulent drainage is noted at inner corner of OD. Thick, purulent drainage is noted at inner corner of both eyes. Thick, purulent drainage is noted at inner corner of OU.
Thick, purulent drainage is noted at inner corner of both eyes. Explanation: The abbreviations OD (right eye), OS (left eye), and OU (both eyes) are no longer used due to the potential for order errors. Instead, it is recommended to use "right eye," "left eye," or "both eyes."
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? Permits the entrance of light to the eye Refracts light rays onto the posterior surface of the eye Controls the amount of light entering the eye Transforms light rays into nerve impulses that are conducted to the brain
Transforms light rays into nerve impulses that are conducted to the brain Explanation: Visual perception occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted. The lens functions to refract (bend) light rays onto the retina. Muscles in 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.
The nurse should make it a priority to assess which client for papilledema? a 12-year-old demonstrating a deviated left eye a 45-year-old suspected of experiencing a subarachnoid hemorrhage an 80-year-old diagnosed with chronic open-angle glaucoma a 56-year-old reporting double vision
a 45-year-old suspected of experiencing a subarachnoid hemorrhage Explanation: Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup. Increased intracranial pressure is transmitted to the optic nerve, causing edema of the optic nerve. Papilledema often signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions. An enlarged physiological cup suggests chronic open-angle glaucoma. If cranial nerve IV is paralyzed, the left eye will deviate from its normal position in that direction of gaze, and the eyes will no longer appear conjugate, or parallel. Diplopia in adults may arise from a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of cranial nerve (CN) III or VI, or vertical diplopia from palsy of CN III or IV.
The conjunctiva of the eye is divided into the palpebral portion and the: intraocular portion. canthus portion. bulbar portion. nasolacrimal portion.
bulbar portion. 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 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: constant misalignment of the eyes. muscle weakness. congenital cataracts. decreased accommodation.
decreased accommodation. Explanation: 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.
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. document the findings in the client's records. ask the client if there is a genetic history of blindness. examine the client for other signs of glaucoma.
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 adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible: ophthalmic migraine. increased intracranial pressure. glaucoma. hypertension.
increased intracranial pressure. Explanation: Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor.
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. viral infection. double vision. allergic reactions.
lacrimal obstruction. Explanation: 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? detached retina glaucoma cataracts macular degeneration
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.
The bony orbit and fat cushion of the eye serves as a: caruncle. channel. protector. filter.
protector. Explanation: The eyeball is located in the eye orbit, a round, bony hollow formed by several different bones of the skull. In the orbit, a cushion of fat surrounds the eye. The bony orbit and fat cushion protect the eyeball.
