Health Assessment Prep U: Chapter 16- Assessing the Eyes

The nurse is assessing a client's visual acuity and visual fields. The nurse evaluates that the assessment results are within expected parameters. How should the nurse document this assessment finding? A. Cranial nerve II intact B. Cranial nerves III, IV, and VI intact C. Cranial nerve XI intact D. Cranial nerve I intact

A. Cranial nerve II intact

Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)? A. IV (trochlear) B. VI (abducens) C. III (oculomotor) D. II (optic)

C. III (oculomotor)

What part of the eye receives and transmits visual stimuli to the brain for processing? A. Posterior chamber B. Vitreous chamber C. Retina D. Optic disc

C. Retina

The nurse selects the chart shown here to assess a client's vision. Which client characteristic caused the nurse to select the E chart?

Does not speak English

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

A. There is no reaction in the opposite pupil to light.

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

A. accommodation.

The meibomian glands secrete A. an oily substance to lubricate the eyes. B. clear liquid tears. C. hormones. D. sweat.

A. an oily substance to lubricate the eyes.

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 A. glaucoma. B. increased intracranial pressure. C. migraine headaches. D. bacterial infection.

A. glaucoma.

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? A. macular degeneration B. cataracts C. detached retina D. glaucoma

A. macular degeneration

Which area of the fundus is the central focal point for incoming images? A. The macula B. The fovea C. The optic disk D. The physiologic cup

B. The fovea

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

B. document the findings in the client's records.

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

C. A left temporal hemianopsia

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? A. This could be a sign of strabismus B. High-velocity injuries are typically non-penetrating C. Blunt-force trauma often results in fracture of the orbit D. The client could have optic atrophy

C. Blunt-force trauma often results in fracture of the orbit

While the nurse examines a client's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse? A. Myopia B. Direct reaction C. Consensual reaction D. Presbyopia

C. Consensual reaction

A client 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? A. 20/100 or less B. 20/400 or less C. 20/300 or less D. 20/200 or less

D. 20/200 or less

What muscles control the eye movement and hold the eye in place in the socket? A. Trochlear B. Oculomotor C. Abducens D. Extraocular

D. Extraocular

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? A. Upward toward the forehead B. Downward toward the chin C. Laterally toward the ear D. Medially toward the nose

D. Medially toward the nose

Photoreceptors of the eye are located in the eye's A. pupil. B. ciliary body. C. lens. D. retina.

D. retina.

What is a characteristic symptom of Graves hyperthyroidism?

Exophthalmos

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

True

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

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to

corneal damage.

The nurse is planning to assess a client's near vision. Which technique should be used?

have the client read newspaper print held 14 inches from the eyes

When assessing the eye, the nurse recognizes that which physical structures of the face limit the normal visual field that a client can experience? List all that apply.

the brow, the medial aspect of the nose, the cheek

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 presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition? A. Blepharitis B. Iris nevus C. Hyphema D. Chalazion

C. Hyphema

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? A. Controls the amount of light entering the eye B. Permits the entrance of light to the eye C. Transforms light rays into nerve impulses that are conducted to the brain D. Refracts light rays onto the posterior surface of the eye

C. Transforms light rays into nerve impulses that are conducted to the brain

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

The optic nerves from each eyeball cross at the A. optic disc. B. vitreous humor. C. visual cortex. D. optic chiasma.

D. optic chiasma.

What do retinal abnormalities include? A. Horner's syndrome B. Age-related macular degeneration C. Argyll Robertson syndrome D. Mydriasis

B. Age-related macular degeneration

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

A. Perform both the distant and near visual acuity tests

The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents A. ptosis B. exophthalmos C. entropion D. ectropion

C. entropion

The bony orbit and fat cushion of the eye serves as a A. channel. B. caruncle. C. protector. D. filter.

C. protector.

The nurse is performing visual acuity testing on an older adult who has fallen and fractured their femur. What finding would be considered normal for this client? (Select all that apply.) A. Arcus senilis B. Increased tear production C. Small cataract D. Decreased central vision C. Increased pupillary response

A. Arcus senilis C. Small cataract D. Decreased central vision

A 60-year-old client is concerned about developing cataracts in her eyes. She asks the nurse whether there is anything she can do to reduce her risk. Consumption of which of the following foods should the nurse recommend to the client for this purpose? Select all that apply. A. Kale B. Eggs C. Turkey D. Red wine E. Oranges D. Skim milk

A. Kale B. Eggs E. Oranges

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 client's vision? A. PERRLA B. Snellen E C. Ishihara D. Allen

B. Snellen E

A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition? A. "Is night blindness a problem for you?" B. "How often do you have redness or tearing?" C. "Are the blind spots constant or intermittent?" D. "Do you see floaters in front of your eyes?"

C. "Are the blind spots constant or intermittent?"

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? A. Sinus B. Aqueous chamber C. Lacrimal apparatus D. Vitreous chamber

C. Lacrimal apparatus

The nurse should make it a priority to assess which client for papilledema? A. an 80-year-old diagnosed with chronic open-angle glaucoma B. a 12-year-old demonstrating a deviated left eye C. a 56-year-old reporting double vision D. a 45-year-old suspected of experiencing a subarachnoid hemorrhage

D. a 45-year-old suspected of experiencing a subarachnoid hemorrhage

The nurse asks the client to perform the action of reading an article 14 inches away from the client. What is the nurse assessing?

Near 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? A. Arcus senilis B. Myopia C. Ectropion D. Presbyopia

A. Arcus senilis

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

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

A client asks a nurse if any foods promote eye health. What food would the nurse include as a response? A. Deep-water fish B. Multigrain foods C. Foods that contain lots of water D. Low-fat meat

A. Deep-water fish

A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye? A. "In children, this problem is usually caused by an increase in pressure within the eye." B. "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." C. "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." D. "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage."

B. "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

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

B. A left temporal hemianopsia

A nurse is inspecting the bulbar conjunctiva 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? A. Ask the client whether he has recently had trouble focusing when reading up close B. Document the finding and proceed with the examination C. Examine the client's eye for presence of a foreign body D. Notify the physician of the finding

B. Document the finding and proceed with the examination

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? A. Strabismus B. Exotropia C. Esotropia D. Presbyopia

B. Exotropia

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? A. Instruct the client to hold the chart away from the body at arm's length B. Instruct the client hold the chart 14 inches from the eyes C. Place the chart 20 feet away from the client on the wall D. Place the chart on a table 17 inches away from the client

B. Instruct the client hold the chart 14 inches from the eyes

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? A. Strabismus B. Presbyopia C. Exotropia D. Esotropia

B. Presbyopia

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? A. She can accurately name 20% of the letters at 20 feet. B. She can see at 20 feet what a normal person could see at 100 feet. C. She obtains a 20% correct score at 100 feet. D. She can see at 100 feet what a normal person could see at 20 feet.

B. She can see at 20 feet what a normal person could see at 100 feet.

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 A. double vision. B. lacrimal obstruction. C. viral infection. D. allergic reactions.

B. lacrimal obstruction.

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? A. Cataract formation B. Loss of convergence C. Presbyopia D. Macular degeneration

C. Presbyopia

Which of the following is a symptom of the eye? A. Rhinorrhea B. Tinnitus C. Scotomas D. Dysphagia

C. Scotomas

A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis? A. Chalazion B. Xanthelasma C. Stye D. Dacryocystitis

C. Stye

Which of the following assessment findings suggests a problem with the client's cranial nerves? A. A client states that he has recently begun seeing lights flashing in his field of vision. B. Fundoscopic examination reveals intraocular bleeding. C. A client's lens appears cloudy and she claims that her visual acuity has recently declined. D. A client's extraocular movements are asymmetrical and she complains of diplopia.

D. A client's extraocular movements are asymmetrical and she complains of diplopia.

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

D. Pupillary constriction on near gaze; dilation on distant gaze

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? A. Self-Care Deficit B. Ineffective Individual Coping C. Disturbed Self Concept D. Risk for Injury

D. Risk for Injury

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? A. Aqueous humor B. Meibomian humor C. Lacrimal humor D. Vitreous humor

D. Vitreous humor

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.