Ch. 13 Eye Assessment (Prep U)

A 52-year-old patient with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse?

"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."

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?

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

Which vision acuity reading indicates blindness?

20/200

The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?

4 mm

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 left temporal hemianopsia

A client reports, "There is something in my left eye that is causing me considerable discomfort." What initial step should the nurse take when everting the client's upper eyelid in order to search for the foreign body?

Ask the client to look down toward the left 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 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 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 nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following?

Consensual response

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

Which of the following would a nurse expect to assess in a client with esotropia?

Eye turning inward

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 the Jaeger card 14 inches from the face and read with one eye at a time

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

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following?

Narcotic use

The nurse asks the client to perform the action pictured. What is the nurse assessing?

Near vision

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

Nonreaction of the opposite pupil to light

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 assesses the pupillary reaction to light for a client who has lost vision in one eye. 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

During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?

Presbyopia

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

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

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?

Snellen E

A client is being assessed for indications of a possible obstructed nasolacrimal duct in the right eye. Under what circumstances should the nurse avoid compressing the lacrimal sac?

The area around the sac is inflamed.

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

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.

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

The lacrimal apparatus (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears.

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

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

True

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?

Up

The functional reflex that allows the eyes to focus on near objects is termed

accommodation This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens.

The functional reflex that allows the eyes to focus on near objects is termed

accommodation.

A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following?

consensual response

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.

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

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's

esotropia.

What muscles control the eye movement and hold the eye in place in the socket?

extraocular

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

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.

he 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

A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent

macular degeneration

The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from?

myopia

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

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

position the client 609.6 cm (20 ft) away from the chart.

During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?

presbyopia

A client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his right eye. The nurse should

refer the client to an opthomolagist

Photoreceptors of the eye are located in the eye's

retina.

client wants to use beta-carotene supplements to reduce the risk of developing cataracts and age-related macular degeneration. For which reason should the nurse counsel the client to avoid using this supplement?

smokes ciggs may increase the risk of lung cancer in people who smoke.

A 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should

tell the client that these often occur with aging

A patient has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis

watery, mucoid discharge