Ch16-PU

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

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

On visual confrontation testing, a client with a recent stroke cannot see the examiner's fingers on the entire right side with either eye covered. Which of the terms would describe this finding?

Right homonymous hemianopsia

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

Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination?

Touch the cornea with a wisp of cotton

How can a nurse accurately assess the distant visual acuity of a client who is non-English-speaking?

Use a Snellen E chart to perform the examination

A client notices that the newspaper print is not as clear to read as it used to be. What health problem should the nurse consider is occurring with this client?

hyperopia

Which of the following health problems necessitates the use of an ophthalmoscope during assessment? papilledema cataracts subconjunctival hemorrhage tonic pupil

A (Papilledema is characterized by swelling of the optic disc and bulging of the physiologic cup. It is necessary to use an ophthalmoscope to view these parts of the eye. Cataracts, subconjunctival hemorrhage, and a tonic pupil are normally visible to the unaided eye of the clinician.)

Which of the following assessment findings suggests a problem with the client's cranial nerves?

A client's extra-ocular movements are asymmetrical and she complains of diplopia

The meibomian glands secrete

An oily substance to lubricate the eyes

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

Conjunctiva

While the nurse examines a patient'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?

Consensual reaction

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

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

A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder? a) Glaucoma b) Cataract c) Diabetes d) Hypertension

Glaucoma Explanation: Seeing rings around lights or halos is associated with narrow angle glaucoma. Diabetes produces change in the retina that can cause blurred vision. Cataracts are caused by clouding of the lens of the eyes. Hypertension affects the blood vessels of the eyes which may not cause any eye symptoms until the damage is severe.

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

Lacrimal apparatus

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

Macular Degeneration

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?

Macular degeneration

When testing the near reaction, an expected finding includes which of the following?

Pupillary constriction on near gaze; dilation on distant gaze

The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test

Requires the covering of each eye separately.

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking?

Use a snellen E chart to perform the examination

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 a) constant misalignment of the eyes. b) muscle weakness. c) congenital cataracts. d) 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 is assessing cranial nerves III, IV, and VI. Which instructions should the nurse provide to the client in order to perform this assessment?

"Follow my finger with only your eyes."

A comprehensive physical examination of the eye includes tests for which of the following? Select all that apply.

-Visual acuity -Eye muscle function -Internal ocular structures -The external eye

Which vision acuity reading indicates blindness?

20/200

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

The nurse practitioner is assessing the eyes of a client with long-standing uncontrolled hypertension. What might the nurse practitioner visualize during an assessment with an ophthalmoscope?

AV nicking

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?

Arcus senilis

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 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.

The middle layer of the eye is known as the

Choroid layer

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 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

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 client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

Corrective lenses

A patient 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) Low-fat meat d) Foods that contain lots of water

Deep-water fish Explanation: Foods that promote eye health include deep-water fish, fruits, and vegetables

An elderly client presents to the health care clinic with reports of decreased tearing in both eyes. The nurse observes the presence of ectropion. What is an appropriate action by the nurse?

Document the finding as a normal sign of aging

When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are clients most likely at increased risk for if a first-degree relative has it?

Glaucoma

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

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

A patient is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the patient's medical record supports this diagnosis?

Increased intraocular pressure

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

On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear 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?

Perform both the distant and near visual acuity tests

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

Position the client 609.6cm (20ft) away from the chart

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?

Presbyopia

Photoreceptors of the eye are located in the eye's

Retina

Which of the following is a symptom of the eye?

Scotomas

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

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

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

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

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. vitreous humor

b (Vitreous humor is the clear and gelatinous substance that fills the vitreous chamber, the largest chamber of the eye, which is located in the area behind the lens to the retina. Aqueous humor is a clear liquid substance produced by the ciliary body that fills the anterior and posterior chambers of the eye. It helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure. Lacrimal and meibomian refer to glands that produce tears and a lubricating substance of the eyelids, respectively, and not to types of humor.)

An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should

check the clients blood pressure

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

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.

Which area of the fundus is the central focal point for incoming images?

fovea

What are the glands that are located on the tarsal plates and open on the lid margins?

meibomian glands

What part of the eye receives and transmits visual stimuli to the brain for processing?

retina

The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead? white red yellow black

white

A patient comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse?

"You will need to see the doctor to have your eye checked."

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

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 to hold the chart 14 inches from the eyes

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?

Presbyopia

The nurse is teaching about the importance of regular eye examinations and should include information about which conditions that place clients at highest risk for blindness? (Select all that apply.)

-Diabetes -Hypertension

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

Accommodation

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test the near visual acuity using a Jaeger reading card?

Instruct the client hold the chart 14 inches from the eyes

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?

Perform both the distant and near visual acuity tests

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?

Stye

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?While the nurse examines a patient'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?

Up

What eye function is the nurse preparing to assess when the patient is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

Distant vision

What is a characteristic symptom of Graves hyperthyroidism?

Exopthalamus

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? a) Observe the response in the eye focused with light b) Shine a bright light directly into the eye to be tested c) Instruct the client to close the eye not focused with light d) Place an opaque card in between the eyes of the client

Place an opaque card in between the eyes of the client Explanation: The nurse should place an opaque card in between the eyes of the client when assessing the client for consensual response to avoid inaccurate results. The light should not be focused directly into the eye to be tested; it should be focused obliquely into one eye, and the response should be checked in the other eye. The client should not be instructed to close the other eye not focused with light because the response is checked in the other eye.

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states 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?

Risk for injury

A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which underlying condition should the nurse most suspect in this client?

brain tumor

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

entropion

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is a) ultraviolet light exposure. b) use of antibiotics. c) obesity. d) lack of vitamin C in the diet.

ultraviolet light exposure. Explanation: Exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lenses of the eyes). Consistent use of sunglasses during exposure minimizes the client's risk.

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? a) Medially toward the nose b) Downward toward the chin c) Upward toward the forehead d) Laterally toward the ear

Medially toward the nose Explanation: Follow the blood vessels as they get wider. Follow the vessels medially toward the nose and look for the round yellowish orange structure which is the optic disc.

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?

Risk for injury

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? 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."

"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." Explanation: Conjunctivitis usually has an infectious etiology. Severe pain and vision damage are not common con

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

Hyphema Explanation: Hyphema is blood in the anterior chamber of the eye, usually caused by blunt trauma. Blepharitis is inflammation of the margin of the eyelid. Chalazion is a cyst in the eyelid. Iris nevus is a rare condition affecting one eye. The latter 3 conditions are not commonly attributed to blunt force trauma to the head as hyphema is.

Which statement demonstrates the safest way to document assessment findings of drainage noted in both eyes of a client? a) Thick, purulent drainage is noted at inner corner of OU. b) Thick, purulent drainage is noted at inner corner of both eyes. c) Thick, purulent drainage is noted at inner corner of OS. d) Thick, purulent drainage is noted at inner corner of OD.

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." (less) Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 16: Assessing Eyes, pg. 328.

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) Permits the entrance of light to the eye b) Transforms light rays into nerve impulses that are conducted to the brain c) Controls the amount of light entering the eye d) Refracts light rays onto the posterior surface of the eye

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 pupil's 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.