Chapter 11: The Eyes

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

"Are the blind spots constant or intermittent?"

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? Report this to the health care provider Ask the client about previous trauma to the eyes Document this finding in the client's record Continue with the examination

Ask the client about previous trauma to the eyes 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.

A client complains of excessive tearing of the eyes. Which assessment would the nurse do next? Assess the nasolacrimal sac Inspect the palpebral conjunctiva Perform the eye positions test Test pupillary reaction to light

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. Client did not wear his glasses for this test and therefore it is not accurate. Client can read the 20/50 line correctly and two other letters on the line above. When 50 feet from the chart, the client can see better than a person standing at 20 feet.

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

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? Direct reaction Consensual reaction Near reaction Accommodation

Consensual reaction

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? Presbyopia Strabismus Exotropia Esotropia

Exotropia Explanation:With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision. (less)

What is vital in maintaining vision and a healthy outlook for clients? Health education Physical exercise Emotional support Monthly eye exams

Health education

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

Lacrimal apparatus

The nursing instructor should include what information regarding the effects of mydriatic drops on glaucoma? Mydriatic drops constrict the pupils in clients with glaucoma. Mydriatic drops do not specifically affect glaucoma. Mydriatic drops may precipitate acute angle-closure glaucoma. Mydriatic drops may cause a crisis in clients with open-angle glaucoma.

Mydriatic drops may precipitate acute angle-closure glaucoma.

When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following? Optic disc Physiologic cup Retinal vessels Fovea

Optic disc

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

Perform both the distant and near visual acuity tests

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? Loss of convergence Macular degeneration Cataract formation Presbyopia

Presbyopia

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? Ineffective Individual Coping Risk for Injury Disturbed Self Concept Self-Care Deficit

Risk for Injury

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

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

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

an oily substance to lubricate the eyes.

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 exotropia. strabismus. esotropia. phoria.

esotropia.

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should ask the client to remove his glasses. instruct the client to begin reading from the bottom of the chart. ask the client to read each line with both eyes open. position the client 609.6 cm (20 ft) away from the chart.

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

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? Myopia Ectropion Presbyopia Arcus senilis

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.

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 Move an object through the six cardinal positions of gaze Perform the confrontation test Have the client read from a Jaeger reading card

Use a Snellen E chart to perform the examination.