Chapter 13: Eye Assessment for Advanced and Specialty Practice - ML5

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

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

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

accommodation.

The nurse is planning to assess a client's near vision. Which technique should be used? shine a light on the bridge of the nose have the client stand 20 feet from a wall chart and read the letters after covering one eye ask the client to move the eyes in the direction of a moving finger have the client read newspaper print held 14 inches from the eyes

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

The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope in the left hand for both eyes in the left hand for the right eye and in the right hand for the left eye in the right hand for both eyes in the right hand for the right eye and in the left hand for the left eye

in the right hand for the right eye and in the left hand for the left eye

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent retinal detachment open-angle glaucoma macular degeneration hemianopsia

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 cataracts glaucoma detached retina

macular degeneration

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

optic chiasma.

A 52-year-old client with documented myopia presents to the emergency department because of "spots" floating in their line of vision. What should the nurse respond to the client about this symptom? "This is a normal change in the eye associated with aging." "A cataract is forming and cannot be treated until it ripens." "This means you have glaucoma and need to have your eye pressure checked." "You have a detached retina and need to lie down immediately."

"This is a normal change in the eye associated with aging."

The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal? 6 mm 8 mm 2 mm 4 mm

4 mm

A 2-month-old infant is being examined at the pediatrician's office. The mother said she noticed the baby was not making tears in the left eye. What does this finding suggest? A blocked lacrimal apparatus Blepharitis Vision loss Amblyopia

A blocked lacrimal apparatus

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

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

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 Ectropion Arcus senilis Myopia

Arcus senilis

A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate? Have the client keep the glasses on but occlude one eye. Test the client's near visual acuity instead. Use the E chart rather than the Snellen chart for testing. Ask the client to remove the glasses before testing.

Ask the client to remove the glasses before testing.

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 Approaches the client directly in front of the pupil Uses right eye to examine the client's left eye Moves the scope around so the entire optic disk may be seen

Asks the client to fix the gaze upon an object and look straight ahead

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

Blunt-force trauma often results in fracture of the orbit

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 of the following underlying conditions should the nurse most suspect in this client? Viral infection Brain tumor Allergies Vitamin A deficiency

Brain tumor

A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, "Do you wear sunglasses during exposure to the sun?" the nurse is addressing a known risk factor for what health problem? Presbyopia Nystagmus Glaucoma Cataracts

Cataracts

A woman who is 5 months pregnant is being assessed at a routine visit. She has increased pigmentation around the eyes. This is known as what? Chloasma Hyphema Conjunctivitis Pink eye

Chloasma

Which of the following would a nurse expect to assess in a client with esotropia? Eye turning outward Eye malalignment Eye oscillating Eye turning inward

Eye turning inward

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

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

Health education

A client is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left eye noted in the client's medical record supports this diagnosis? Increased intraocular pressure Opaque lens Sluggish pupillary reaction Displaced optic nerve

Increased intraocular pressure

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

Lacrimal apparatus

A client reports an area of distortion when looking at the Amsler chart. What does this finding indicate to the nurse? Cataract formation Glaucoma Macular degeneration Detached retina

Macular degeneration

When using hand gel to clean the hands, what must the nurse do before touching a client's eyes? Wash the hands again with soap and water Make sure the hands are completely dry Assess for color blindness Assess visual acuity

Make sure the hands are completely dry

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

Perform both the distant and near visual acuity tests

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 Ineffective Individual Coping Disturbed Self-Concept Self-Care Deficit

Risk for Injury

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? Allen Ishihara Snellen E PERRLA

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? Eyes converge on an object as it is moved towards the nose. Client's consensual pupil constricts in response to indirect light. The client and the examiner see the examiner's finger at the same time. Direct light shown into the client's pupils results in constriction.

The client and the examiner see the examiner's finger at the same time.

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? Client is legally blind in the left eye Glasses are needed by the client for near vision Vision is worse in the left eye than the right eye The larger the bottom number, the worse the visual acuity

The larger the bottom number, the worse the visual acuity

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

There is no reaction in the opposite pupil to light.

A nurse assesses the vision of an older adult client with a long history of uncontrolled type 2 diabetes. The nurse determines the client's vision with corrective lenses is 20/200. How should the nurse interpret these findings? This is normal vision for a client over 65. The client will need a new pair of glasses. These findings indicate the client is legally blind. The client must have developed macular degeneration.

These findings indicate the client is legally blind.

What is the primary purpose of the health history in relation to the eyes? To test the acuity of central vision To identify if problems are unilateral or bilateral To identify changes To identify a family history of ocular disease

To identify changes

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction? Down To the right To the left Up

Up