Chapter 16: Assessing Eyes

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

"Are the blind spots constant or intermittent?" Explanation: A scotoma is the presence of blind spots that can be constant or intermittent. If they are constant it may indicate retinal detachment. Intermittent blind spots may be due to vascular spasm or pressure on the optic nerve. Floaters are a common finding in individuals with myopia or in person over the age of 40 years and are a sign of normal aging. Redness or tearing is associated with allergies or inflammation of the eye. Night blindness is associated with optic nerve atrophy, glaucoma, or vitamin A deficiency.

Which question should the nurse ask when assessing a client for a possible detached retina? "Is your vision loss located in the center of your view of vision?" "Is the vision in both of your eyes affected?" "Can you see objects on the outer edges of your field of vision?" "Are you seeing flashing lights?"

"Are you seeing flashing lights?" Explanation: Flashing lights suggest detachment of vitreous from retina. Slow central loss of vision is associated with macular degeneration. Peripheral loss in advanced open-angle glaucoma. Bilateral loss is often related to a chemical exposure.

Diplopia present with one eye covered can be caused by which of the following problems? Weakness of CN IV Weakness of CN III A lesion of the brainstem An irregularity in the cornea or lens

An irregularity in the cornea or lens Explanation: Double vision in one eye alone points to a problem in "processing" the light rays of an incoming image. The other causes of diplopia result in a misalignment of the two eyes.

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? Ectropion Presbyopia Arcus senilis Myopia

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.

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

Deep-water fish Explanation: Foods that promote eye health include deep-water fish, fruits, and vegetables (e.g., carrots, spinach).

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 Retinal detachment Anemia Renal insufficiency

Diabetes Explanation: Exudates appear as light-colored spots on the retinal background and occur in individuals with diabetes or hypertension. Anemia, renal insufficiency, and retinal detachment do not cause this appearance on the retina.

What is a characteristic symptom of Graves hyperthyroidism? Exophthalmos Pterygium Episcleritis Pinguecula

Exophthalmos Explanation: In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.

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? Epicanthus Ectropion Exophthalmos Ptosis

Exophthalmos Explanation: In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumor and inflammation in the orbit.

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? Chalazion Blepharitis Iris nevus Hyphema

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.

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

Lacrimal apparatus Explanation: 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.

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

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

Myopia Explanation: Myopia is nearsightedness, meaning the client can see objects better up close. Asthenopia is eye strain, and symptoms include fatigue, red eyes, eye pain, blurred vision, and headaches. Hyperopia is farsightedness. Presbyopia commonly occurs naturally due to the aging process; therefore it's rare to observe this condition in young adults

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

She can see at 20 feet what a normal person could see at 100 feet. Explanation: The denominator of an acuity score represents the line on the chart the client can read. In the example above, the client could read the larger letters corresponding with what a normal person could see at 100 feet.

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

The fovea Explanation: The fovea is the area of the retina that responsible for central vision. It is surrounded by the macula, which is responsible for more peripheral vision. The optic disc and physiologic cup are where the optic nerve enters the eye.

What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client? Thick, purulent drainage is noted at inner corner of OS. Thick, purulent drainage is noted at inner corner of OU. Thick, purulent drainage is noted at inner corner of both eyes. 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."

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

accommodation. Explanation: Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens.

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

an oily substance to lubricate the eyes. Explanation: Meibomian glands secrete an oily substance that lubricates the eyelid.

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. esotropia. phoria. strabismus.

esotropia. Explanation: Esotropia is an inward turn of the eye.

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

glaucoma. Explanation: A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.

The tarsal plates of the upper eyelid contain tear ducts. ocular muscles. sebaceous glands. meibomian glands.

meibomian glands. Explanation: The upper eyelid is larger, more mobile, and contains tarsal plates made up of connective tissue. These plates contain the meibomian glands, which secrete an oily substance that lubricates the eyelid.

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 ask the client if he sees "halos." assess the client for double vision. refer the client to an ophthalmologist. examine the area of head trauma.

refer the client to an ophthalmologist. Explanation: Consistent blind spots may indicate retinal detachment. Any report of a blind spot requires immediate attention and referral to a physician.

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 Vitamin A deficiency Allergies

Brain tumor Explanation: Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor. Vitamin A deficiency is a cause of night blindness. Allergies are usually indicated by burning or itching pain in the eye. Viral infection is usually indicated by redness or swelling of the eye.

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 double vision. lacrimal obstruction. allergic reactions. viral infection.

lacrimal obstruction. Explanation: Excessive tearing (epiphora) is caused by exposure to irritants or obstruction of the lacrimal apparatus. Unilateral epiphora is often associated with foreign body or obstruction.

When a client reports a sudden but painless loss of vision in the right eye, which question should the nurse ask? "Are you currently prescribed a steroid medication?" "Do you have a history of diabetes?" "Have you ever been diagnosed with acute angle closure glaucoma?" "May I assess your eye for a possible corneal ulcer?

"Do you have a history of diabetes?" Explanation: If sudden visual loss is unilateral and painless, the nurse should consider vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion. Corneal ulcers and acute angle closure glaucoma are painful. Steroids can cause bilateral vision problems

A 52-year-old client 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? "Please come into the clinic right away so we can see what is wrong." "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." "I have an opening tomorrow at 2 in the afternoon. Can you come in then?"

"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." Explanation: Floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted clients; no additional follow-up is needed.

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? "In children, this problem is usually caused by an increase in pressure within the eye." "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

"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 consequences.

Which of the following assessment findings suggests a problem with the client's cranial nerves? Fundoscopic examination reveals intraocular bleeding. A client states that he has recently begun seeing lights flashing in his field of vision. A client's extraocular movements are asymmetrical and she complains of diplopia. 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. Explanation: Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology.

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 bitemporal hemianopsia A left temporal hemianopsia A quadrantic defect A homonymous hemianopsia

A left temporal hemianopsia Explanation: When the client's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.

Which of the following statements most accurately describes the maintenance of normal intraocular pressure? The eye is a closed system whose contents of aqueous humor provide consistent internal pressure. Aqueous humor is continuously circulating through the eye with production equaling drainage. The lacrimal gland produces increased fluid when intraocular pressure is low and ceases production when pressure is high. The muscles of the ciliary body adjust the volume of the eye in response to increased or decreased pressure.

Aqueous humor is continuously circulating through the eye with production equaling drainage. Explanation: Aqueous humor, produced by the ciliary body, maintains intraocular pressure with production equaling drainage. It is not a closed system, and pressure is not adjusted through muscular control of eye volume.

Which technique by the nurse demonstrates proper use of the ophthalmoscope? Uses right eye to examine the client's left eye Asks the client to fix the gaze upon an object and look straight ahead Moves the scope around so the entire optic disk may be seen Approaches the client directly in front of the pupil

Asks the client to fix the gaze upon an object and look straight ahead Explanation: After turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye & left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula.

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

Blunt-force trauma often results in fracture of the orbit Explanation: High-velocity injuries are typically penetrating. Blunt-force trauma often results in fracture of the orbit. Optic atrophy is atrophy of the optic nerve. Strabismus is the medical term for cross-eye.

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 Near reaction Accommodation Consensual reaction

Consensual reaction Explanation: The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object.

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

entropion