Chapter 16 - Eyes

A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition?

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.

A diabetes educator is teaching a group of adults about the risks to vision that result from poorly controlled blood glucose levels. Which of the following pathophysiologic processes underlies the vision loss associated with diabetes mellitus?

Blood vessels supplying the retina become weak and bleeding occurs. In diabetic retinopathy, the vessels that feed the retina change and weaken. Eventually, they may become blocked and cause bleeding into the eye, which blocks vision. Diabetes does not directly cause an increase in pressure in the eye, osmotic changes in the aqueous humor or corneal infection.

When a client reports a sudden but painless loss of vision in the right eye, which question should the nurse ask?

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.

What systemic diseases may cause nodular episcleritis? (Mark all that apply.)

If you need a fuller view of the eye, rest your thumb and finger on the bones of the cheek and brow, respectively, and spread the lids. The local redness below is from nodular episcleritis, often self-limiting in younger adults; it is also seen in rheumatoid arthritis and system lupus erythematosus.

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?

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. (not notify the provider or document)

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

Within the eyelids lie firm strips of connective tissue called tarsal plates. Each plate contains a parallel row of meibomian glands, which open on the lid margin. an oily substance to lubricate the eyes.

A nurse cares for a client with optic atrophy. The nurse recognizes that an ophthalmoscopic examination of the eye should reveal which characteristic change in the optic disc?

A white-colored optic disc is the characteristic finding in optic atrophy due to a lack of disc vessels. This condition is caused by the death of optic nerve fibers. An oval-shaped, orange-colored optic disc which is 1.5mm wide is normal. Blurred margins indicate papilledema or swelling.

An client presents at the ophthalmologist's office after being referred by his family physician. The referral was made after a benign growth of the conjunctiva was found growing from the nasal side of the sclera to the limbus in the client's right eye. The client asks the nurse what this growth is. What is the best answer the nurse can give?

An abnormal thickening of the conjunctiva from the limbus over the cornea is known as a pterygium. It is not known as hypertrophied conjunctiva or sclera. A pterygota is a class of insects.

When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals?

An eye assessment of a dark-skinned person would include the grayish brown, almost purplish cast to the normal fundus. The remaining options are noted in an eye assessment of the normal fundus of a fair-skinned person.

What is the primary purpose of the health history in relation to the eyes?

To identify changes The purpose of the health history is to identify changes in the eyes.

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?

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 pupils 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.

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?

When testing the corneal light reflex, the nurse should shine the light toward the bridge of the nose. At the same time, the client is instructed to stare straight ahead. This facilitates a parallel image on the cornea. The eye response upon shining the light toward the eye may interfere with the assessment. The light should not be shined toward the forehead or on an object on the wall.

The patient asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse?

"It identifies a problem with the normal pathways for sound to travel to your inner ear."

An adult client tells the nurse that his 80-year-old father is almost completely deaf. After an explanation to the client about risk factors for hearing loss, the nurse determines that the client needs further instruction when the client says

"It is difficult to prevent hearing loss or worsening of hearing."

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 patient in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?

20/200

Upon examination, the Advanced Practice Nurse finds that a patient has otitis media with effusion. What assessment finding is most clearly indicative of this diagnosis?

A diffuse cone of light

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

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.

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's

Contact with a wisp of cotton stimulates a blink in both eyes known as the corneal reflex. This reflex is supported by the trigeminal nerve, which carries the afferent sensation into the brain, and the facial nerve, which carries the efferent message that stimulates the blink.

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.)

Diabetic retinopathy is the most common cause of blindness in the United States. Hypertensive retinopathy is another high risk factor for blindness over hypothyroidism, hyperlipidemia, and osteoarthritis.

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

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.

An older adult client presents at the clinic, reporting otalgia in the right ear. Physical assessment reveals cerumen impacted in the client's ear. Removing this mechanical blockage may do what for this client? (Select all that apply.)

Improve hearing Enhance socialization Prevent injury

The nurse performs the action shown when assessing a client's eyes. What is the nurse assessing?

Ocular alignment The assessment pictured is the cover test. The cover test assesses ocular alignment. The Jaeger chart is used to assess near vision. The Snellen chart is used to assess distant vision. Ishihara cards are used to assess color discrimination.

Which data collected in a health history interview of a client should the nurse document as risk factors for the development of cataracts? Select all that apply.

Risk factors for the development of cataracts include age over 50, exposure to ultraviolet B light, diabetes mellitus, alcohol use, cigarette smoking, a diet low in antioxidants, high blood pressure, eye injuries, and steroid use.

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

The labyrinth within the inner ear senses the position and movements of the head and helps to maintain balance. If these structures are infected or inflamed, the patient could develop vertigo. Rhinorrhea, fever, and headache are not potential problems associated with an inner ear infection.

A nurse performs an initial examination of a client brought to the emergency department after sustaining a head injury in an automobile accident. Which characteristic of discharge from the ears should alert the nurse that the client has a cerebrospinal fluid leak?

The presence of watery or bloody discharge in the external auditory canal indicates leakage of cerebrospinal fluid in the client with a head injury. Sticky, yellow discharge is found in cases of otitis externa. Bloody, purulent discharge is found in otitis media with ruptured tympanic membrane. Brown, odorless discharge is a normal finding in the external auditory canal.

Transmission of sound waves in the inner ear is known as

The transmission of sound waves in the inner ear is referred to as "perceptive" or "sensorineural hearing."

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. Perform the positions test, which assesses eye muscle strength and cranial nerve function. Instruct the client to focus on an object you are holding (approximately 12 inches from the client's face). Move the object through the six cardinal positions of gaze in a clockwise direction, and observe the client's eye movements.

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?

Aqueous humor is produced by the ciliary body, circulates from the posterior chamber through the pupil into the anterior chamber, and drains out through the canal of Schlemm. This system controls the pressure within the eye. If there is an obstruction of the canal of Schlemm, aqueous humor will not drain, increasing pressure within the eye. An obstruction of the canal of Schlemm will not displace the optic nerve because the optic nerve is located within the posterior portion of the eye. An opaque lens is a cataract, which is not caused by an obstruction of the canal of Schlemm. Pupil reaction is a neurological function not affected by intraocular pressure.

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?

Because the right visual field in both eyes is affected, this is a right homonymous hemianopsia. A bitemporal hemianopsia refers to loss of both lateral visual fields. A right temporal hemianopsia is unilateral, and binasal himanopsia is the loss of the nasal visual fields bilaterally.

When assessing the client's risk for hearing loss, it is important to ask about the history of exposure to noise. What related client teaching would be important? (Select all that apply.)

Clients need to be asked about their exposure to noise and what protective equipment they use. Educating clients on the types, effectiveness, and instructions for the use of protective ear equipment allows them to make decisions based on their needs. The other options do not address the history of exposure to noise noted in the question.

The nurse is assessing a client's visual acuity and visual fields. The nurse evaluates that the assessment results are within expected parameters. How should the nurse document this assessment finding?

Cranial nerve II, or the optic nerve, is tested by assessing visual acuity, visual fields, and through fundoscopic examination. The cardinal fields of gaze and pupil reaction are tested when assessing cranial nerves III, IV, and VI. Cranial nerve I is the olfactory nerve. Cranial nerve XI is the accessory nerve.

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?

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.

A nurse is preparing a community education session on hearing loss. Which information should the nurse include?

Hearing is a critical sense with which one can experience the world. Loss of hearing is associated with social and emotional isolation which can lead to mental health problems. All ethnic groups do not experience hearing loss in the same way. African Americans experience less hearing loss due to higher amounts of melanin in the cochlea. Unlike vision prerequisites for driving, there is no mandate for widespread testing of hearing. Hearing loss can begin at any age, not just after 40.

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?

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 presents with otalgia and yellow-green discharge from the external ear canal. Which question should the nurse ask to determine the cause of this problem?

Otalgia and yellow-green discharge from the external ear canal suggest a ruptured tympanic membrane. In order to identify the cause of the rupture, it would be most effective to ask the client about trauma to the inside of the ear. Asking the client about ringing in the ears would suggest the nurse suspects tinnitus. The yellow-green drainage and pain are not associated with this condition. Asking the client about feeling dizzy suggests the nurse suspects vertigo. Yellow-green drainage and pain are not associated with this condition. Asking the client if she has ever taken medication that is ototoxic suggests the nurse is focusing the assessment on sensorineural hearing loss. Discharge and pain are not associated with this condition.

A patient comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa Pain with auricle movement or tragus palpation indicates otitis externa or furuncle.

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 observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger or a delay in seeing it indicates reduced peripheral vision. Client's consensual pupils constricting in response to indirect light as well as direct light shown into the client's pupils resulting in constriction are observed when testing the pupils for reaction to light. Eyes converging on an object as it is moved towards the nose is a normal result for accommodation.

A nurse assesses the distant vision acuity of a client using the Snellen chart. Which action should the nurse implement to perform the test with accuracy?

The nurse should instruct the client to read without reading glasses to accurately test the distant vision acuity with a Snellen chart. Reading glasses blur the vision when reading in the distance, so they can interfere with the assessment. The nurse should position the client 20 feet, not 12 feet, away from the Snellen chart. The nurse should ensure that the client does not lean forward and read because it may be an unconscious attempt to see well. The client's eye should be covered with an opaque card. Covering the eye with the hand may encourage the client to peek through the fingers.

A nurse is inspecting the bulbar conjunctiva and sclera of a 67-year-old client, and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nursing action at this time?

Yellowish nodules on the bulbar conjunctiva are called pinguecula. These harmless nodules are common in older clients and appear first on the medial side of the iris and then on the lateral side. Therefore, the nurse should document this finding and proceed with the examination. There is no need to notify the physician of the finding. Having trouble focusing when reading up close is a sign of presbyopia, or impaired near vision, which is not associated with the finding of pinguecula. A foreign body or lesion may cause irritation, burning, pain and/or swelling of the upper eyelid but would not cause yellowish nodules.

An adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. The nurse should assess the client for

Throbbing, stabbing, or deep, aching pain suggests a foreign body in the eye or changes within the eye.

A nurse is assessing a client's tympanic membrane. The nurse suspects that the client may have otitis media. Which of the following findings would confirm this suspicion?

To evaluate the mobility of the tympanic membrane, perform pneumatic otoscopy by using an otoscope with a bulb insufflator. With otitis media, the membrane does not move or flutter when the bulb is inflated. Pain on wiggling the ear indicates probable swimmer's ear (otitis externa). The membrane appearing pearly gray, shiny, and translucent is a normal finding. The client hearing air conduction sound longer than bone conduction sound on the Rinne test could indicate either normal hearing or sensorineural hearing loss but is not consistent with otitis media.