Health Assessment Chapter 13
The nurse should make it a priority to assess which client for papilledema?
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
An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for
allergies.
An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should
check the client's blood pressure.
The middle layer of the eye is known as the
choroid layer.
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
decreased accommodation.
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
document the findings in the client's records.
When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals?
fundus is grayish brown with a purplish cast
The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope
in the right hand for the right eye and in the left hand for the left 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
lacrimal obstruction.
A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom c
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
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should
position the client 609.6 cm (20 ft) away from the chart.
Photoreceptors of the eye are located in the eye's
retina.
A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with
vitamin A deficiency.
A nurse is conducting an assessment of a client's eyes and vision and has completed the cardinal fields of gaze test. Following this test, the nurse will be able to document data that address what aspect(s) of eye health? Select all that apply.
*Accommodation *Eye muscle strength *Cranial nerve function xDistant visual acuity xNear visual acuity
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 left temporal hemianopsia
What do retinal abnormalities include?
Age-related macular degeneration
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
A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next?
Arrange for worker to be promptly assessed by an eye specialist.
A client reports, "There is something in my left eye that is causing me considerable discomfort." What initial step should the nurse take when everting the client's upper eyelid in order to search for the foreign body?
Ask the client to look down toward the left cheek.
A client complains of excessive tearing of the eyes. Which assessment would the nurse do next?
Assess the nasolacrimal sac
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?
Brain tumor
While the nurse examines a client'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
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 intact
A client asks a nurse if any foods promote eye health. What food would the nurse include as a response?
Deep-water fish
A nurse is inspecting a client's eyelids and eyelashes. Which of the findings would the nurse document as abnormal?
Drooping of the upper lid
Which action by the nurse indicates the appropriate use of an ophthalmoscope?
Employ the right eye to examine the client's right eye
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
What is a characteristic symptom of Graves hyperthyroidism?
Exophthalmos
The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test?
Far, then near
A client has sought care because she states that she has begun to see halos around headlights and streetlights when she is out at night. The nurse should recognize the need to refer the client for further assessment related to what health problem?
Glaucoma
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
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?
Lacrimal apparatus
When using hand gel to clean the hands, what must the nurse do before touching a client's eyes?
Make sure the hands are completely dry
During adolescence, what vision change is common?
Nearsightedness
What part of the eye receives and transmits visual stimuli to the brain for processing?
Retina
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?
Snellen E
A client is being assessed for indications of a possible obstructed nasolacrimal duct in the right eye. Under what circumstances should the nurse avoid compressing the lacrimal sac?
The area around the sac is inflamed.
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
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 o
The larger the bottom number, the worse the visual acuity
A nurse cares for a client with optic atrophy. The nurse recognizes that an ophthalmoscopic examination of the eye should reveal which characteristic finding in the optic
White-colored
The optic nerves from each eyeball cross at the
optic chiasma.
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?
"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."
Which of the following eye abnormalities would the nurse observe for during assessment of the external eyes? Select all that apply.
*Iris nevus *Exophthalmos *Osteogenesis Ximperfecta Anisocoria XMiosis
A client 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 or less
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 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?
Ask the client about previous trauma to the eyes
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
A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following?
Conjunctiva
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
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
Which of the following would a nurse expect to assess in a client with esotropia?
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
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 the Jaeger card 14 inches from the face and read with one eye at a time
What is vital in maintaining vision and a healthy outlook for clients?
Health education
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 hold the chart 14 inches from the eyes
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?
Medially toward the nose
The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from?
Myopia
A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which action?
Observing the eye's reaction when a light is shone into the opposite eye
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
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.
What is the primary purpose of the health history in relation to the eyes?
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?
Up
During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide?
"Cover one of your eyes and then read out the letters on the chart, starting from the top."
A nurse is completing a comprehensive health history of a 69-year-old woman who is a new client of the clinic. Which of the nurse's interview questions most directly addresses the client's risk for developing cataracts?
"Have you ever been tested for diabetes?"
A client 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 is providing discharge teaching on preventative measures that can be used to reduce risk to a client who is at high risk for eye disorders. What should the nurse include in the discharge teaching? Select all that apply.
*"Eat a well-balanced diet that includes green leafy vegetables." *"Wear sunglasses when you are exposed to sunlight." X"Have a thorough eye exam at least every 5 years." *"Have tonometry testing annually." *"Avoid smoking tobacco."
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 xRinne test *The external eye
The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?
4 mm
A nurse is caring for several clients. Which client would be at the highest risk for developing cataracts?
A 55-year-old female client
Which of the following statements most accurately describes the maintenance of normal intraocular pressure?
Aqueous humor is continuously circulating through the eye with production equaling drainage.
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?
Ask the client to remove the glasses before testing
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?
Blunt-force trauma often results in fracture of the orbit
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?
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
The nurse is preparing to assess a client's visual fields to evaluate her gross peripheral vision. Which test would the nurse perform?
Confrontation test
The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?
Conjunctiva
The muscles of the ciliary body control the thickness of the lens, allowing the eye to:
Focus on near or distant objects
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
A nurse is presenting a class to a local community about vision and eye health. As part of the presentation the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation?
Involves light rays striking the retina
A nurse is testing a client's pupillary reaction to light, noting that the pupil constricts when shining light obliquely into it. The nurse understands that muscles in which of the following structures adjust to control the amount of light entering the eye through the aperture of the pupil?
Iris
A nurse assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following?
Narcotic use
The nurse is performing a cardinal fields of gaze test on a client who has an inner ear infection. What would be an expected finding?
Nystagmus
A nurse assesses the pupillary reaction to light for a client. Which precaution should the nurse follow to get an accurate result of consensual response?
Place an opaque card in between the eyes of the client
During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?
Presbyopia
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
When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze; dilation on distant gaze
A client wants to use beta-carotene supplements to reduce the risk of developing cataracts and age-related macular degeneration. For which reason should the nurse counsel the client to avoid using this supplement?
Smokes cigarettes
A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?
Subconjunctival hemorrhage
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.
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?
These findings indicate the client is legally blind.
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?
Transforms light rays into nerve impulses that are conducted to the brain
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?
Upward toward the forehead
The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and
cleanse the cornea and the lens.
A nurse is performing a focused visual assessment on a client. The nurse assesses the pupillary response with a pen light. Both of the client's pupils immediately constrict when the light is shone into the right pupil. How should the nurse document this finding?
consensual reflexes observed
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
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
increased intracranial pressure.
Straight movements of the eye are controlled by the
rectus muscles.
