Ch 16

When considering eye safety, what instructions should the nurse provide to a client newly prescribed contact lenses? (Select all that apply.)

+Keep the lenses clean +Discard unused portions of contact solutions at the expiration date. +Do not share lenses +Wash hands before inserting or removing the lenses

Which vision acuity reading indicates blindness?

20/200 20/20 is considered normal vision - a person can distinguish from 20 ft. away. Top is always 20, indicating the distance fm client to chart. Bottom refers to the last full line the client could read.

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 +Mydriasis +Argyll Robertson syndrome +Horner's syndrome

Age-related macular degeneration Age-related macular degeneration gradually causes loss of sharp central vision, needed for common daily tasks (e.g., driving, reading). The macula degenerates (dry) or abnormal blood vessels behind the retina grow under the macula (wet).

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

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 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

The conjunctiva of the eye is divided into the palpebral portion and the ______?

Bulbar portion

The thin mucous membrane that lines the inner eyelid & covers the sclera is known as the __________?

Conjunctiva

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?

Consensual reaction 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.

What test would the nurse perform to test for strabismus?

Corneal light reflex

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

Corrective lenses

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 record.

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

Entropion

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 ___________?

Esotropia

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

The nurse is assessing cranial nerves III, IV, and VI. Which instructions should the nurse provide to the client in order to perform this assessment?

Follow my finger with only your eyes

A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for?

Glaucoma

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

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

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 client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

Lacrimal apparatus

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent

Macular degeneration

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?

Medially toward the nose

The nurse asks the client to perform the action pictured. What is the nurse assessing?

Near vision The client is using the Jaeger chart which is used to assess NEAR VISION. The Snellen chart is used to assess distant vision. The nurse would not assess intraocular pressure. Ishihara cards are used to assess color discrimination.

The optic nerves from each eyeball cross at the _________?

Optic Chiasma

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?

Perform both the distant and near visual acuity tests

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should_______________?

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

A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?

Presbyopia

The RN 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

The bony orbit and fat cushion of the eye serves as a ____________.

Protector

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.

A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?

Stye

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.

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 both eyes.

T/F - The nurse tests the six cardinal directions to test extraocular movement of the eye.

True

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

Use of safety equipment

The meibomian glands secrete_____?

an oily substance to lubricate the eyes

A client is concerned because the sclera of the right eye has been pink in color for several days and tearing. What should the RN suspect is occurring with this client?

conjunctivitis Pink-colored sclera with tearing is associated with conjunctivitis which can be caused by allergies, or bacterial or viral infections. Hyphema is blood in the anterior chamber of the eye which is usually caused by blunt trauma. Anisocoria is a term used to describe pupils of unequal size. Exophthalmos is protrusion of the eye ball usually caused by a problem with the thyroid gland.