Ch.11: The 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?"
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'."
A client recently diagnosed with Grave's diseases exhibits protruded eyeballs. Which eye care instruction should the nurse discuss with this client?
"Wear an eyepatch and use moisturizing eye drops."
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.
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 complains of excessive tearing of the eyes. Which assessment would the nurse do next?
Assess the nasolacrimal sac
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
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
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
A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following?
Consensual response
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?
Corrective lenses
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
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 muscles of the ciliary body control the thickness of the lens, allowing the eye to:
Focus on near or distant objects
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
How do our lens change from birth to adulthood ?
Lens are spherical at birth and grow flatter throughout life The consistency changes from soft plastic at birth to rigid glass in old age
The nursing instructor is discussing the eye with the nursing students. What would the instructor cite as part of the lacrimal apparatus?
Nasolacrimal duct Punctum Lacrimal sac Lacrimal gland
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
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
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
What do aging adults develop in their eyes?
Presbyopia (farsightedness) Occurs when lens become hard and decreases it ability to accommodate for near vision
What are the developmental changes in the eyes for aging adults?
Pupil size decreases Lens loses elasticity (presbyopia) Visual acuity diminishes after 40 and more after 70
When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze; dilation on distant gaze
What is confrontation test?
To test visual fields. compares pt peripheral vision to examiners. decreased peripheral vision suggests glaucoma. if severe- stroke or diseases of the retina
A nurse is examining the eyes of a 7-year-old boy. The boy asks the nurse, "What's inside my eyeball?" The nurse explains that the biggest space inside the eyeball contains a clear, gelatinous substance that light passes through. Which of the following is the technical name for this gelatinous substance?
Vitreous humor
The functional reflex that allows the eyes to focus on near objects is termed
accommodation
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 nurse suspect is occurring with this client?
conjunctivitis
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
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
glaucoma
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
When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. How would the nurse document this finding?
optic disc
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.
What is the Cover -uncover test ?
pt focuses on far object; cover one eye and watch for movement in the other; remove cover and note movement of eye that was just uncovered Used if Pt does not pass corneal light reflex EX) PT w/ Exotropia
What is PERRLA?
pupils equal, round, reactive to light and accommodation
Photoreceptors of the eye are located in the eye's
retina
A 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should
tell the client that these often occur with aging.