Chapter 16: Assessing Eyes
The meibomian glands secrete
an oily substance to lubricate the eyes.
While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's
corneal reflexes. 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.
A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent
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 Macular degeneration causes a loss of central vision. Risk factors for macular degeneration are age, smoking history, obesity, family history, and female gender
When a client reports a sudden but painless loss of vision in the right eye, which question should the nurse ask?
"Do you have a history of diabetes?" 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
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
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
You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document?
Papilledema
When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze; dilation on distant gaze
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.
Which area of the fundus is the central focal point for incoming images?
The fovea
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
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 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
A client asks a nurse if any foods promote eye health. What food would the nurse include as a response?
Deep-water fish Foods that promote eye health include deep-water fish, fruits, and vegetables (e.g., carrots, spinach)
What is a characteristic symptom of Graves hyperthyroidism?
Exophthalmos In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?
Medially toward the nose
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 Presbyopia, which is impaired near vision, is indicated when the client moves a reading chart or other reading material away from the eyes to focus on the print. It is caused by decreased accommodation and is a common condition in clients over 45 years of age.
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 on these results?
The larger the bottom number, the worse the visual acuity.
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 client is considered legally blind when vision in the better eye with corrective lenses is 20/200 or less. In this case the client has to be only 20 feet away from an object to see it when others can see the same object from 200 feet
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 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.
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 With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision.
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 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.
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
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.
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 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
The functional reflex that allows the eyes to focus on near objects is termed
accommodation. 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.
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 When exposed either directly or indirectly to light, pupils will constrict; the term consensual means that constriction occurs in both eyes when light is only shown into one 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
document the findings in the client's records.
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. A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.
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
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.
Papilledema
swelling and inflammation of the optic nerve at the point of entrance into the eye through the optic disk Papilledema often signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions
