Chapter 16 Assessing eyes

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

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.

Which of the following statements most accurately describes the maintenance of normal intraocular pressure?

Aqueous humour is continuously circulating through the eye with production equalling

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 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

Which symptom is associated with hyperthyroid graves disease?

Exophthalmos (bulging eyes)

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?

Increased intraocular pressure

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 52-year-old patient 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 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye?

"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

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 fingers with only your eyes"

You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what?

A left temporal hemianopsia

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 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.

A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response?

Deep-Water fish

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.) Hypertension Diabetes Hyperlipidemia Hypothyroidism Osteoarthritis

Diabetes and hypertension

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

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

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

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

Macular degeneration ( vision degeneration, mostly for people over 60)

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.

In order to effectively examine a patient's eyes with an ophthalmoscope, the The nurse should follow which procedure related to this piece of equipment?

Place the ophthalmoscope in the right hand and look through the right eye.

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

When testing the near reaction, an expected finding includes which of the following?

Pupillary constriction on near gaze; dilation on distant gaze

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?

Risk for injury.

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.

When assessing the eye, the nurse recognizes that which physical structures of the face limit the normal visual field that a client can experience? Select all that apply.

The brow, the medial aspect of the nose, and the cheek.

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 (distance) 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.

Which statement demonstrates the safest way to document assessment findings of drainage noted in both eyes of a client?

Thick, purulent drainage is noted at inner corner of both eyes.

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is

Ultraviolet light exposure

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

accommodation

What is the definition of presbyopia?

age related far-sightedness

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

The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding?

consensual light response present in left eye.

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

entropion (entro=entering inward)

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. (cross-eyed)

When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are clients most likely at increased risk for if a first-degree relative has it?

glaucoma

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= pooling of blood inside of the eye.

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test the near visual acuity using a Jaeger reading card

instruct the client to hold the chart 14 inches from the eyes

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

lacrimal apparatus

The optic nerves from each eyeball cross at the...?

optic chiasma

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should? a)ask the client to read each line with both eyes open b) ask the client to remove his glasses. c)instruct the client to begin reading from the bottom of the chart. d)position the client 609.6 cm (20 ft) away from the chart.

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

Photoreceptors of the eye are located in the eye's

retina

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?

right homonymous hemianopsia

Which of the following is a symptom of the eye? Scotomas Rhinorrhea Tinnitus Dysphagia

scotomas (partial loss of vision)

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 patient's vision?

snellen E

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