Eye Assessment

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'." -"Please come into the clinic right away so we can see what is wrong." -"Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." -"I have an opening tomorrow at 2 in the afternoon. Can you come in then?"

"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."

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. -Distant visual acuity -Near visual acuity -Accommodation -Eye muscle strength -Cranial nerve function

-Eye muscle strength -Cranial nerve function

Which of the following assessment findings suggests a problem with the client's cranial nerves? -A client states that he has recently begun seeing lights flashing in his field of vision. -A client's extraocular movements are asymmetrical and she complains of diplopia. -Fundoscopic examination reveals intraocular bleeding. -A client's lens appears cloudy and she claims that her visual acuity has recently declined.

A client's extraocular movements are asymmetrical and she complains of diplopia.

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 -A homonymous hemianopsia -A bitemporal hemianopsia -A quadrantic defect

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 -Presbyopia -Ectropion -Myopia

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? -Attempt to remove the splinter using sterile forceps. -Irrigate the eye with dilute hydrogen peroxide. -Arrange for worker to be promptly assessed by an eye specialist. -Encourage the worker to see an optometrist as soon as possible.

Arrange for worker to be promptly assessed by an eye specialist.

A client complains of excessive tearing of the eyes. Which assessment would the nurse do next? -Inspect the palpebral conjunctiva -Assess the nasolacrimal sac -Perform the eye positions test -Test pupillary reaction to light

Assess the nasolacrimal sac

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? -Client did not wear his glasses for this test and therefore it is not accurate -When 50 feet from the chart, the client can see better than a person standing at 20 feet -Client can read the 20/50 line correctly and two other letters on the line above -At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet

At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet

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 -Esotropia -Strabismus -Presbyopia

Exotropia

A client has been found to have abnormal vision. What would be the nurse's next step? -Facilitate a referral to an ophthalmologist. -Refer the client to social services to get money for glasses. -Refer the client to a community-based support group. -Encourage the client to adopt a healthier diet.

Facilitate a referral to an ophthalmologist.

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 -Lateral, then near -Near, then far -Lateral, then far

Far, then near

What is vital in maintaining vision and a healthy outlook for clients? -Health education -Monthly eye exams -Emotional support -Physical exercise

Health education

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? -Place the chart 20 feet away from the client on the wall -Instruct the client to hold the chart away from the body at arm's length -Instruct the client hold the chart 14 inches from the eyes -Place the chart on a table 17 inches away from the client

Instruct the client hold the chart 14 inches from the eyes

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? -Refers to what a person sees with one eye -Involves light rays striking the retina -Acts as a protective reflex to limit light -Allows the eyes to focus on near objects

Involves light rays striking the retina

When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. How would the nurse document this finding? -Physiologic cup -Optic disc -Retinal vessels -Fovea

Optic disc

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? -Document the findings in the client's record -Perform both the distant and near visual acuity tests -Test the pupils for direct and consensual reaction to light -Obtain a referral to the ophthalmologist for a complete eye exam

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? -Document the findings in the client's record -Perform both the distant and near visual acuity tests -Test the pupils for direct and consensual reaction to light -Obtain a referral to the ophthalmologist for a complete eye exam

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 obtains a 20% correct score at 100 feet. -She can accurately name 20% of the letters at 20 feet. -She can see at 20 feet what a normal person could see at 100 feet. -She can see at 100 feet what a normal person could see at 20 feet.

She can see at 20 feet what a normal person could see at 100 feet.

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? -Allen -Snellen E -Ishihara -PERRLA

Snellen E

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? -Client's consensual pupil constricts in response to indirect light -Eyes converge on an object as it is moved towards the nose -Direct light shown into the client's pupils results in constriction -The client and the examiner see the examiner's finger at the same time

The client and the examiner see the examiner's finger at the same time

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? -Client's consensual pupil constricts in response to indirect light. -Eyes converge on an object as it is moved towards the nose. -Direct light shown into the client's pupils results in constriction. -The client and the examiner see the examiner's finger at the same time.

The client and the examiner see the examiner's finger at the same time.

The middle layer of the eye is known as the -choroid layer. -scleral layer. -retinal layer. -optic layer.

choroid layer.

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. -increased intracranial pressure. -bacterial infection. -migraine headaches.

glaucoma

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. -ask the client to remove his glasses. -ask the client to read each line with both eyes open. -instruct the client to begin reading from the bottom of the chart.

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