Health Assesment: Eyes
Which data collected in a health history interview of a client should the nurse document as risk factors for the development of cataracts? Select all that apply. a) Thyroid disease b) Cigarette smoking c) Eats very few fruits or vegetables d) Hit on the back of the head with a hammer e) Blood pressure medications f) Works in lawn maintenance
Correct response: • Cigarette smoking • Works in lawn maintenance • Eats very few fruits or vegetables Explanation: Risk factors for the development of cataracts include age over 50, exposure to ultraviolet B light, diabetes mellitus, alcohol use, cigarette smoking, a diet low in antioxidants, high blood pressure, eye injuries, and steroid use. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 305.
Choice Multiple question - Select all answer choices that apply. Normal movement of the eye involves what cranial nerves? (Mark all that apply.) a) VI b) III c) V d) II e) IV
Correct response: • II • III • IV • VI Explanation: As the nurse inspects and palpates the eye, he or she assesses for the sensory and motor functions of four cranial nerves: Cranial nerve II, optic nerve, visual acuity, visual fields, fundoscopic examination; cranial nerve III, oculomotor, cardinal fields of gaze, eyelid inspection, pupil reaction (direct/consensual/ accommodation); cranial nerve IV, trochlear, cardinal fields of gaze; and cranial nerve VI, abducens, cardinal fields of gaze. Cranial nerve V, known as the trigeminal nerve, is a nerve responsible for sensation in the face and certain motor functions such as biting and chewing. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 321.
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? a) "Stand very still with your eyes closed." b) "Rotate your head from side to side." c) "Follow my finger with only your eyes." d) "Shrug your shoulders as I push down on them."
Correct response: "Follow my finger with only your eyes." Explanation: Testing cranial nerves III, IV, and VI also tests the movement of the eye muscles by asking the client to move the eyes in different directions. Turning the head assesses neck range of motion and mobility. Shrugging shoulder against resistance assesses a different cranial nerve. Asking the client to stand still with the eyes closed is known as the Romberg's test to test balance. (less) Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 16: Assessing Eyes pp. 298-326.
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? a) Ectropion b) Presbyopia c) Myopia d) Arcus senilis
Correct response: Arcus senilis Explanation: Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 16: Assessing Eyes, p. 314.
A client performs the test for distant visual acuity and scores 20/50-2. How should the nurse most accurately interpret this finding? a) Client can read the 20/50 line correctly and two other letters on the line above. b) At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet. c) When 50 feet from the chart, the client can see better than a person standing at 20 feet. d) Client did not wear his glasses for this test and therefore it is not accurate.
Correct response: At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet. Explanation: The Snellen chart tests distant visual acuity by seeing how far the client can read the letters standing 20 feet from the chart. The top number is how far the client is from the chart and the bottom number refers to the last line the client can read. A reading of 20/50 means the client sees at 20 feet what a person with normal vision can see at 50 feet. The minus number is the number of letters missed on the last line the client can distinguish. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 16: Assessing Eyes, p. 308.
While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse? a) Direct reaction b) Presbyopia c) Myopia d) Consensual reaction
Correct response: Consensual reaction Explanation: The consensual reaction is when the pupil constricts in the opposite eye. Myopia is impaired far vision. Presbyopia is impaired near vision often seen in middle-aged and older patients. The direct reaction is when the pupil constricts in the same eye. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 298.
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? a) Accommodation b) Consensual reaction c) Direct reaction d) Near reaction
Correct response: Consensual reaction Explanation: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 315.
The nurse is assessing a client's visual acuity and visual fields. The nurse evaluates that the assessment results are within expected parameters. How should the nurse document this assessment finding? a) Cranial nerve XI intact b) Cranial nerve I intact c) Cranial nerves III, IV, and VI intact d) Cranial nerve II intact
Correct response: Cranial nerve II intact Explanation: Cranial nerve II, or the optic nerve, is tested by assessing visual acuity, visual fields, and through fundoscopic examination. The cardinal fields of gaze and pupil reaction are tested when assessing cranial nerves III, IV, and VI. Cranial nerve I is the olfactory nerve. Cranial nerve XI is the accessory nerve. (less) Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 16: Assessing Eyes pp. 297-298.
Which action by the nurse indicates the appropriate use of ophthalmoscope? a) Approach the client from the side using the same eye as being examined b) Hold the ophthalmoscope with the middle finger on the lens wheel c) Stand in front of the client with the light directly on the pupil d) Employ the right eye to examine the client's right eye e) Ask the client to gaze at an object straight ahead and slightly towards the floor
Correct response: Employ the right eye to examine the client's right eye Explanation: The nurse should employ the right eye to examine the client's right eye; this action of the nurse indicates the correct use of the ophthalmoscope. The nurse should hold the ophthalmoscope with the left hand and the index finger on the lens wheel. The nurse should ask the client to gaze at an object straight ahead and slightly upward, not downward. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 308.
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? a) Ectropion b) Epicanthus c) Exophthalmos d) Ptosis
Correct response: Exophthalmos Explanation: In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumour and inflammation in the orbit. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 322.
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? a) Presbyopia b) Esotropia c) Strabismus d) Exotropia
Correct response: Exotropia Explanation: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 310, 321.
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? a) Directly on the eye being examined b) Shined on the forehead c) Pointed at a fixed object on the wall d) Focused on the bridge of the nose
Correct response: Focused on the bridge of the nose Explanation: When testing the corneal light reflex, the nurse should shine the light toward the bridge of the nose. At the same time, the client is instructed to stare straight ahead. This facilitates a parallel image on the cornea. The eye response upon shining the light toward the eye may interfere with the assessment. The light should not be shined toward the forehead or on an object on the wall. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 16: Assessing Eyes, p. 310.
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? a) Hyphema b) Blepharitis c) Iris nevus d) Chalazion
Correct response: Hyphema Explanation: Hyphema is blood in the anterior chamber of the eye, usually caused by blunt trauma. Blepharitis is inflammation of the margin of the eyelid. Chalazion is a cyst in the eyelid. Iris nevus is a rare condition affecting one eye. The latter 3 conditions are not commonly attributed to blunt force trauma to the head as hyphema is. (less) Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 16: Assessing Eyes pp. 318-322.
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? a) Place the chart 20 feet away from the client on the wall b) Instruct the client to hold the chart away from the body at arm's length c) Place the chart on a table 17 inches away from the client d) Instruct the client hold the chart 14 inches from the eyes
Correct response: Instruct the client hold the chart 14 inches from the eyes Explanation: To test the near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arm's length is an arbitrary length depending on the size of the client & is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 307.
A nurse assesses the pupillary reaction to light for a client who has lost vision in one eye. Which precaution should the nurse follow to get an accurate result of consensual response? a) Observe the response in the eye focused with light b) Shine a bright light directly into the eye to be tested c) Instruct the client to close the eye not focused with light d) Place an opaque card in between the eyes of the client
Correct response: Place an opaque card in between the eyes of the client Explanation: The nurse should place an opaque card in between the eyes of the client when assessing the client for consensual response to avoid inaccurate results. The light should not be focused directly into the eye to be tested; it should be focused obliquely into one eye, and the response should be checked in the other eye. The client should not be instructed to close the other eye not focused with light because the response is checked in the other eye. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 315.
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? a) Cataract formation b) Loss of convergence c) Presbyopia d) Macular degeneration
Correct response: Presbyopia Explanation: Prebyopia denotes an age-related deficit in close vision. It is less likely that cataracts, macular degeneration, or loss of convergence underlie the colleague's visual changes. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 309.
Which of the following is a symptom of the eye? a) Rhinorrhea b) Tinnitus c) Scotomas d) Dysphagia
Correct response: Scotomas Explanation: Scotomas are specks in the vision or areas where the client cannot see; therefore, this is a common and concerning symptom of the eye. Tinnitus is a ringing in the ears, dysphagia is difficulty swallowing, and rhinorrhea is a "runny nose." (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 299.
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? a) Stye b) Dacryocystitis c) Xanthelasma d) Chalazion
Correct response: Stye Explanation: A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 311.
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? a) The client and the examiner see the examiner's finger at the same time b) Eyes converge on an object as it is moved towards the nose c) Direct light shown into the client's pupils results in constriction d) Client's consensual pupil constricts in response to indirect light
Correct response: The client and the examiner see the examiner's finger at the same time Explanation: 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 and a delay in seeing indicates reduced peripheral vision. Client's consensual pupils constrict in response to indirect light as well as direct light shown into the client's pupils resulting in constriction is observed when testing the pupils for reaction to light. Eyes converge on an object as it is moved towards the nose tests for accommodation. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 309.
Which statement demonstrates the safest way to document assessment findings of drainage noted in both eyes of a client? a) Thick, purulent drainage is noted at inner corner of OU. b) Thick, purulent drainage is noted at inner corner of both eyes. c) Thick, purulent drainage is noted at inner corner of OS. d) Thick, purulent drainage is noted at inner corner of OD.
Correct response: Thick, purulent drainage is noted at inner corner of both eyes Explanation: The abbreviations OD (right eye), OS (left eye), and OU (both eyes) are no longer used due to the potential for order errors. Instead, it is recommended to use "right eye," "left eye," or "both eyes." (less) Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 16: Assessing Eyes, pg. 328.
How can a nurse accurately assess the distant visual acuity of a client who is non-English-speaking? a) Perform the confrontation test in all four fields b) Have the client read from a Jaeger reading card c) Move an object through the six cardinal positions of gaze d) Use a Snellen E chart to perform the examination
Correct response: Use a Snellen E chart to perform the examination Explanation: If a client does not speak English, is unable to read, or has a verbal communication problem, the Snellen E chart can be used to test the client's distant visual acuity. With this test, the client is asked to indicate by pointing which way the E is open on the chart. The six cardinal positions of gaze test eye muscle function & cranial nerve function. The Jeager chart tests near visual acuity. Confrontation test is used to test visual fields for peripheral vision. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 307.
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent a) macular degeneration b) hemianopsia c) open-angle glaucoma d) retinal detachment
Correct response: macular degeneration Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 304.
When testing the near reaction, an expected finding includes which of the following? a) Pupillary dilation on near gaze; constriction on distant gaze b) Pupillary constriction on near gaze; constriction on distant gaze c) Pupillary constriction on near gaze; dilation on distant gaze d) Pupillary dilation on near gaze; dilation on distant gaze
Explanation: During accommodation, pupils constrict with near gaze and dilate with far gaze. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 315.
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? a) Retinoblastoma b) Strabismus c) Glaucoma d) Retinitis pigmentosa
Explanation: Glaucoma in a first-degree relative increases the client's risk for the same problem two to three times. Retinoblastoma can be inherited from either parent but does not have increased incidence if a first-degree relative has the disease. Retinitis pigmentosa is also a genetic disease, but a client's risk of the disease is not increased if a first-degree relative is affected. Strabismus is not genetic. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 300.
Which vision acuity reading indicates blindness? a) 20/100 b) 20/20 c) 20/40 d) 20/200
Explanation: The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision. This means that the client being tested can distinguish what a person with normal vision can distinguish from 20 feet away. The top or first number is always 20, indicating the distance from the client to the chart. The bottom or second number refers to the last full line the client could read. The higher the second number, the poorer the vision. 20/40 and 20/100 also denote poor vision. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 308
The open space between the eyelids is called what? a) The palpebral fissure b) The eyeball c) The lacrimal fissure d) The limbus
The palpebral fissure Explanation: The palpebral fissure is the almond-shaped open space between the eyelids. The limbus is the border of the cornea and the sclera. Eyeball and lacrimal fissure are distracters for the question. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 295.
Which of the following assessment findings suggests a problem with the client's cranial nerves? a) A client states that he has recently begun seeing lights flashing in his field of vision. b) Fundoscopic examination reveals intraocular bleeding. c) A client's extraocular movements are asymmetrical and she complains of diplopia. d) A client's lens appears cloudy and she claims that her visual acuity has recently declined.
You selected: A client's extraocular movements are asymmetrical and she complains of diplopia. Correct Explanation: Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 16: Assessing Eyes, p. 299.
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? a) No night driving b) Daily use of eye drops c) Surgery d) Corrective lenses
Correct response: Corrective lenses Explanation: Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition. (less) Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 16: Assessing Eyes pg. 322.