(Health Assess/Combined)- Chapter 16: Assessing Eyes

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 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.

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'." Explanation: Floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted clients; no additional follow-up is needed.

A client comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse?

"You will need to see the doctor to have your eye checked." Explanation: Pain in the eye is never normal and should always be further explored.

The nurse is caring for a healthy adult client with no history of vision problems. The nurse should tell the client that a thorough eye examination is recommended every

2 years. Explanation: A thorough eye examination is recommended for healthy clients without risk factors every 2 years, for ages 18 through 60; annually for those age 61 and older.

Which vision acuity reading indicates blindness?

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.

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. 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.

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 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.

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 Explanation: 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. All other options the nurse can do after this is determined.

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 Explanation: After turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye & left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula.

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. 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.

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 Explanation: High-velocity injuries are typically penetrating. Blunt-force trauma often results in fracture of the orbit. Optic atrophy is atrophy of the optic nerve. Strabismus is the medical term for cross-eye.

A client tells the nurse that his eyes "are not working right." When the nurse asks what the client means, the client states, "It is like one eye is moving faster than the other." What test would be most appropriate for the nurse to use to assess this client?

Cardinal fields Explanation: The cardinal fields of gaze allow the nurse to detect muscle defects that cause misalignment or uncoordinated movement of the eyes. Kinetic and static confrontation tests are used to test peripheral vision. The cover test is for accommodation.

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.

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.

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

Conjunctiva Explanation: The conjunctiva is a thin mucous membrane that lines the inner eyelid (palpebral conjunctivae) and also covers the sclera (bulbar conjunctivae). The border between the cornea and the sclera is the limbus. The lacrimal apparatus protects and lubricates the cornea and the conjunctiva by producing and draining tears. The eyelid is a loose fold of skin that covers and protects the eye.

While the nurse examines a client'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?

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 clients. The direct reaction is when the pupil constricts in the same eye.

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 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

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?

Correct response: Presbyopia Explanation: Presbyopia 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.

An elderly client presents to the health care clinic with reports of decreased tearing in both eyes. The nurse observes the presence of ectropion. What is an appropriate action by the nurse?

Document the finding as a normal sign of aging Explanation: Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client.

The nurse selects the chart shown here to assess a client's vision. Which client characteristic caused the nurse to select this chart?

Does not speak English Explanation: The Snellen E chart can be used for clients who do not speak English. This chart is not used for clients being treated for glaucoma, color blindness, or recovering from cataract surgery.

What is a characteristic symptom of Graves hyperthyroidism?

Exophthalmos Explanation: In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.

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 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 tumor and inflammation in the orbit.

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 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.

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 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 in nature.

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 Explanation: Near vision is tested with a Jaeger card, Snellen card, or comparable card), held 14 inches from the face. Have the client cover one eye with an opaque card before reading from top to bottom. Sitting the client in front of the examiner, extending one arm, and slowly move one finger upward until it is seen by both the client and the examiner is a test for gross peripheral vision. If the client wears glasses, they should be left on for the test. Placing the client 20 feet from the chart and record the smallest line the client can read is the test for distant acuity.

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 Explanation: 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. An obstruction of the canal of Schlemm will not displace the optic nerve because the optic nerve is located within the posterior portion of the eye. An opaque lens is a cataract, which is not caused by an obstruction of the canal of Schlemm. Pupil reaction is a neurological function not affected by intraocular pressure.

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

Instruct the client hold the chart 14 inches from the eyes Explanation: To test near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The Snellen chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arms length is an arbitrary length depending on the size of the client and is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client.

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

Lacrimal apparatus Explanation: The lacrimal apparatus (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears.

The nurse asks the client to perform the action pictured. What is the nurse assessing?

Near vision Explanation: The client is using the Jaeger chart which is used to assess near vision. The Snellen chart is used to assess distant vision. The nurse would not assess intraocular pressure. Ishihara cards are used to assess color discrimination.

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 Explanation: The first thing the nurse should do is perform both the distant and near visual acuity exams to assess for loss of far and near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the client's record. If abnormalities are found upon assessment, the client should be referred for a complete eye examination.

In order to effectively examine a client's eyes with an ophthalmoscope, 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. Explanation: When using the ophthalmoscope, the nurse should hold the scope in the right hand and use the right eye. The nurse should wear glasses or contacts when using an ophthalmoscope for an examination. The nurse should not place the scope in the left hand and look through the right eye. The nurse should keep both eyes open during the examination.

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 Explanation: 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. 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.

The nursing instructor is discussing the eye with the nursing students. What would the instructor cite as part of the lacrimal apparatus? (Select all that apply.)

Punctum Lacrimal sac Lacrimal gland Nasolacrimal duct Explanation: The lacrimal apparatus, which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct, protects and lubricates the cornea and conjunctiva by producing and draining tears. The limbus is the border between the cornea and the sclera.

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

Pupillary constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far 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. The client states that 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 Explanation: The only nursing diagnosis that can be confirmed with these data is Risk for Injury. The client is aware of the dangers of driving due to changes in his vision. There is not enough data to support the other diagnoses.

Which of the following is a symptom of the eye?

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."

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. Explanation: The denominator of an acuity score represents the line on the chart the client can read. In the example above, the client could read the larger letters corresponding with what a normal person could see at 100 feet.

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 Explanation: A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.

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. 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 or a delay in seeing it indicates reduced peripheral vision. Client's consensual pupils constricting in response to indirect light as well as direct light shown into the client's pupils resulting in constriction are observed when testing the pupils for reaction to light. Eyes converging on an object as it is moved towards the nose is a normal result for accommodation.

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?

Up Explanation: The correct technique to use when examining a client's sclera and conjunctiva during an eye examination is to instruct the client to look up. Having the client look down, to the right, or to the left will not provide visualization of the sclera or conjunctiva during the examination.

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 Explanation: The nurse should assess with each client the use of safety equipment when playing sports. Proper eye protection can prevent many sports-related eye injuries. All options are points for client teaching for this client; however, the most important opportunity involves the use of safety equipment.

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

accommodation. Explanation: 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.

An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for

allergies. Explanation: Burning or itching pain is usually associated with allergies or superficial irritation.

The meibomian glands secrete

an oily substance to lubricate the eyes. Explanation: Meibomian glands secrete an oily substance that lubricates the eyelid.

An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should

check the client's blood pressure. Explanation: Hypertension narrows blood vessels in the retina affecting vision.

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and

cleanse the cornea and the lens. Explanation: Aqueous humor helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure.

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 Explanation: Pink-colored sclera with tearing is associated with conjunctivitis which can be caused by allergies, or bacterial or viral infections. Hyphema is blood in the anterior chamber of the eye which is usually caused by blunt trauma. Anisocoria is a term used to describe pupils of unequal size. Exophthalmos is protrusion of the eye ball usually caused by a problem with the thyroid gland.

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 Explanation: The consensual light response occurs when one eye is exposed to light and the pupil of the other eye constricts. Since the light was shined in the right eye, the left pupil constricted. The left eye was not exposed to direct light. There is not enough information to determine if the pupils are equal or reacting to accommodation.

The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to

decreased accommodation. Explanation: Presbyopia (impaired near vision) is indicated when the client moves the chart away from the eyes to focus on the print. It is caused by decreased accommodation.

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

entropion

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. Explanation: Esotropia is an inward turn of the eye.

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. Explanation: 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 Explanation: Near vision is tested by asking the client to read newspaper print held 14 inches from the eyes. Shining a light on the bridge of the nose tests the corneal light reflex. Moving the eyes in the direction of a moving finger tests for extraocular movements. Having the client read letters on a wall chart tests for central and distance vision.

The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope

in the right hand for the right eye and in the left hand for the left eye

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for

lacrimal obstruction. Explanation: Excessive tearing (epiphora) is caused by exposure to irritants or obstruction of the lacrimal apparatus. Unilateral epiphora is often associated with foreign body or obstruction.

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

macular degeneration Explanation: Macular degeneration causes deterioration in the center of the retina, which leads to a gradual loss of central vision.

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. Explanation: Used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked one above the other. The letters are large at the top and decrease in size from top to bottom. The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20 feet from the chart and covers one eye with an opaque card (which prevents the client from peeking through the fingers). Then the client reads each line of letters until he or she can no longer distinguish them.

The bony orbit and fat cushion of the eye serves as a

protector. Explanation: The eyeball is located in the eye orbit, a round, bony hollow formed by several different bones of the skull. In the orbit, a cushion of fat surrounds the eye. The bony orbit and fat cushion protect the eyeball.

A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should

refer the client to an optometrist. Explanation: Myopia (impaired far vision) is present when the second number in the test result is larger than the first (20/40). The higher the second number, the poorer the vision.

Photoreceptors of the eye are located in the eye's

retina. Explanation: The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends it to the brain. The retina consists of numerous layers of nerve cells, including the cells commonly called rods and cones. These specialized nerve cells are often referred to as "photoreceptors" because they are responsive to light

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 the cheek