Health Assessment - Ch. 13

Eye muscles - CN VI

*Muscle: Lateral rectus / Cranial Nerve Innervation: CN VI / Insertion: Anterior, lateral surface / Action: Abduction (lateral - toward temple)

Eye muscles - CN IV

*Muscle: Superior oblique / Cranial Nerve Innervation: CN IV / Insertion: Posterior, superior, lateral surface / Action: Depression, abduction (lateral - toward temple)

Eye muscles - CN III

*Muscle: Superior rectus / Cranial Nerve Innervation: CN III / Insertion: Anterior, superior surface / Action: Elevation, adduction (medial - toward nose) *Muscle: Inferior rectus / Cranial Nerve Innervation: CN III / Insertion: Anterior, inferior surface / Action: Depression, abduction (medial - toward nose) *Muscle: Medial rectus / Cranial Nerve Innervation: CN III / Insertion: Anterior, medial surface / Action: Adduction (medial - toward nose) *Muscle: Inferior oblique / Cranial Nerve Innervation: CN III / Insertion: Posterior, inferior, lateral surface / Action: Elevation, abduction (lateral - toward temple)

The extraocular muscles

*Superior rectus: elevates the eye upward and adducts (toward the nose) and rotates the eye medially (inward) • Inferior rectus: rotates the eye downward and adducts and rotates the eye medially • Lateral rectus: moves the eye laterally (toward the temple) • Medial rectus: moves the eye medially • Superior oblique: turns the eye downward and abducts (toward the temple) and rotates the eye laterally • Inferior oblique: turns the eye upward and abducts and turns the eye laterally

Cranial nerves innervation - eyes

*The oculomotor (CN III) *The trochlear (CN IV) *The abducens (CN VI) nerves innervate and control the motor nerve activities of the eye

Which of the following teaching points related to eye health would the nurse emphasize? A. Always wear eye protection for occupational exposures. B. Eat a diet high in animal protein and dairy. C. Exercise five times a week for at least 20 minutes. D. Get at least 7 hours of sleep each night.

A. Always wear eye protection for occupational exposures. Rationale: Two health goals are to (1) increase the proportion of public and private schools that require use of appropriate head, face, eye, and mouth protection for students participating in school-sponsored physical activities and (2) reduce occupational eye injury and increase the use of appropriate personal protective eyewear in recreational activities and hazardous situations around the home.

The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of A. the loss of accommodation. B. anisocoria. C. amblyopia. D. asthenopia

A. The loss of accommodation. Rationale: Loss of the ability to accommodate (contract the pupil for near vision) begins at around age 40 years, when many patients start using reading glasses. Unequal pupils usually are from a defect in efferent nervous pathways controlling the oculomotor nerve. Amblyopia (lazy eye) is used to describe a condition in which vision in one eye is reduced because the eye and brain do not work together correctly. Asthenopia (eye strain) develops after reading, computer work, or other visually tedious tasks

Which of the following patients would require immediate nursing care? A. An 8-year-old girl with pink conjunctivae and drainage B. A 20-year-old man with sudden visual loss after playing football C. A 52-year-old woman with clouding of vision D. A 77-year-old man with loss of vision in his peripheral fields

B. A 20-year-old man with sudden visual loss after playing football. Rationale: Sudden loss of vision is an emergency, especially following a potentially traumatic injury; this patient is at risk for retinal detachment. The 8-year-old girl may have conjunctivitis. The 52-year-old woman has symptoms of cataract, and the 77-year-old man has symptoms of macular degeneration.

The cranial nerves involved with eye movement include A. II, V, and VII. B. III, IV, and VI. C. IV, V, and VIII. D. V, VI, and VII.

B. III, IV, and VI. Rationale: The cranial nerves for the eye include II, III, IV, and VI. The optic nerve is in the CNS, whereas cranial nerves III, IV, and VI control the muscles of the eye

The nurse assesses the response of the eye to light and documents normal findings as A. PEERLA. B. PERRLA. C. PERLLA. D. PERLAA.

B. PERRLA. Rationale: The pupils are equal, round, and reactive to light and accommodation. This is abbreviated as PERRLA

A public health nurse is performing annual vision screening for residents in senior housing. Which of the following charts would the nurse most likely be using? A. Jaegar chart B. Snellen chart C. Ishihara cards D. Confrontation cards

B. Snellen chart. Rationale: The Allen chart is used to test near vision. Ishihara cards are used to test color blindness. Confrontation is a test for peripheral vision.

Peripheral vision is evaluated by the nurse using the A. corneal light test. B. cover test. C. confrontation test. D. cardinal fields of gaze test.

C. Confrontation test. Rationale: The corneal light reflex is a test for strabismus. The cover test is to assess the presence and amount of ocular deviation. The cardinal fields of gaze test is used to evaluate motor function in the eyes.

When working with an older adult, what would the nurse emphasize as increased risks for the patient? A. Myopia and strabismus B. Blepharitis and chalazion C. Glaucoma and cataracts D. Exophthalmos and presbyopia

C. Glaucoma and cataracts. Rationale: Glaucoma, cataracts, and macular degeneration are all more common in the elderly. Myopia is nearsightedness; with strabismus, a person cannot align both eyes simultaneously under normal conditions (cross eyes). Blepharitis is inflammation of the margin of the eyelid; chalazion is a cyst in the eyelid. Exophthalmos is anterior protrusion of the eyeball out of the socket; presbyopia is believed to be caused by the loss of elasticity of the crystalline lens

Which of the following scores for distance vision indicates the patient with the poorest vision? A. 200/20 B. 18/20 C. 24/20 D. 20/100

D. 20/100. Rationale: Normal refractive index is 20/20. Visual acuity for distance vision is documented in reference to what a person with normal vision can see standing 6 m (20 ft) in front of the test (which is the numerator). The numerator is compared to what a person with normal visual acuity could read on that particular line (which is the denominator). Someone with 20/20 vision can read at 20 ft what a person with normal vision can read at 20 ft.

Which of the following symptoms would the nurse expect the patient to report as translucent specks that drift across the visual field? A. Blind spots B. Ptosis C. Halos D. Floaters

D. Floaters. Rationale: A blind spot may be related to a problem of the optic nerve (CN II). Ptosis is usually related to stroke or paralysis in the eye area. A halo is seen in patients with glaucoma, lens opacities, and some drug toxicities

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what? a) Conjunctiva b) Eyelid c) Lacrimal apparatus d) Limbus

a) Conjunctiva Rationale: The conjunctiva is a thin mucous membrane that lines the inner eyelid (palpebral conjunctivae) and also covers the sclera (bulbar conjunctivae).

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? a) The client could have optiatrophy b) Blunt-force trauma often results in fracture of the orbit c) High-velocity injuries are typically non-penetrating d) This could be a sign of strabismus

b) Blunt-force trauma often results in fracture of the orbit Rationale: High-velocity injuries are typically penetrating. Blunt-force trauma often results in fracture of the orbit. Optiatrophy is atrophy of the optic nerve. Strabismus is the medical term for cross-eyed.

What muscles control the eye movement and hold the eye in place in the socket? a) Trochlear b) Extraocular c) Oculomotor d) Abducents

b) Extraocular The six extraocular muscles control the eye movement and hold the eye in place in the socket.

A woman who is 5 months pregnant is being assessed at a routine visit. She has increased pigmentation around the eyes. This is known as what? a) Pink eye b) Hyphema c) Conjunctivitis d) Chloasma

d) Chloasma Rationale: Chloasma, or increased pigmentation around the eyes, may result from increased progesterone levels in pregnant women.

What part of the eye receives and transmits visual stimuli to the brain for processing? a) Optic disc b) Vitreous chamber c) Posterior chamber d) Retina

d) Retina Rationale: The retina, which is the innermost layer of the eye, receives and transmits visual stimuli to the brain for processing.