Health Assessment Ch 16: assessing the eyes

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) Consensual reaction b) Direct reaction c) Myopia d) Presbyopia

a) Consensual reaction

Choice Multiple question - Select all answer choices that apply. What systemic diseases may cause nodular episcleritis? (Mark all that apply.) a) Systemic lupus erythematosus b) Muscular dystrophy c) Fibromyalgia d) Multiple sclerosis e) Rheumatoid arthritis

a) Systemic lupus erythematosus e) Rheumatoid arthritis

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) A client's lens appears cloudy and she claims that her visual acuity has recently declined. c) A client's extraocular movements are asymmetrical and she complains of diplopia. d) Fundoscopic examination reveals intraocular bleeding.

b) A client's lens appears cloudy and she claims that her visual acuity has recently declined.

Which technique by the nurse demonstrates proper use of the ophthalmoscope? a) Moves the scope around so the entire optic disk may be seen b) Approaches the client directly in front of the pupil c) Asks the client to fix the gaze upon an object and look straight ahead d) Uses right eye to examine the client's left eye

After turning on the ophthalmoscope, the nurse should ask c) Asks the client to fix the gaze upon an object and look straight ahead 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 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? a) "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." b) "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." c) "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." d) "In children, this problem is usually caused by an increase in pressure within the eye."

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

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

Conjunctiva 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

A patient 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? a) "You will need to see the doctor to have your eye checked." b) "It is probably just allergies. If it still hurts in the morning call me." c) "A painful eye happens sometimes with allergies. Do you have allergies?" d) "Did you do anything different yesterday? You may have eye strain."

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

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? a) Corrective lenses b) Daily use of eye drops c) No night driving d) Surgery

a) Corrective lenses 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

When testing the near reaction, an expected finding includes which of the following? a) Pupillary constriction on near gaze; constriction on distant gaze b) Pupillary constriction on near gaze; dilation on distant gaze c) Pupillary dilation on near gaze; constriction on distant gaze d) Pupillary dilation on near gaze; dilation on distant gaze

a) Pupillary constriction on near gaze; constriction on distant gaze

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? a) "Please come into the clinic right away so we can see what is wrong." b) "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." c) "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." d) "I have an opening tomorrow at 2 in the afternoon. Can you come in then?"

b) "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." Floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted patients; no additional follow-up is needed.

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) Myopia b) Arcus senilis c) Presbyopia d) Ectropion

b) Arcus senilis 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 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 hold the chart 14 inches from the eyes c) Place the chart on a table 17 inches away from the client d) Instruct the client to hold the chart away from the body at arm's length

b) Instruct the client hold the chart 14 inches from the eyes 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

When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction? a) To the right b) Up c) Down d) To the left

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

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking? a) Have the client read from a Jaeger reading card b) Use a Snellen E chart to perform the examination c) Perform the confrontation test d) Move an object through the six cardinal positions of gaze

b) Use a Snellen E chart to perform the examination 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 and cranial nerve function. The Jaeger chart tests near visual acuity. Confrontation test is used to test visual fields for peripheral vision

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 a) exotropia. b) esotropia. c) phoria. d) trabismus.

b) esotropia. 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 a) migraine headaches. b) glaucoma. c) bacterial infection. d) increased intracranial pressure.

b) glaucoma. A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? a) She can accurately name 20% of the letters at 20 feet. b) She obtains a 20% correct score at 100 feet. c) She can see at 20 feet what a normal person could see at 100 feet. d) She can see at 100 feet what a normal person could see at 20 feet.

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

The functional reflex that allows the eyes to focus on near objects is termed a) pupillary reflex. b) indirect reflex. c) accommodation. d) refraction.

c) accommodation.

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

d) Perform both the distant and near visual acuity tests

A client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his right eye. The nurse should a) examine the area of head trauma. b) ask the client if he sees "halos." c) assess the client for double vision. d) refer the client to an ophthalmologist.

d) refer the client to an ophthalmologist. Consistent blind spots may indicate retinal detachment. Any report of a blind spot requires immediate attention and referral to a physician.