HHA PrepU: Chapter 16 Eyes
A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response? -Deep-water fish -Low-fat meat -Foods that contain lots of water -Multigrain foods
-Deep-water fish Foods that promote eye health include deep-water fish, fruits, and vegetables (e.g., carrots, spinach).
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? -Medially toward the nose -Laterally toward the ear -Upward toward the forehead -Downward toward the chin
-Medially toward the nose
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? -Presbyopia -Cataract formation -Loss of convergence -Macular degeneration
-Presbyopia 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.
The nurse tests the six cardinal directions to test extraocular movement of the eye. -True -False
-True
A comprehensive physical examination of the eye includes tests for which of the following? Select all that apply. -Visual acuity -Eye muscle function -Internal ocular structures -Rinne test -The external eye
-Visual acuity -Eye muscle function -Internal ocular structures -The external eye
An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for -a foreign body. -recent trauma. -blind spots. -allergies.
-allergies. Burning or itching pain is usually associated with allergies or superficial irritation.
The conjunctiva of the eye is divided into the palpebral portion and the -canthus portion. -intraocular portion. -nasolacrimal portion. -bulbar portion.
-bulbar portion. The conjunctiva is a thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion. The palpebral conjunctiva lines the inside of the eyelids, and the bulbar conjunctiva covers most of the anterior eye, merging with the cornea at the limbus.
The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead? -white -red -black -yellow
-white
A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder? -Diabetes -Cataract -Glaucoma -Hypertension
-Glaucoma
The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from? -Asthenopia -Myopia -Hyperopia -Presbyopia
-Myopia
The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from? -Asthenopia -Myopia -Hyperopia -Presbyopia
-Myopia Myopia is nearsightedness, meaning the client can see objects better up close. Asthenopia is eye strain, and symptoms include fatigue, red eyes, eye pain, blurred vision, and headaches. Hyperopia is farsightedness. Presbyopia commonly occurs naturally due to the aging process; therefore it's rare to observe this condition in young adults.
The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and -transmit light rays. -maintain the retinal vessels. -change refractory of the lens. -cleanse the cornea and the lens.
-cleanse the cornea and the lens. Aqueous humor helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure.
A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following? -Retina -Sclera -Cornea -Conjunctiva
-Conjunctiva
What muscles control the eye movement and hold the eye in place in the socket? -Extraocular -Oculomotor -Trochlear -Abducens
-Extraocular The six extraocular muscles control the eye movement and hold the eye in place in the socket. These muscles coordinate their actions to produce vision within both eyes. The oculomotor, trochlear, and abducens are not muscles; they are cranial nerves.
What features would most likely be noted on fundoscopic examination of someone with glaucoma? -Increased cup-to-disc ratio -AV nicking -Cotton wool spots -Microaneurysms
-Increased cup-to-disc ratio It is important to screen for glaucoma on fundoscopic examination. The cup and disc are among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension. Microaneurysms are seen in diabetes.
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? -Medially toward the nose -Laterally toward the ear -Upward toward the forehead -Downward toward the chin
-Medially toward the nose Follow the blood vessels as they get wider. Follow the vessels medially toward the nose and look for the round yellowish orange structure which is the optic disc.
You note anterior bulging of the physiologic cup when performing a funduscopic examination of your patient's eyes. What would you document? -Positive axoplasmic sign -Arteriovenous crossings -Papilledema -Hyperopia
-Papilledema
You note anterior bulging of the physiologic cup when performing a funduscopic examination of your patient's eyes. What would you document? -Positive axoplasmic sign -Arteriovenous crossings -Papilledema -Hyperopia
-Papilledema Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup.
The open space between the eyelids is called what? -The palpebral fissure -The limbus -The lacrimal fissure -The eyeball
-The palpebral fissure 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.
What do retinal abnormalities include? -Age-related macular degeneration -Mydriasis -Argyll Robertson syndrome -Horner's syndrome
-Age-related macular degeneration Age-related macular degeneration gradually causes loss of sharp central vision, needed for common daily tasks (eg, driving, reading). The macula degenerates (dry) or abnormal blood vessels behind the retina grow under the macula (wet). Mydriasis, Argyll Robertson syndrome, and Horner's syndrome all affect the pupils, not the retina.
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? -Report this to the health care provider -Ask the client about previous trauma to the eyes -Document this finding in the client's record -Continue with the examination
-Ask the client about previous trauma to the eyes
What are the glands that are located on the tarsal plates and open on the lid margins? -Levator glands -Chalazion glands -Pterygium glands -Meibomian glands
-Meibomian glands Within the eyelids lie firm strips of connective tissue called tarsal plates. Each plate contains a parallel row of meibomian glands, which open on the lid margin.
What systemic diseases may cause nodular episcleritis? (Mark all that apply.) -Systemic lupus erythematosus -Multiple sclerosis -Fibromyalgia -Muscular dystrophy Rheumatoid arthritis
-Systemic lupus erythematosus Rheumatoid arthritis If you need a fuller view of the eye, rest your thumb and finger on the bones of the cheek and brow, respectively, and spread the lids. The local redness below is from nodular episcleritis, often self-limiting in younger adults; it is also seen in rheumatoid arthritis and system lupus erythematosus.
What is the primary purpose of the health history in relation to the eyes? -To identify a family history of ocular disease -To identify if problems are unilateral or bilateral -To test the acuity of central vision -To identify changes
-To identify changes The purpose of the health history is to identify changes in the eyes.
An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible -glaucoma. -increased intracranial pressure. -hypertension. -ophthalmic migraine.
-increased intracranial pressure. Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor
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? -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 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 has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? -Pupils dilate in response to a light shone in the eyes. -Eyes do not converge to focus on a shining light. -There is no reaction in the opposite pupil to light. -Light reflection appears at different spots on both eyes.
-There is no reaction in the opposite pupil to light.
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 -Prevention of knee injuries -Prevention of head injuries -Use of correct foot gear
-Use of safety equipment 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.
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? -"In children, this problem is usually caused by an increase in pressure within the eye." -"I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." -"Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." -"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."
-"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." Conjunctivitis usually has an infectious etiology. Severe pain and vision damage are not common consequences.
A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results? -Vision is worse in the left eye than the right eye. -The larger the bottom number, the worse the visual acuity. -Client is legally blind in the left eye. -Glasses are needed by the client for near vision.
-The larger the bottom number, the worse the visual acuity.
A client has anisocoria on examination. Pathological causes of this include which of the following? -Horner's syndrome -Benign anisocoria -Differing light intensities for each eye -Eye prosthesis
-Horner's syndrome Anisocoria can be associated with serious pathology. Remember to exclude benign causes before embarking on an intensive follow-up. Testing the near reaction in this case may help locate an Argyll-Robertson or tonic (Adie's) pupil.
What part of the eye receives and transmits visual stimuli to the brain for processing? -Retina -Optic disc -Posterior chamber -Vitreous chamber
-Retina The retina, which is the innermost layer of the eye, receives and transmits visual stimuli to the brain for processing. The posterior and vitreous chambers of the eye contain aqueous and vitreous humor of the eye. The optic disc, a well-defined round or oval area, is the opening for the optic nerve head.
Which of the following statements most accurately describes the maintenance of normal intraocular pressure? -The lacrimal gland produces increased fluid when intraocular pressure is low and ceases production when pressure is high. -The eye is a closed system whose contents of aqueous humour provide consistent internal pressure. -The muscles of the ciliary body adjust the volume of the eye in response to increased or decreased pressure. -Aqueous humour is continuously circulating through the eye with production equalling drainage.
-Aqueous humour is continuously circulating through the eye with production equalling drainage. Aqueous humour, produced by the ciliary body, maintains intraocular pressure with production equalling drainage. It is not a closed system, and pressure is not adjusted through muscular control of eye volume.
The optic nerves from each eyeball cross at the -optic chiasma. -vitreous humor. -optic disc. -visual cortex.
-optic chiasma. At the point where the optic nerves from each eyeball cross—the optic chiasma—the nerve fibers from the nasal quadrant of each retina (from both temporal visual fields) cross over to the opposite side.
A client presents to the clinic complaining of sudden visual loss in the left eye. What is the nurse's priority action? -Assess cranial nerve function. -Notify the healthcare provider immediately. -Ask the client if protective eyewear was worn. -Perform the Allen test and report the findings urgently.
-Notify the healthcare provider immediately. Sudden visual loss is an emergency and should be immediately reported to the healthcare provider. Wearing protective eyewear is irrelevant at this time; the healthcare provider should be notified whether the client wore protective eyewear or not. Assessing cranial nerve function and vision testing is not realistically possible when the client suffers sudden visual loss.
What features would most likely be noted on fundoscopic examination of someone with glaucoma? -Increased cup-to-disc ratio -AV nicking -Cotton wool spots -Microaneurysms
-Increased cup-to-disc ratio It is important to screen for glaucoma on fundoscopic examination. The cup and disc are among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension. Microaneurysms are seen in diabetes.
Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination? -Touch the cornea with a wisp of cotton -Shine a penlight on the eye in a darkened room -Ask the client to read the Snellen chart -Test the cornea of the eye with an ophthalmoscope
-Touch the cornea with a wisp of cotton The nurse should assess the corneal reflex by lightly touching the corneal surface with a wisp of cotton. Shining a penlight may help to test the pupillary response and accommodation. A Snellen chart tests the visual vision acuity. An ophthalmoscope is used to assess the internal structures of the eye.
A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina? -Refracts light rays onto the posterior surface of the eye -Controls the amount of light entering the eye -Transforms light rays into nerve impulses that are conducted to the brain -Permits the entrance of light to the eye
-Transforms light rays into nerve impulses that are conducted to the brain Visual perception occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted. The lens functions to refract (bend) light rays onto the retina. Muscles in the iris adjust to control the pupils size, which controls the amount of light entering the eye. The cornea permits the entrance of light, which passes through the lens to the retina.
A nurse assesses the pupillary reaction to light for a client. Which precaution should the nurse follow to get an accurate result of consensual response? -Shine a bright light directly into the eye to be tested -Observe the response in the eye focused with light -Place an opaque card in between the eyes of the client -Instruct the client to close the eye not focused with light
-Place an opaque card in between the eyes of the client 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.
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 -Prevention of knee injuries -Prevention of head injuries -Use of correct foot gear
-Use of safety equipment
Straight movements of the eye are controlled by the -lacrimal muscles. -oblique muscles. -corneal muscles. -rectus muscles.
-rectus muscles. The extraocular muscles are the six muscles attached to the outer surface of each eyeball. These muscles control six different directions of eye movement. Four rectus muscles are responsible for straight movement, and two oblique muscles are responsible for diagonal movement.
The muscles of the ciliary body control the thickness of the lens, allowing the eye to: -Focus on near or distant objects -Coordinate extraocular movement -Adjust the pressure inside the eye -Control the amount of light entering the eye
-Focus on near or distant objects The muscles of the ciliary body allow the lens to focus light appropriately for discerning far and near objects clearly. They do not control extraocular movements or intraocular pressure. The iris controls the amount of light entering the eye.
The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and -transmit light rays. -maintain the retinal vessels. -change refractory of the lens. -cleanse the cornea and the lens.
-cleanse the cornea and the lens.
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 -year. -2 years. -3 years. -4 years.
-2 years. 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.
A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should -document the results in the client's record. -ask the client to read a handheld vision chart. -ask the client to return in 2 weeks for another examination. -refer the client to an optometrist.
-refer the client to an optometrist.
A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should -document the results in the client's record. -ask the client to read a handheld vision chart. -ask the client to return in 2 weeks for another examination. -refer the client to an optometrist.
-refer the client to an optometrist. 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.
Which technique by the nurse demonstrates proper use of the ophthalmoscope? -Uses right eye to examine the client's left eye -Moves the scope around so the entire optic disk may be seen -Approaches the client directly in front of the pupil -Asks the client to fix the gaze upon an object and look straight ahead
-Asks the client to fix the gaze upon an object and look straight ahead 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.
When considering eye safety, what instructions should the nurse provide to a patient newly prescribed contact lenses? (Select all that apply.) -Do not share lenses. -Keep the lenses clean. -Wash hands before inserting or removing the lenses. -Inspect the lenses every week for scratches or damage. -Discard unused portions of contact solutions at the expiration date.
-Do not share lenses. -Keep the lenses clean. -Wash hands before inserting or removing the lenses. -Discard unused portions of contact solutions at the expiration date. The nurse should instruct the patient to not share the lenses, to keep the lenses clean, to wash hands before inserting or removing the lenses, and to discard unused portions of contact solutions at the expiration date. The lenses should be inspected for scratches or damage every year.
The nurse performs the cover test when assessing a client's eyes. What is the nurse assessing? -Near vision -Distance vision -Ocular alignment -Color discrimination
-Ocular alignment The assessment pictured is the cover test. The cover test assesses ocular alignment. The Jaeger chart is used to assess near vision. The Snellen chart is used to assess distant vision. Ishihara cards are used to assess color discrimination.
An adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in vision are often associated with -diabetes. -the aging process. -hypertension. -head trauma.
-head trauma. Sudden changes in vision are associated with acute problems such as head trauma or increased intracranial pressure.
Straight movements of the eye are controlled by the -lacrimal muscles. -oblique muscles. -corneal muscles. -rectus muscles.
-rectus muscles.
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 -Palpebral fissure -Lacrimal gland -Limbus -Nasolacrimal duct
-Punctum -Lacrimal gland -Nasolacrimal duct 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 palpebral fissure is the open space between the eyelids. The limbus is the border between the cornea and the sclera.
What part of the eye receives and transmits visual stimuli to the brain for processing? -Retina -Optic disc -Posterior chamber -Vitreous chamber
-Retina
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 -year. -2 years. -3 years. -4 years.
-2 years. 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.
What is a characteristic symptom of Graves hyperthyroidism? -Pterygium -Exophthalmos -Pinguecula -Episcleritis
-Exophthalmos In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.
An adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. The nurse should assess the client for -recent exposure to irritants. -increased intracranial pressure. -excessive tearing. -a foreign body in the eye.
-a foreign body in the eye. Throbbing, stabbing, or deep, aching pain suggests a foreign body in the eye or changes within the eye.
The middle layer of the eye is known as the -choroid layer. -scleral layer. -retinal layer. -optic layer.
-choroid layer. The middle layer contains both an anterior portion, which includes the iris and the ciliary body, and a posterior layer, which includes the choroid.
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 -congenital cataracts. -decreased accommodation. -muscle weakness. -constant misalignment of the eyes.
-decreased accommodation. 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.
A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following? -Retina -Sclera -Cornea -Conjunctiva
-Conjunctiva The conjunctiva is a thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion. The palpebral conjunctiva lines the inside of the eyelids, and the bulbar conjunctiva covers most of the anterior eye, merging with the cornea at the limbus. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends them to the brain. The sclera is a dense, protective, white covering that physically supports the internal structures of the eye. The transparent cornea permits the entrance of light, which passes through the lens to the retina.
A nurse is inspecting the bulbar conjunctiva and sclera of a 67-year-old client, and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nursing action at this time? -Document the finding and proceed with the examination -Notify the physician of the finding -Ask the client whether he has recently had trouble focusing when reading up close -Examine the client's eye for presence of a foreign body
-Document the finding and proceed with the examination Yellowish nodules on the bulbar conjunctiva are called pinguecula. These harmless nodules are common in older clients and appear first on the medial side of the iris and then on the lateral side. Therefore, the nurse should document this finding and proceed with the examination. There is no need to notify the physician of the finding. Having trouble focusing when reading up close is a sign of presbyopia, or impaired near vision, which is not associated with the finding of pinguecula. A foreign body or lesion may cause irritation, burning, pain and/or swelling of the upper eyelid but would not cause yellowish nodules.
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? -Hyphema -Blepharitis -Chalazion -Iris nevus
-Hyphema 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.
A patient is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the patient's medical record supports this diagnosis? -Increased intraocular pressure -Sluggish pupillary reaction -Displaced optic nerve -Opaque lens
-Increased intraocular pressure 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 patient is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the patient's medical record supports this diagnosis? -Increased intraocular pressure -Sluggish pupillary reaction -Displaced optic nerve -Opaque lens
-Increased intraocular pressure 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 client is being assessed for indications of a possible obstructed nasolacrimal duct in the right eye. Under what circumstances should the nurse avoid compressing the lacrimal sac? -Mucopurulent fluid is observed near the sac. -There is excessive tearing in the right eye. -The area around the sac is inflamed. -The client reports experiencing floaters.
-The area around the sac is inflamed.
A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results? -Vision is worse in the left eye than the right eye. -The larger the bottom number, the worse the visual acuity. -Client is legally blind in the left eye. -Glasses are needed by the client for near vision.
-The larger the bottom number, the worse the visual acuity. OD = right eye, OS = left eye. Therefore, the client has worse vision in the right eye because the larger the number on the bottom, the worse the visual acuity. A client is considered legally blind when the vision in the better eye with corrective lens is 20/200 or less. Snellen test is to test for distant vision (far) not near vision.
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? -Pupils dilate in response to a light shone in the eyes. -Eyes do not converge to focus on a shining light. -There is no reaction in the opposite pupil to light. -Light reflection appears at different spots on both eyes.
-There is no reaction in the opposite pupil to light. When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict. An abnormal response to this test is if either or both pupils do not constrict in response to light. Pupils do not dilate in response to light shone into them. Convergence of the eyes is called accommodation and occurs when focus of vision is moved from a far object to a close object. Light reflection appearing at different spots on both eyes is an abnormal result of the corneal light reflex test, not of the consensual pupillary reaction to light test.
The nurse is caring for a client with an eye injury. The client asks about the eye, and the nurse explains its structures and functions. What would the nurse tell the client is the largest chamber of the eye? -Anterior -Posterior -Corneal -Vitreous
-Vitreous The interior eye has three chambers: anterior, posterior, and vitreous. The anterior chamber is the space between the cornea in the front and the iris and lens in the back. It contains aqueous humor, produced by the ciliary body; the amount varies to maintain pressure in the eye. The posterior chamber starts behind the iris and goes to the lens. It is also filled with aqueous humor that helps to nourish the cornea and lens. The largest vitreous chamber is adjacent to the inner retinal layer and lens. This chamber is filled with vitreous humor, which is gel-like, holds the retina in place, and maintains the shape of the eyeball. Corneal is a distracter for this question.
A nurse is examining the eyes of a 7-year-old boy. The boy asks the nurse, "What's inside my eyeball?" The nurse explains that the biggest space inside the eyeball contains a clear, gelatinous substance that light passes through. Which of the following is the technical name for this gelatinous substance? -Aqueous humor -Vitreous humor -Lacrimal humor -Meibomian humor
-Vitreous humor Vitreous humor is the clear and gelatinous substance that fills the vitreous chamber, the largest chamber of the eye, which is located in the area behind the lens to the retina. Aqueous humor is a clear liquid substance produced by the ciliary body that fills the anterior and posterior chambers of the eye. It helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure. Lacrimal and meibomian refer to glands that produce tears and a lubricating substance of the eyelids, respectively, and not to types of humor.
The nurse should make it a priority to assess which client for papilledema? -a 45-year-old suspected of experiencing a subarachnoid hemorrhage -an 80-year-old diagnosed with chronic open-angle glaucoma -a 12-year-old demonstrating a deviated left eye -a 56-year-old reporting double vision
-a 45-year-old suspected of experiencing a subarachnoid hemorrhage Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup. Increased intracranial pressure is transmitted to the optic nerve, causing edema of the optic nerve. Papilledema often signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions. An enlarged physiological cup suggests chronic open-angle glaucoma. If cranial nerve IV is paralyzed, the left eye will deviate from its normal position in that direction of gaze, and the eyes will no longer appear conjugate, or parallel. Diplopia in adults may arise from a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of cranial nerve (CN) III or VI, or vertical diplopia from palsy of CN III or IV.
The nurse should make it a priority to assess which client for papilledema? -a 45-year-old suspected of experiencing a subarachnoid hemorrhage -an 80-year-old diagnosed with chronic open-angle glaucoma -a 12-year-old demonstrating a deviated left eye -a 56-year-old reporting double vision
-a 45-year-old suspected of experiencing a subarachnoid hemorrhage Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup. Increased intracranial pressure is transmitted to the optic nerve, causing edema of the optic nerve. Papilledema often signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions. An enlarged physiological cup suggests chronic open-angle glaucoma. If cranial nerve IV is paralyzed, the left eye will deviate from its normal position in that direction of gaze, and the eyes will no longer appear conjugate, or parallel. Diplopia in adults may arise from a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of cranial nerve (CN) III or VI, or vertical diplopia from palsy of CN III or IV.
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? -direct light response present in left eye -pupils equal and react to accommodation -consensual light response present in left eye -consensual light response present in right eye
-consensual light response present in left eye 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 -congenital cataracts. -decreased accommodation. -muscle weakness. -constant misalignment of the eyes.
-decreased accommodation. 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.
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. 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 using the ophthalmoscope to examine the patient's eyes. The nurse holds the scope -in the right hand for the right eye and in the left hand for the left eye -in the left hand for the right eye and in the right hand for the left eye -n the right hand for both eyes -in the left hand for both eyes
-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 -viral infection. -double vision. -allergic reactions. -lacrimal obstruction.
-lacrimal obstruction. 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.
An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing? -cataracts -glaucoma -detached retina -macular degeneration
-macular degeneration Macular degeneration causes a loss of central vision. Risk factors for macular degeneration are age, smoking history, obesity, family history, and female gender. Cataracts are characterized by cloudiness of the eye lenses. Glaucoma is an increase in intraocular pressure that places pressure on eye structures and affecting vision. A detached retina is the sudden loss of vision in one eye. This health problem may be precipitated by the appearance of blind spots.
The tarsal plates of the upper eyelid contain -meibomian glands. -sebaceous glands. -tear ducts. -ocular muscles.
-meibomian glands. The upper eyelid is larger, more mobile, and contains tarsal plates made up of connective tissue. These plates contain the meibomian glands, which secrete an oily substance that lubricates the eyelid.
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 -examine the area of head trauma. -refer the client to an ophthalmologist. -assess the client for double vision. -ask the client if he sees "halos."
-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.
A 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should -tell the client that these often occur with aging. -refer the client to an ophthalmologist. -re-examine the client in 2 weeks. -assess the client for signs of diabetes.
-tell the client that these often occur with aging. Spots or floaters are common among clients with myopia or in clients over age 40. In most cases, they are due to normal physiologic changes in the eye associated with aging and require no intervention
A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with -retinal deterioration. -head trauma. -migraine headaches. -vitamin A deficiency.
-vitamin A deficiency. Night blindness is associated with optic atrophy, glaucoma, and vitamin A deficiency.
