Nurs 114 Exam 1 Chapter 16 (assessing the eyes) prepU

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'."

Which vision acuity reading indicates blindness?

20/200

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.

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

Accommodation

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

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

A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client?

Brain tumor

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to

Corneal damage

A client asks a nurse if any foods promote eye health. What food would the nurse include as a response?

Deep-water fish

When considering eye safety, what instructions should the nurse provide to a client newly prescribed contact lenses? (Select all that apply.)

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.

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

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

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

What is a characteristic symptom of Graves hyperthyroidism?

Exophthalmos

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

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

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

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

Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)?

III (oculomotor)

What features would most likely be noted on fundoscopic examination of someone with glaucoma?

Increased cup-to-disc ratio

A client is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the client's medical record supports this diagnosis?

Increased 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

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

Lacrimal apparatus

The optic nerves from each eyeball cross at the

Optic chiasma

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

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

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

Pupillary constriction on near gaze; dilation on distant gaze

Which of the following is a symptom of the eye?

Scotomas

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.

The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this client's vision?

Snellen E

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.

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

There is no reaction in the opposite pupil to light.

What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client?

Thick, purulent drainage is noted at inner corner of both eyes.

The nurse tests the six cardinal directions to test extraocular movement of the eye.

True

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

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking?

Use a Snellen E chart to perform 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

The nurse should make it a priority to assess which client for papilledema?

a 45-year-old suspected of experiencing a subarachnoid hemorrhage

The meibomian glands secrete

an oily substance to lubricate the eyes.

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

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

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

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.

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

macular degeneration

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.

Photoreceptors of the eye are located in the eye's

the Retina

A client in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?

20/200 or less

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

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