Ch. 16 health assessment -Assessing eyes
You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what?
A left temporal hemianopsia
The nurse practitioner is assessing the eyes of a client with long-standing uncontrolled hypertension. What might the nurse practitioner visualize during an assessment with an ophthalmoscope?
AV nicking
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 bacterial infection. migraine headaches. glaucoma. increased intracranial pressure.
Glaucoma A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.
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 to hold the chart 14 inches from the eyes
The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test
Requires the covering of each eye separately.
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 client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition? "Are the blind spots constant or intermittent?" "Is night blindness a problem for you?" "Do you see floaters in front of your eyes?" "How often do you have redness or tearing?"
"Are the blind spots constant or intermittent?" A scotoma is the presence of blind spots that can be constant or intermittent. If they are constant it may indicate retinal detachment. Intermittent blind spots may be due to vascular spasm or pressure on the optic nerve. Floaters are a common finding in individuals with myopia or in person over the age of 40 years and are a sign of normal aging. Redness or tearing is associated with allergies or inflammation of the eye. Night blindness is associated with optic nerve atrophy, glaucoma, or vitamin A deficiency.
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."
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? "Please come into the clinic right away so we can see what is wrong." "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." "I have an opening tomorrow at 2 in the afternoon. Can you come in then?"
"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.
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." "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." "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." Conjunctivitis usually has an infectious etiology. Severe pain and vision damage are not common consequences.
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?
"You will need to see the doctor to have your eye checked."
The nurse is teaching about the importance of regular eye examinations and should include information about which conditions that place clients at highest risk for blindness? (Select all that apply.)
-Diabetes -Hypertension
Which vision acuity reading indicates blindness?
20/200 In the United States, a person is usually considered legally blind when vision in the better eye, corrected by glasses, is 20/200 or less.
You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what? a. A quadrantic defect b. A left temporal hemianopsia c. A homonymous hemianopsia d. A bitemporal hemianopsia
A left temporal hemianopsia When the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.
The functional reflex that allows the eyes to focus on near objects is termed refraction. accommodation. pupillary reflex. indirect reflex.
Accommodation 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
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.
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 Viral infection Vitamin A deficiency Allergies
Brain tumor Explanation: Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor. Vitamin A deficiency is a cause of night blindness. Allergies are usually indicated by burning or itching pain in the eye. Viral infection is usually indicated by redness or swelling of the eye.
The middle layer of the eye is known as the
Choroid layer
The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?
Conjunctiva
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
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
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 a. myopia. b. corneal damage. c. cataracts. d. retinal damage.
Corneal Damage Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage.
A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process? Anemia Retinal detachment Renal insufficiency Diabetes
Diabetes Explanation: Exudates appear as light-colored spots on the retinal background and occur in individuals with diabetes or hypertension. Anemia, renal insufficiency, and retinal detachment do not cause this appearance on the retina.
What eye function is the nurse preparing to assess when the patient is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?
Distant vision
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? Has blue-green color blindness Recovering from cataract surgery Does not speak English Being treated for glaucoma
Does not speak English 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.
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. strabismus.
Esotropia Esotropia is an inward turn of the eye.
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? a. Strabismus b. Exotropia c. Presbyopia d. Esotropia
Exotropia 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.
When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are clients most likely at increased risk for if a first-degree relative has it?
Glaucoma
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? Chalazion Hyphema Blepharitis 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. (less)
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
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Vitreous chamber Sinus Lacrimal apparatus Aqueous chamber
Lacrimal apparatus 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.
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? Medially toward the nose Downward toward the chin Laterally toward the ear Upward toward the forehead
Medially toward the nose Explanation: 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.
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent
Muscular Degeneration
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
On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear 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
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? Document the findings in the client's record Perform both the distant and near visual acuity tests Test the pupils for direct and consensual reaction to light Obtain a referral to the ophthalmologist for a complete eye exam
Perform both the distant and near visual acuity tests 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.
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
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 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.
When testing the near reaction, an expected finding includes which of the following? a. Pupillary constriction on near gaze; dilation on distant gaze b. Pupillary dilation on near gaze; dilation on distant gaze c. Pupillary constriction on near gaze; constriction on distant gaze d. Pupillary dilation on near gaze; constriction on distant gaze
Pupillary constriction on near gaze; dilation on distant gaze During accommodation, pupils constrict with near gaze and dilate with far gaze.
On visual confrontation testing, a client with a recent stroke cannot see the examiner's fingers on the entire right side with either eye covered. Which of the terms would describe this finding?
Right homonymous hemianopsia
A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states 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
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
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 patient's vision?
Snellen E
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 patient's vision? Allen PERRLA Snellen E Ishihara
Snellen E The Snellen E chart can be used for people who cannot read or speak English.
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?
The larger the bottom number, the worse the visual acuity
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
The nurse tests the six cardinal directions to test extraocular movement of the eye.
True
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?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?
Up
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
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 safety equipment
The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and cleanse the cornea and the lens. change refractory of the lens. maintain the retinal vessels. transmit light rays.
cleanse the cornea and the lens. Aqueous humor helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure.
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 a. congenital cataracts. b. decreased accommodation. c. muscle weakness. constant d. 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 accommodatio
The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents a. ptosis b. entropion c. exophthalmos d. ectropion
entropion
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 allergic reactions. double vision. lacrimal obstruction. viral infection.
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.
The meibomian glands secrete a. sweat. b. clear liquid tears. c. an oily substance to lubricate the eyes. d. hormones.
An oily substance to lubricate the eyes Meibomian glands secrete an oily substance that lubricates the eyelid.
A patient 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? 20/300 or less 20/400 or less 20/100 or less 20/200 or less
In the United States, a person is usually considered legally blind when vision in the better eye, corrected by glasses, is 20/200 or less. 20/200 or less
Normal movement of the eye involves what cranial nerves? (Mark all that apply.) IV II VI III V
Correct response: • II • III • IV • VI Explanation: As the nurse inspects and palpates the eye, he or she assesses for the sensory and motor functions of four cranial nerves: Cranial nerve II, optic nerve, visual acuity, visual fields, fundoscopic examination; cranial nerve III, oculomotor, cardinal fields of gaze, eyelid inspection, pupil reaction (direct/consensual/ accommodation); cranial nerve IV, trochlear, cardinal fields of gaze; and cranial nerve VI, abducens, cardinal fields of gaze. Cranial nerve V, known as the trigeminal nerve, is a nerve responsible for sensation in the face and certain motor functions such as biting and chewing. (less) Reference:
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? a. Exophthalmos b. Ptosis c. Epicanthus d. Ectropion
Exophthalmos 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 tumour and inflammation in the orbit
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? a. macular degeneration b. cataracts c. glaucoma d. detached retina
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.
Photoreceptors of the eye are located in the eye's iliary body. retina. pupil. lens.
Retina 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
Which technique by the nurse demonstrates proper use of the ophthalmoscope? Approaches the client directly in front of the pupil Asks the client to fix the gaze upon an object and look straight ahead Uses right eye to examine the client's left eye Moves the scope around so the entire optic disk may be seen
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.
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? a. Place the client 20 feet from the Snellen chart and record the smallest line the client can read b. Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time c. Sit the client in front of the examiner, extend one arm, and slowly move one finger upward s. Tell the client to remove glasses, if present, and read the Snellen card using both eye
Have the client hold Jaeger card 14 inches from the face & read with one eye at a time 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 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. 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 c. Place the chart 20 feet away from the client on the wall d. 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.
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
A comprehensive physical examination of the eye includes tests for which of the following? Select all that apply. a. Eye muscle function b. The external eye c. Rinne test d. Visual acuity e. Internal ocular structures
-Visual acuity -Eye muscle function -Internal ocular structures -The external eye A comprehensive physical examination of the eye involves assessment of visual acuity, the external eye, eye muscle function, external ocular structures (including pupil reflexes), and internal ocular structures. The Rinne test is a type of hearing exam.
Which of the following assessment findings suggests a problem with the client's cranial nerves? a. A client's lens appears cloudy and she claims that her visual acuity has recently declined. b. A client's extraocular movements are asymmetrical and she complains of diplopia. c. Fundoscopic examination reveals intraocular bleeding. d. A client states that he has recently begun seeing lights flashing in his field of vision.
A client's extra-ocular movements are asymmetrical and she complains of diplopia 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.
What do retinal abnormalities include?
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.
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 right eye consensual light response present in left 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.
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?
Consensual reaction
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? a. Daily use of eye drops b. Surgery c. Corrective lenses d. No night driving
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.
A client is diagnosed with glaucoma. When performing the ophthalmic exam, what changes should the nurse anticipate finding? Hyperemia of the optic disc due to accumulation of blood Enlarged physiologic cup that occupies more than half of disc's diameter Widening of the light reflex and a coppery color to the arterioles Opaque or silver appearance of the arteriole wall
Enlarged physiologic cup that occupies more than half of disc's diameter Glaucoma is a condition of increased pressure within the eye. This causes the physiologic cup to enlarge to more than half of the disc's diameter. Widening of the light reflex with a coppery color to the arterioles and an opaque or silver appearance of the arteriole wall are seen with hypertension. Hyperemia of the optic disc due to accumulation of blood is called papilledema.
What is a characteristic symptom of Graves hyperthyroidism? a. Episcleritis b. Exophthalmos c. Pterygium d. Pinguecula
Exopthalamus In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.
A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?
Focused on the bridge of the nose
The nurse is planning to assess a client's near vision. Which technique should be used? a. have the client stand 20 feet from a wall chart and read the letters after covering one eye b. ask the client to move the eyes in the direction of a moving finger c. have the client read newspaper print held 14 inches from the eyes d. shine a light on the bridge of the nose
Have the client read newspaper print held 14 inches from the eyes 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 preparing to examine an adult client's eyes, using a Snellen chart. The nurse should a. ask the client to remove his glasses. b. position the client 609.6 cm (20 ft) away from the chart. c. instruct the client to begin reading from the bottom of the chart. d. ask the client to read each line with both eyes open.
Position the client 609.6cm (20ft) away from the chart 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. Reference:
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? a. Chalazion b. Dacryocystitis c. Xanthelasma d. Stye
Stye A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.
What systemic diseases may cause nodular episcleritis? (Mark all that apply.) a. Fibromyalgia b. Multiple sclerosis c. Muscular dystrophy d. Systemic lupus erythematosus d. 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.
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 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.
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