Chapter 14
The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?
ANS: Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber Intraocular pressure is determined by a balance between the amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.
A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:
ANS: consider this a normal finding. By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy.
The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has "lazy eye" and should:
ANS: test for strabismus by performing the corneal light reflex test. Testing for strabismus is done by performing the corneal light reflex test as well as the cover test. The Snellen eye chart and confrontation test are not used to test for strabismus.
A mother asks when her newborn infant's eyesight will be developed. The nurse should reply:
ANS: "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate on a single image with both eyes simultaneously
Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?
ANS: A dark retinal background There is an ethnically based variability in the color of the iris and in retinal pigmentation, with darker irides having darker retinas behind them.
The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal?
ANS: An optic disc that is a yellow-orange color The optic disc is located on the nasal side of the retina. It is a creamy yellow-orange to pink color, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black, and it is due to the accumulation of pigment in the choroid.
During an assessment the nurse notices that an elderly patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct?
ANS: Assess for other signs of ectropion. The condition described is known as ectropion, and it occurs in aging due to atrophy of elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot siphon tears effectively, and excessive tearing results. Ptosis is drooping of the upper eyelid. These are not signs of a foreign body in the eye or basal cell carcinoma.
When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:
ANS: Elevates the eyelid and dilates the pupil. Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.
A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:
ANS: Has poor vision. Normal visual acuity is 20/20 in each eye. The larger the denominator, the poorer the vision.
When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding:
ANS: Is expected. The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.
When assessing the pupillary light reflex, the nurse should use which technique?
ANS: Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.
The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?
ANS: The outer layer of the eye is very sensitive to touch. The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal (CN V) and facial (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.
A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:
ANS: The patient can read at 20 feet what a person with normal vision can read at 30 feet. The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.
During an assessment of the sclera of an African-American patient, the nurse would consider which of these an expected finding?
ANS: The presence of small brown macules on the sclera In dark-skinned people, one normally may see small brown macules in the sclera.
The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:
ANS: ask the patient if he or she has a history of heart failure. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.
When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:
ANS: consider this a normal finding. Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.
In a patient who has anisocoria, the nurse would expect to observe:
ANS: pupils of unequal size. Unequal pupil size is termed anisocoria. It exists normally in 5% of the population but may also be indicative of central nervous system disease.
A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:
ANS: shadow or diminished vision in one quadrant or one half of the visual field. With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.
A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that:
ANS: she may have macular degeneration. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision.
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this?
ANS: Observe the distance between the palpebral fissures. Ptosis is drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis.
The nurse is performing the diagnostic positions test. Normal findings would be which of these results?
ANS: Parallel movement of both eyes A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it.
The nurse is testing a patient's visual accommodation, which refers to which action?
ANS: Pupillary constriction when looking at a near object The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.
A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?
ANS: Shorten the distance between the patient and the chart until it is seen and record that distance. If the person is unable to see even the largest letters, then the nurse should shorten the distance to the chart until it is seen and should record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but first the nurse must assess the visual acuity.
During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:
ANS: Stimulated by cranial nerves III, IV, and VI. Movement of the extraocular muscles is stimulated by three cranial nerves: III, IV, and VI.
During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?
ANS: The absence of drainage from the puncta when pressing against the inner orbital rim There should be no swelling, redness, or drainage from the puncta when it is pressed. Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.
A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion?
ANS: A shattered look to the light rays reflecting off the cornea A corneal abrasion causes irregular ridges in reflected light, which produce a shattered look to light rays. There should be no opacities in the cornea. The other responses are not correct.
A 52-year-old patient describes the presence of occasional "floaters" or "spots" moving in front of his eyes. The nurse should:
ANS: Know that floaters are usually not significant and are caused by condensed vitreous fibers. Floaters are a common sensation with myopia or after middle age owing to condensed vitreous fibers. Usually they are not significant, but acute onset of floaters may occur with retinal detachment.
The nurse is reviewing for a class in age-related changes in the eye. Which of these physiological changes is responsible for presbyopia?
ANS: Loss of lens elasticity The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:
ANS: Constriction of both pupils occurs in response to bright light. The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.
The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?
ANS: Convergence of the axes of the eyes The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.
During an ophthalmoscopic examination of the eye, the nurse notices areas of exudate that look like "cotton wool" or fluffy gray-white cumulus clouds. This finding indicates which possible problem?
ANS: Diabetes Soft exudates or "cotton wool" areas look like fluffy gray-white cumulus clouds, They occur with diabetes, hypertension, subacute bacterial endocarditis, lupus, and papilledema of any cause. These exudates are not found with hyperthyroidism, glaucoma, or hypotension.
The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?
ANS: The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.
During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply.
ANS: The patient experiences tunnel vision in late stages. Vision loss begins with peripheral vision. There are virtually no symptoms. Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.
The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?
ANS: Unequal pupillary constriction in response to light Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?
ANS: Use the Snellen chart positioned 20 feet away from the patient. The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.
In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would:
ANS: consider this a normal reflection of the ophthalmoscope light off the inner retina. The red glow filling the person's pupil is the red reflex, and it is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.
A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is
ANS: dacryocystitis. A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling. Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids. See Table 14-3.
During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:
ANS: hyphema. Hyphema is the term for blood in anterior chamber is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. See Table 14-7 for descriptions of the other terms.
An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:
ANS: increased intracranial pressure. Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.
The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:
ANS: test for color vision once between the ages of 4 and 8. Test only boys for color vision once between the ages of 4 and 8 years. It is not tested in females because it is rare in females. Testing is done with the Ishihara test, which is a series of polychromatic cards.
When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for:
ANS: the presence of shadows, which may indicate glaucoma. The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This is not the correct method for assessment for dacryocystitis, conjunctivitis, or cataracts.