Chapter 15 Adult Nursing
Lazy eye-=
amblyopia
Increases pigmintation around pregnant woman's eyes
cholasma
What does the top number in vision test indicate?What does the bottom number indicate?
feet patient away from the chart that the patient stoood, smallest line of letters they could read
A patient has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis
has a watery, mucoid discharge
Abnormal findings in light reflex test indicate
improper alignment
To exam lacrimal apparatus you ____ and ____
inspect and palpate
External eyes and external ocular structures are examined through what?
inspection and palpation
OS=
left eye
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent
macular degeneration
Tunneling in visual field=
macular degeneration
Interior ocular structures are inspected how?
opthalmoscope
Cover test is for ____ and amount of ____ ____
presence, ocular deviation
Abnormal thickening of conjuctava from the limbus over to cornea is known as _______
pterygium
OD=
right eye
Enlarged lacrimal apparatus is suspect of conditions such as _____ and _____
sacriod disease and Sjogren's syndrome
Corneal light reflex tests for _____
stabismus
Sharply defined bright red conjuctiva indicates
subconjuctival hemmorage
Patient hold Jaegar card how far from their face?
14 in
Explain static confrontation technique.
2-3ft away from patient, at eye level, left hand on left eye, close your right eye and tell patient to look at your open eye at all times, place different number of fingers in quaderants
Snellen's test is ____ feet from the chart, Allen's test is ____ feet from the chart
20, 15
Which vision acuity reading indicates blindness?
20/200
The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?
4mm
A 2-month-old infant is being examined at the pediatrician's office. The mother said she noticed the baby was not making tears in the left eye. What does this finding suggest?
A blocked lacrimal apparatus
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.
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 complains of excessive tearing of the eyes. Which assessment would the nurse do next?
Assess the nasolacrimal sac
A client performs the test for distant visual acuity & scores 20/50-2. 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 woman who is 5 months pregnant is being assessed at a routine visit. She has increased pigmentation around the eyes. This is known as what?
Chloasma
The nurse is preparing to assess a client's visual fields to evaluate her gross peripheral vision. Which test would the nurse perform?
Confrontation test
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
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 nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following?
Consensual response
Explain kinetic confrontation
Covering eyes and than moving fingers until patient says it's in their range of view
Why is it important to ask the patient if he or she is experiencing discharge or drainage from the eyes?
Discharge is associated with inflammation or infection
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
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?
Exotropia
Which of the following would a nurse expect to assess in a client with esotropia?
Eye turning inward
The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test?
Far, then near
Confrontation test is used to determine what?
Field of Vision
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 & read with one eye at a time
A patient is diagnosed with an obstruction of the canal of Schlemm. What will the nurse find when assessing this patient's eyes?
Increased intraocular pressure
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?
Instruct the client hold the chart 14 inches from the eyes
A patient being tested for near vision will use either a ____ test or read _____
Jaegar, newsprint
When using hand gel to clean the hands, what must the nurse do before touching a patient's eyes?
Make sure the hands are completely dry
During adolescence, what vision change is common?
Nearsightedness
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?
Nonreaction of the opposite pupil to light
When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following?
Optic discs
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
condition in which the lens of the eye loses its ability to focus, making it difficult to see objects up close
Presbyopia
When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze; dilation on distant gaze
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 of Injury
A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?
Subconjunctival hemorrhage
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 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
The nurse is preparing to examine a patient's eyes using an ophthalmoscope. Which technique should the nurse follow when using this equipment?
The nurse should place the ophthalmoscope in the right hand and look through the right eye.
A parent is very upset because she is told her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in children.
True
The nurse tests the six cardinal directions to test extraocular movement of the eye
True
