Client Assessment Chapter 16: Eyes

Which question should the nurse ask when assessing a client for a possible detached retina?

"Are you seeing flashing lights?" Flashing lights suggest detachment of vitreous from retina. Slow central loss of vision is associated with macular degeneration. Peripheral loss in advanced open-angle glaucoma. Bilateral loss is often related to a chemical exposure.

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 The consensual reaction is when the pupil constricts in the opposite eye. Myopia is impaired far vision. Presbyopia is impaired near vision often seen in middle-aged and older patients. The direct reaction is when the pupil constricts in the same 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?

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.

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

accommodation. 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.

The nurse selects the chart shown here to assess a client's vision. Which client characteristic caused the nurse to select this chart? (Snellen E Chart)

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.

What is a characteristic symptom of Graves hyperthyroidism?

Exophthalmos In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.

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 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.

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 When testing the corneal light reflex, the nurse should shine the light toward the bridge of the nose. At the same time, the client is instructed to stare straight ahead. This facilitates a parallel image on the cornea. The eye response upon shining the light toward the eye may interfere with the assessment. The light should not be shined toward the forehead or on an object on the wall.

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 If a client does not speak English, is unable to read, or has a verbal communication problem, the Snellen E chart can be used to test the client's distant visual acuity. With this test, the client is asked to indicate by pointing which way the E is open on the chart. The six cardinal positions of gaze test eye muscle function and cranial nerve function. The Jaeger chart tests near visual acuity. Confrontation test is used to test visual fields for peripheral vision.

A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder?

Glaucoma Seeing rings around lights or halos is associated with narrow angle glaucoma. Diabetes produces change in the retina that can cause blurred vision. Cataracts are caused by clouding of the lens of the eyes. Hypertension affects the blood vessels of the eyes which may not cause any eye symptoms until the damage is severe.

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?

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.

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

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.

The nurse asks the client to perform the action pictured. What is the nurse assessing?

Near vision The client is using the Jaeger chart which is used to assess near vision. The Snellen chart is used to assess distant vision. The nurse would not assess intraocular pressure. Ishihara cards are used to assess color discrimination.

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?" 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.

Diplopia present with one eye covered can be caused by which of the following problems?

An irregularity in the cornea or lens Double vision in one eye alone points to a problem in "processing" the light rays of an incoming image. The other causes of diplopia result in a misalignment of the two eyes.

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

Pupillary constriction on near gaze; dilation on distant gaze During accommodation, pupils constrict with near gaze and dilate with far gaze.

Which of the following is a symptom of the eye?

Scotomas Scotomas are specks in the vision or areas where the client cannot see; therefore, this is a common and concerning symptom of the eye. Tinnitus is a ringing in the ears, dysphagia is difficulty swallowing, and rhinorrhea is a "runny nose."

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?

UP The correct technique to use when examining a patient's sclera and conjunctiva during an eye examination is to instruct the patient to look up. Having the patient look down, to the right, or to the left will not provide visualization of the sclera or conjunctiva during the examination.

The meibomian glands secrete

an oily substance to lubricate the eyes. Meibomian glands secrete an oily substance that lubricates the eyelid.

A 52-year-old patient with myopia calls the ophthalmology clinic very upset. Shetells 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'." 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 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?

20/200 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.

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. 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.

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 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 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 Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision.

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

Deep-water fish Foods that promote eye health include deep-water fish, fruits, and vegetables (e.g., carrots, spinach).

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?

Diabetes 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.

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 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 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 scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from 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 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 60-year-old client is concerned about developing cataracts in her eyes. She asks the nurse whether there is anything she can do to reduce her risk. Consumption of which of the following foods should the nurse recommend to the client for this purpose? Select all that apply.

Kale Eggs Oranges Lutein and zeaxanthin found in green leafy vegetables, eggs, and other foods reduce the risk of chronic eye diseases, including age-related macular degeneration and cataracts. Foods rich in these nutrients include kale, spinach, collards, turnip greens, corn, green peas, broccoli, romaine lettuce, green beans, eggs, and oranges. Consumption of red wine, turkey, and skim milk are not associated with a reduced risk for cataracts.

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 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 assesses the pupillary reaction to light for a client. Which precaution should the nurse follow to get an accurate result of consensual response?

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.

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.

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 denominator of an acuity score represents the line on the chart the client can read. In the example above, the client could read the larger letters corresponding with 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

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 A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.

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 abbreviations OD (right eye), OS (left eye), and OU (both eyes) are no longer used due to the potential for order errors. Instead, it is recommended to use "right eye," "left eye," or "both eyes."

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 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.

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 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

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.

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should

document the findings in the client's records. Validate the eye assessment data that you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.

The nurse observes an inward turning of the lower lid in a 77-year-old patient. 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. Esotropia is an inward turn of the eye.

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 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.

When the client reports a problem associated with the drainage of tears from the left eye, the nurse would focus the eye assessment on which eye structure?

lacrimal puncta The lacrimal gland lies mostly within the bony orbit, above and lateral to the eyeball. The tear fluid spreads across the eye and drains medially through two tiny holes called lacrimal puncta. The nurse can easily find a punctum atop the small elevation of the lower lid medially. The tears then pass into the lacrimal sac and into the nose through the nasolacrimal duct.

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

macular degeneration

The optic nerves from each eyeball cross at the

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.

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 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.

Photoreceptors of the eye are located in the eye's

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

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is

ultraviolet light exposure. Exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lenses of the eyes). Consistent use of sunglasses during exposure minimizes the client's risk.