HA - Unit 2 - Chapter 16: Assessing Eyes

A nurse is examining the eyes of a 7-year-old boy. The boy asks the nurse, "What's inside my eyeball?" The nurse explains that the biggest space inside the eyeball contains a clear, gelatinous substance that light passes through. Which of the following is the technical name for this gelatinous substance? Aqueous humor Vitreous humor Lacrimal humor Meibomian humor

Vitreous humor Vitreous humor is the clear and gelatinous substance that fills the vitreous chamber, the largest chamber of the eye, which is located in the area behind the lens to the retina. Aqueous humor is a clear liquid substance produced by the ciliary body that fills the anterior and posterior chambers of the eye. It helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure. Lacrimal and meibomian refer to glands that produce tears and a lubricating substance of the eyelids, respectively, and not to types of humor.

A nurse cares for a client with optic atrophy. The nurse recognizes that an ophthalmoscopic examination of the eye should reveal which characteristic finding in the optic disc? Oval-shaped White-colored Blurred margins Orange-colored

White-colored A white-colored optic disc is the characteristic finding in optic atrophy due to a lack of disc vessels. This condition is caused by the death of optic nerve fibers. An oval-shaped, orange-colored optic disc that is 1.5 mm wide is normal. Blurred margins indicate papilledema, or swelling.

The nurse should make it a priority to assess which client for papilledema? a 45-year-old suspected of experiencing a subarachnoid hemorrhage an 80-year-old diagnosed with chronic open-angle glaucoma a 12-year-old demonstrating a deviated left eye a 56-year-old reporting double vision

a 45-year-old suspected of experiencing a subarachnoid hemorrhage Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup. Increased intracranial pressure is transmitted to the optic nerve, causing edema of the optic nerve. Papilledema often signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions. An enlarged physiological cup suggests chronic open-angle glaucoma. If cranial nerve IV is paralyzed, the left eye will deviate from its normal position in that direction of gaze, and the eyes will no longer appear conjugate, or parallel. Diplopia in adults may arise from a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of cranial nerve (CN) III or VI, or vertical diplopia from palsy of CN III or IV.

An adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. The nurse should assess the client for recent exposure to irritants. increased intracranial pressure. excessive tearing. a foreign body in the eye.

a foreign body in the eye. Throbbing, stabbing, or deep, aching pain suggests a foreign body in the eye or changes within the eye.

The functional reflex that allows the eyes to focus on near objects is termed pupillary reflex. accommodation. refraction. indirect reflex.

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.

A client is concerned because the sclera of the right eye has been pink in color for several days and tearing. What should the nurse suspect is occurring with this client? hyphema anisocoria conjunctivitis exophthalmos

conjunctivitis Pink-colored sclera with tearing is associated with conjunctivitis which can be caused by allergies, or bacterial or viral infections. Hyphema is blood in the anterior chamber of the eye which is usually caused by blunt trauma. Anisocoria is a term used to describe pupils of unequal size. Exophthalmos is protrusion of the eye ball usually caused by a problem with the thyroid gland.

A nurse is performing a focused visual assessment on a client. The nurse assesses the pupillary response with a pen light. Both of the client's pupils immediately constrict when the light is shone into the right pupil. How should the nurse document this finding? consensual reflexes observed negative for nystagmus equal accommodation positive corneal reflex

consensual reflexes observed When exposed either directly or indirectly to light, pupils will constrict; the term consensual means that constriction occurs in both eyes when light is only shown into one eye. Oscillating or shaking of an eye is referred to as nystagmus. Accommodation is tested by having the client focus their vision on something distant and then a near object, which causes the pupils to constrict. A wisp of cotton is used to test corneal reflex, which stimulates a blink in both eyes when the cotton touches the eye.

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's eyelid reflexes. refractory mechanism. lacrimal reflexes. corneal reflexes.

corneal reflexes. Contact with a wisp of cotton stimulates a blink in both eyes known as the corneal reflex. This reflex is supported by the trigeminal nerve, which carries the afferent sensation into the brain, and the facial nerve, which carries the efferent message that stimulates the blink.

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 congenital cataracts. decreased accommodation. muscle weakness. constant 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 accommodation.

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. strabismus. phoria. exotropia.

esotropia. Esotropia is an inward turn of the eye.

A 48-year-old client reports a recent loss of peripheral vision and eye pain. Based on these findings, the nurse determines these signs and symptoms may be the result of which of the following eye disorders? macular degeneration presbyopia glaucoma cataracts

glaucoma Acute angle closure glaucoma is the only eye disorder that causes pain. The pain is the result of increased ocular pressure (greater than 22 mm Hg). Acute angle closure glaucoma is an emergency; if not treated promptly, the client could lose their vision. Macular degeneration causes a loss of central vision. 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. Opacities of the lens are seen with cataracts, causing hazy vision.

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. increased intracranial pressure. bacterial infection. migraine headaches.

glaucoma. A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.

An adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in vision are often associated with diabetes. the aging process. hypertension. head trauma.

head trauma. Sudden changes in vision are associated with acute problems such as head trauma or increased intracranial pressure.

The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope in the right hand for the right eye and in the left hand for the left eye in the left hand for the right eye and in the right hand for the left eye in the right hand for both eyes in the left hand for both eyes

in the right hand for the right eye and in the left hand for the left eye

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 viral infection. double vision. allergic reactions. lacrimal obstruction.

lacrimal obstruction 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.

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 viral infection. double vision. allergic reactions. lacrimal obstruction.

lacrimal obstruction. 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.

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? cataracts glaucoma detached retina macular degeneration

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.

The optic nerves from each eyeball cross at the optic chiasma. vitreous humor. optic disc. visual cortex.

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. ask the client to remove his glasses. ask the client to read each line with both eyes open. instruct the client to begin reading from the bottom of the chart.

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.

A client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his right eye. The nurse should examine the area of head trauma. refer the client to an ophthalmologist. assess the client for double vision. ask the client if he sees "halos."

refer the client to an ophthalmologist. Consistent blind spots may indicate retinal detachment. Any report of a blind spot requires immediate attention and referral to a physician.

A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should document the results in the client's record. ask the client to read a handheld vision chart. ask the client to return in 2 weeks for another examination. refer the client to an optometrist.

refer the client to an optometrist. Myopia (impaired far vision) is present when the second number in the test result is larger than the first (20/40). The higher the second number, the poorer the vision.

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 assesses the muscle strength of the eye. assesses the functioning of the cranial nerves innervating the eye muscles. requires the covering of each eye separately. requires the client to focus on an object.

requires the covering of each eye separately. Perform the positions test, which assesses eye muscle strength and cranial nerve function. Instruct the client to focus on an object you are holding (approximately 12 inches from the client's face). Move the object through the six cardinal positions of gaze in a clockwise direction, and observe the client's eye movements.

Photoreceptors of the eye are located in the eye's ciliary body. lens. retina. pupil.

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

A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with retinal deterioration. head trauma. migraine headaches. vitamin A deficiency.

vitamin A deficiency. Night blindness is associated with optic atrophy, glaucoma, and vitamin A deficiency.

The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead? white red black yellow

white

Which question should the nurse ask when assessing a client for a possible detached retina? "Is your vision loss located in the center of your view of vision?" "Are you seeing flashing lights?" "Can you see objects on the outer edges of your field of vision?" "Is the vision in both of your eyes affected?"

"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.

Which vision acuity reading indicates blindness? 20/20 20/200 20/40 20/100

20/200 The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision. This means that the client being tested can distinguish what a person with normal vision can distinguish from 20 feet away. The top or first number is always 20, indicating the distance from the client to the chart. The bottom or second number refers to the last full line the client could read. The higher the second number, the poorer the vision. 20/40 and 20/100 also denote poor vision.

The nurse asks the client to perform the action pictured. What is the nurse assessing? Near vision Distance vision Intraocular pressure Color discrimination

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.

You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document? Positive axoplasmic sign Arteriovenous crossings Papilledema Hyperopia

Papilledema Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup.

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? Allen Snellen E Ishihara PERRLA

Snellen E The Snellen E chart can be used for people who cannot read or speak English.

A client is being assessed for indications of a possible obstructed nasolacrimal duct in the right eye. Under what circumstances should the nurse avoid compressing the lacrimal sac? Mucopurulent fluid is observed near the sac. There is excessive tearing in the right eye. The area around the sac is inflamed. The client reports experiencing floaters.

The area around the sac is inflamed. Pressing on the lower lid close to the medial canthus, just inside the rim of the bony orbit, compresses the lacrimal sac. The nurse should look for fluid regurgitated out of the puncta into the eye. The nurse should avoid this test if the area is inflamed and tender. Discharge of mucopurulent fluid from the puncta would support the diagnosis of an obstructed nasolacrimal duct. This test helps identify the cause of excessive tearing. Vitreous floaters may be seen as dark specks or strands between the fundus and the lens and are usually harmless; they would not interfere with assessing the lacrimal sac.

A student nurse asks the nursing instructor what blood vessels go to the eye. What would be the instructor's best answer? The optic vein The optic plexus The choroids The coronal vein

The choroids The choroids, which cover the recessed portion of the eye, are a network of blood vessels to the eye. The other options are distracters for this question.

The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents entropion ectropion ptosis exophthalmos

entropion

The nurse is planning to assess a client's near vision. Which technique should be used? shine a light on the bridge of the nose have the client read newspaper print held 14 inches from the eyes ask the client to move the eyes in the direction of a moving finger have the client stand 20 feet from a wall chart and read the letters after covering one eye

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.

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent macular degeneration open-angle glaucoma hemianopsia retinal detachment

macular degeneration Macular degeneration causes deterioration in the center of the retina, which leads to a gradual loss of central vision.

A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition? "Do you see floaters in front of your eyes?" "Are the blind spots constant or intermittent?" "How often do you have redness or tearing?" "Is night blindness a problem for you?"

"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.

Which statement by the nurse indicates the best understanding of the purpose of an eye-related health history? "The history allows the client to discuss their vision-related problems." "The nurse is able to visualize the client's eye with the benefit of an ophthalmoscope." "Broad, open-ended questions provide an opportunity to identify changes in the client's eyes." "The history encourages the client to reflect upon the state of client's eyes and vision."

"Broad, open-ended questions provide an opportunity to identify changes in the client's eyes." The purpose of the health history is to identify changes in the eyes. The nurse should begin the inquiry about the eyes with a broad, open-ended question such as: "Have you noticed any changes with your eyes?" This will allow the client to reflect on his or her vision and possibly recognize changes that have been gradual or subtle. The examination of the eye involves various assessment tools including the ophthalmoscope.

When a client reports a sudden but painless loss of vision in the right eye, which question should the nurse ask? "Have you ever been diagnosed with acute angle closure glaucoma?" "May I assess your eye for a possible corneal ulcer?" "Do you have a history of diabetes?" "Are you currently prescribed a steroid medication?"

"Do you have a history of diabetes?" If sudden visual loss is unilateral and painless, the nurse should consider vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion. Corneal ulcers and acute angle closure glaucoma are painful. Steroids can cause bilateral vision problems.

A client presents at the ophthalmologist's office after being referred by his family health care provider. The referral was made after a benign growth of the conjunctiva was found growing from the nasal side of the sclera to the limbus in the client's right eye. The client asks the nurse what this growth is. What is the best answer the nurse can give? "It is called hypertrophied conjunctiva." "It is called a pterygium." "It is called hypertrophied sclera." "It is called a pterygota."

"It is called a pterygium." An abnormal thickening of the conjunctiva from the limbus over the cornea is known as a pterygium. It is not known as hypertrophied conjunctiva or sclera. A pterygota is a class of insects.

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'." "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." "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 clients; 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." "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."

"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 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? 20/100 or less 20/200 or less 20/300 or less 20/400 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.

Which of the following assessment findings suggests a problem with the client's cranial nerves? A client states that he has recently begun seeing lights flashing in his field of vision. A client's extraocular movements are asymmetrical and she complains of diplopia. Fundoscopic examination reveals intraocular bleeding. A client's lens appears cloudy and she claims that her visual acuity has recently declined.

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.

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 Dilated veins Dilated arteries Brass wiring

AV nicking AV nicking results from high blood pressure and retinal hemorrhages in the form of dot-blot spots or flame hemorrhages. Dilated arterioles and venules may be seen, not dilated arteries and veins. Brass wiring is not an assessment finding.

What do retinal abnormalities include? Age-related macular degeneration Mydriasis Argyll Robertson syndrome Horner's syndrome

Age-related macular degeneration Age-related macular degeneration gradually causes loss of sharp central vision, needed for common daily tasks (e.g., 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.

Which of the following statements most accurately describes the maintenance of normal intraocular pressure? The lacrimal gland produces increased fluid when intraocular pressure is low and ceases production when pressure is high. The eye is a closed system whose contents of aqueous humor provide consistent internal pressure. The muscles of the ciliary body adjust the volume of the eye in response to increased or decreased pressure. Aqueous humor is continuously circulating through the eye with production equaling drainage.

Aqueous humor is continuously circulating through the eye with production equaling drainage. Aqueous humor, produced by the ciliary body, maintains intraocular pressure with production equaling drainage. It is not a closed system, and pressure is not adjusted through muscular control of eye volume.

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 Presbyopia Ectropion Myopia

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.

A nurse obtains a tonometer reading of 23 mm Hg on a client. What is the best response of the nurse? Document the finding as normal. Perform Snellen and Amsler tests on the client. Notify the health care provider of abnormal findings. Ask the client if they have experienced any pain or changes in vision.

Ask the client if they have experienced any pain or changes in vision. Tonometry is used to measure pressure within the eye. Normal eye pressures range from 10 mm to 21 mm of mercury (mm Hg). Eye pressures greater than 22 mm Hg increase one's risk for developing glaucoma. Signs and symptoms of glaucoma may include seeing halos around lights, loss of peripheral vision, and eye pain. An intraocular pressure of 23 mg is not a normal finding. Conducting the Snellen and Amsler tests are not the best responses by the nurse. The nurse needs to further assess the client before notifying the health care provider.

Which technique by the nurse demonstrates proper use of the ophthalmoscope? Uses right eye to examine the client's left eye Moves the scope around so the entire optic disk may be seen Approaches the client directly in front of the pupil Asks the client to fix the gaze upon an object and look straight ahead

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 diabetes educator is teaching a group of adults about the risks to vision that result from poorly controlled blood glucose levels. Which of the following pathophysiologic processes underlies the vision loss associated with diabetes mellitus? Diabetes contributes to increased intraocular pressure. Increased blood glucose levels cause osmotic changes in the aqueous humor. Blood vessels supplying the retina become weak and bleeding occurs. Diabetes is associated with recurrent corneal infections and consequent scarring.

Blood vessels supplying the retina become weak and bleeding occurs. In diabetic retinopathy, the vessels that feed the retina change and weaken. Eventually, they may become blocked and cause bleeding into the eye, which blocks vision. Diabetes does not directly cause an increase in pressure in the eye, osmotic changes in the aqueous humor or corneal infection.

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? Vitamin A deficiency Brain tumor Allergies Viral infection

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 is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following? Retina Sclera Cornea Conjunctiva

Conjunctiva The conjunctiva is a thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion. The palpebral conjunctiva lines the inside of the eyelids, and the bulbar conjunctiva covers most of the anterior eye, merging with the cornea at the limbus. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends them to the brain. The sclera is a dense, protective, white covering that physically supports the internal structures of the eye. The transparent cornea permits the entrance of light, which passes through the lens to the retina.

What test would the nurse perform to test for strabismus? Corneal light reflex Cover Allen Static

Corneal light reflex The corneal light reflex tests for strabismus. The cover test is for presence and amount of ocular deviation. A low light level with no direct light sources shining in the client's eyes is ideal. At rest, the extraocular muscles have very little activity. The assessment referred to as cardinal fields of gaze allows nurses to detect muscle defects that cause misalignment or uncoordinated eye movements. The static test can help the nurse detect gross differences in all four quadrants of the visual field. The Allen test tests a toddler's visual acuity.

A client asks a nurse if any foods promote eye health. What food would the nurse include as a response? Deep-water fish Low-fat meat Foods that contain lots of water Multigrain foods

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? Anemia Renal insufficiency Diabetes Retinal detachment

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.

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. Inspect the lenses every week for scratches or damage. Discard unused portions of contact solutions at the expiration date.

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. The nurse should instruct the client to not share the lenses, to keep the lenses clean, to wash hands before inserting or removing the lenses, and to discard unused portions of contact solutions at the expiration date. The lenses should be inspected for scratches or damage every year.

A nurse is inspecting the bulbar conjunctiva and sclera of a 67-year-old client, and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nursing action at this time? Document the finding and proceed with the examination Notify the physician of the finding Ask the client whether he has recently had trouble focusing when reading up close Examine the client's eye for presence of a foreign body

Document the finding and proceed with the examination Yellowish nodules on the bulbar conjunctiva are called pinguecula. These harmless nodules are common in older clients and appear first on the medial side of the iris and then on the lateral side. Therefore, the nurse should document this finding and proceed with the examination. There is no need to notify the physician of the finding. Having trouble focusing when reading up close is a sign of presbyopia, or impaired near vision, which is not associated with the finding of pinguecula. A foreign body or lesion may cause irritation, burning, pain and/or swelling of the upper eyelid but would not cause yellowish nodules.

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? Check the client for the presence of strabismus Immediately cover the eyes with warm saline soaks Ask the client about recent use of eye medications Document the finding as a normal sign of aging

Document the finding as a normal sign of aging Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client.

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 Being treated for glaucoma Has blue-green color blindness Recovering from cataract surgery

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.

Which action by the nurse indicates the appropriate use of an ophthalmoscope? Hold the ophthalmoscope with the middle finger on the lens wheel Stand in front of the client with the light directly on the pupil Ask the client to gaze at an object straight ahead and slightly towards the floor Employ the right eye to examine the client's right eye Approach the client from the front using the same eye as being examined

Employ the right eye to examine the client's right eye The nurse should employ the right eye to examine the client's right eye; this action of the nurse indicates the correct use of the ophthalmoscope. The nurse should hold the ophthalmoscope with the index finger on the lens wheel. The nurse should ask the client to gaze at an object straight ahead and slightly upward, not downward. The nurse should approach the client from the side, not from the front.

What is a characteristic symptom of Graves hyperthyroidism? Pterygium Exophthalmos Pinguecula Episcleritis

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

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? Ptosis Exophthalmos Ectropion Epicanthus

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 tumor and inflammation in the orbit.

The muscles of the ciliary body control the thickness of the lens, allowing the eye to: Focus on near or distant objects Coordinate extraocular movement Adjust the pressure inside the eye Control the amount of light entering the eye

Focus on near or distant objects The muscles of the ciliary body allow the lens to focus light appropriately for discerning far and near objects clearly. They do not control extraocular movements or intraocular pressure. The iris controls the amount of light entering 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 Directly on the eye being examined Pointed at a fixed object on the wall Shined on the forehead

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.

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 Sit the client in front of the examiner, extend one arm, and slowly move one finger upward Tell the client to remove glasses, if present, and read the Snellen card using both eyes Place the client 20 feet from the Snellen chart and record the smallest line the client can read

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 client has anisocoria on examination. Pathological causes of this include which of the following? Horner's syndrome Benign anisocoria Differing light intensities for each eye Eye prosthesis

Horner's syndrome Anisocoria can be associated with serious pathology. Remember to exclude benign causes before embarking on an intensive follow-up. Testing the near reaction in this case may help locate an Argyll-Robertson or tonic (Adie's) pupil.

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 Blepharitis Chalazion 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.

Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)? II (optic) III (oculomotor) IV (trochlear) VI (abducens)

III (oculomotor) Fibers traveling in the oculomotor nerve (CN III) and producing pupillary constriction are part of the parasympathetic nervous system. The iris is also supplied by sympathetic fibers. When these are stimulated, the pupil dilates, and the upper eyelid rises a little, as if from fear. The sympathetic pathway starts in the hypothalamus and passes down through the brainstem and cervical cord into the neck. From there, it follows the carotid artery or its branches into the orbit. A lesion anywhere along this pathway may impair sympathetic effects that dilate the pupil. CN II conveys visual information to the brain; CN IV and VI are involved in moving the eye in its cardinal directions.

What features would most likely be noted on fundoscopic examination of someone with glaucoma? Increased cup-to-disc ratio AV nicking Cotton wool spots Microaneurysms

Increased cup-to-disc ratio It is important to screen for glaucoma on fundoscopic examination. The cup and disc are among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension. Microaneurysms are seen in diabetes.

A client is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left eye noted in the client's medical record supports this diagnosis? Increased intraocular pressure Sluggish pupillary reaction Displaced optic nerve Opaque lens

Increased intraocular pressure Aqueous humor is produced by the ciliary body, circulates from the posterior chamber through the pupil into the anterior chamber, and drains out through the canal of Schlemm. This system controls the pressure within the eye. If there is an obstruction of the canal of Schlemm, aqueous humor will not drain, increasing pressure within the eye. An obstruction of the canal of Schlemm will not displace the optic nerve because the optic nerve is located within the posterior portion of the eye. An opaque lens is a cataract, which is not caused by an obstruction of the canal of Schlemm. Pupil reaction is a neurological function not affected by intraocular pressure.

A nurse assesses the distant vision acuity of a client using the Snellen chart. Which action should the nurse implement to perform the test with accuracy? Position the client 12 feet away from the Snellen chart Instruct the client to read without reading glasses Instruct the client to lean forward and read the chart Ask the client to cover one eye with the hand

Instruct the client to read without reading glasses The nurse should instruct the client to read without reading glasses to accurately test the distant vision acuity with a Snellen chart. Reading glasses blur the vision when reading in the distance, so they can interfere with the assessment. The nurse should position the client 20 feet, not 12 feet, away from the Snellen chart. The nurse should ensure that the client does not lean forward and read because it may be an unconscious attempt to see well. The client's eye should be covered with an opaque card. Covering the eye with the hand may encourage the client to peek through the fingers.

A nurse is testing a client's pupillary reaction to light, noting that the pupil constricts when shining light obliquely into it. The nurse understands that muscles in which of the following structures adjust to control the amount of light entering the eye through the aperture of the pupil? Lens Optic disc Iris Retina

Iris The iris is a circular disc of muscle containing pigments that determine eye color. The central aperture of the iris is called the pupil. Muscles in the iris adjust to control the pupils size, which controls the amount of light entering the eye. The lens is a biconvex, transparent, avascular, encapsulated structure located immediately posterior to the iris that refracts (bends) light rays onto the retina. The optic disc is a cream-colored, circular area located on the retina toward the medial or nasal side of the eye where the optic nerve enters the eyeball. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends it to the brain.

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Vitreous chamber Aqueous chamber Lacrimal apparatus Sinus

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 Laterally toward the ear Upward toward the forehead Downward toward the chin

Medially toward the nose 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.

The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from? Asthenopia Myopia Hyperopia Presbyopia

Myopia Myopia is nearsightedness, meaning the client can see objects better up close. Asthenopia is eye strain, and symptoms include fatigue, red eyes, eye pain, blurred vision, and headaches. Hyperopia is farsightedness. Presbyopia commonly occurs naturally due to the aging process; therefore it's rare to observe this condition in young adults.

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? Shine a bright light directly into the eye to be tested Observe the response in the eye focused with light Place an opaque card in between the eyes of the client Instruct the client to close the eye not focused with light

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.

In order to effectively examine a client's eyes with an ophthalmoscope, the nurse should follow which procedure related to this piece of equipment? Remove eyeglasses before looking into the ophthalmoscope. Place the ophthalmoscope in the right hand and look through the right eye . Place the ophthalmoscope in the left hand and look through the right eye. Close the eye that is not looking through the ophthalmoscope during the examination.

Place the ophthalmoscope in the right hand and look through the right eye. When using the ophthalmoscope, the nurse should hold the scope in the right hand and use the right eye. The nurse should wear glasses or contacts when using an ophthalmoscope for an examination. The nurse should not place the scope in the left hand and look through the right eye. The nurse should keep both eyes open during the examination.

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 Cataract formation Loss of convergence Macular degeneration

Presbyopia Presbyopia 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.

The nursing instructor is discussing the eye with the nursing students. What would the instructor cite as part of the lacrimal apparatus? (Select all that apply.) Punctum Lacrimal sac Lacrimal gland Limbus Nasolacrimal duct

Punctum Lacrimal sac Lacrimal gland Nasolacrimal duct 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 limbus is the border between the cornea and the sclera.

When testing the near reaction, an expected finding includes which of the following? Pupillary dilation on near gaze; dilation on distant gaze Pupillary dilation on near gaze; constriction on distant gaze Pupillary constriction on near gaze; dilation on distant gaze Pupillary constriction 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.

Which of the following is a symptom of the eye? Scotomas Tinnitus Dysphagia Rhinorrhea

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."

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? She obtains a 20% correct score at 100 feet. She can accurately name 20% of the letters at 20 feet. She can see at 20 feet what a normal person could see at 100 feet. She can see at 100 feet what a normal person could see at 20 feet.

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.

A client is admitted to the health care facility after sustaining a crushing injury to the right eye. The nurse should anticipate abnormal results for which vision test? Accommodation Six cardinal positions of gaze Pupillary reaction to light Position and alignment of the eyeballs

Six cardinal positions of gaze Six cardinal positions of gaze test eye muscle strength and cranial nerve function. With an injury to the right eye, the client may experience weakness of the eye muscles or a dysfunction of the cranial nerve that innervates the right eye. Accommodation tests the ability of the eyes to focus from far to near. Pupillary reaction to light tests the pupil reaction and not muscle function. Position of the eyeballs should not be affected by an injury.

Which area of the fundus is the central focal point for incoming images? The fovea The macula The optic disk The physiologic cup

The fovea The fovea is the area of the retina that responsible for central vision. It is surrounded by the macula, which is responsible for more peripheral vision. The optic disc and physiologic cup are where the optic nerve enters the eye.

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? Vision is worse in the left eye than the right eye. The larger the bottom number, the worse the visual acuity. Client is legally blind in the left eye. Glasses are needed by the client for near vision.

The larger the bottom number, the worse the visual acuity. OD = right eye, OS = left eye. Therefore, the client has worse vision in the right eye because the larger the number on the bottom, the worse the visual acuity. A client is considered legally blind when the vision in the better eye with corrective lens is 20/200 or less. Snellen test is to test for distant vision (far) not near vision.

A client is scheduled for removal of a cataract with implantation of a lens. On the diagram, where should the nurse identify the location of the lens for the client?

The lens sits directly behind the pupil and refracts and focuses light on to the retina.

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? Pupils dilate in response to a light shone in the eyes. Eyes do not converge to focus on a shining light. There is no reaction in the opposite pupil to light. Light reflection appears at different spots on both eyes.

There is no reaction in the opposite pupil to light. When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict. An abnormal response to this test is if either or both pupils do not constrict in response to light. Pupils do not dilate in response to light shone into them. Convergence of the eyes is called accommodation and occurs when focus of vision is moved from a far object to a close object. Light reflection appearing at different spots on both eyes is an abnormal result of the corneal light reflex test, not of the consensual pupillary reaction to light test.

A nurse assesses the vision of an older adult client with a long history of uncontrolled type 2 diabetes. The nurse determines the client's vision with corrective lenses is 20/200. How should the nurse interpret these findings? This is normal vision for a client over 65. The client will need a new pair of glasses. These findings indicate the client is legally blind. The client must have developed macular degeneration.

These findings indicate the client is legally blind. A client is considered legally blind when vision in the better eye with corrective lenses is 20/200 or less. In this case the client has to be only 20 feet away from an object to see it when others can see the same object from 200 feet. The Snellen chart is used to test distant visual acuity; the higher the second number the more impaired the vision. Even though vision does decrease as people age, 20/200 is not a normal finding. The client may need a new pair of glasses but this is not the best response. Because the client is an older adult and diabetic, they are at higher risk for macular degeneration, but this is not the best option. Macular degeneration causes a loss of central vision; it does not necessarily affect distant visual acuity.

What is the primary purpose of the health history in relation to the eyes? To identify a family history of ocular disease To identify if problems are unilateral or bilateral To test the acuity of central vision To identify changes

To identify changes The purpose of the health history is to identify changes in the eyes.

A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina? Refracts light rays onto the posterior surface of the eye Controls the amount of light entering the eye Transforms light rays into nerve impulses that are conducted to the brain Permits the entrance of light to the eye

Transforms light rays into nerve impulses that are conducted to the brain Visual perception occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted. The lens functions to refract (bend) light rays onto the retina. Muscles in the iris adjust to control the pupils size, which controls the amount of light entering the eye. The cornea permits the entrance of light, which passes through the lens to the retina.

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 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.

A comprehensive physical examination of the eye includes tests for which of the following? Select all that apply. Visual acuity Eye muscle function Internal ocular structures Rinne test The external eye

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.