Health Assessment; Eyes; PrepU

Which assessment suggests a problem with the client's cranial nerves?

A client's extra ocular movements are asymmetrical and she complains of diplopia.

Assessing visual fields on a client newly admitted for eye surgery. Client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. What does the client have?

A left temporal hemianopsia. Hemianopsia: blindness in one half of the visual field of one or both eyes

Nurse is assessing eyes of client with long-standing uncontrolled hypertension. What might the nurse visualize during an assessment with an ophthalmoscope?

AV nicking; results from high blood pressure and retinal hemorrhages in the form of dot-blot spots or flame hemorrhages.

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

Accommodation.

Client complains of double vision (diplopia), the client has not suffered ant recent head injuries. What underlying condition should the nurse most suspect in this client?

Brain tumor. Diplopia may indicated increased intracranial pressure due to injury or tumor.

The conjunctiva of the eye is divided into the palpebral portion and the

Bulbar portion

The middle layer of the eye is known as the

Choroid layer.

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

Conjunctiva The border between the cornea and sclera is the limbus. The lacrimal apparatus protects and lubricates the cornea and the conjunctiva by producing and draining tears.

Food that promotes eye health.

Deep-water fish, fruits and vegetables (carrots, spinach)

A nurse assess 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.

Client presents to ER after being hit in the head with a baseball bat, what condition should nurse asses for?

Hyphema; 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 Nevis is a rare condition affecting one eye.

What feature would most likely be noted on fundoscoptic examination of someone with glaucoma?

Increased cup-to-disc ratio.

A client is diagnosed with an obstruction of the canal of schlemm affecting the eye left eye. What assessment data concerning the left noted in the clien'ts medical record supports this diagnosis?

Increased intraocular pressure

A 60-YO client is worried about development of cataracts in her eyes. She asks the nurse whether there is anything she can do to reduce her risk. Consumption of what food should the nurse recommend?

Kale, Eggs and Oranges.

Client complains of feeling like he is losing "central vision." The nurse knows this symptom could represent

Macular degeneration.

When examining eye with ophthalmoscope, where should nurse look to visualize optic disc?

Medially, toward the nose.

You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document?

Papilledema. Increased intracranial pressure is transmitted to the optic nerve, causing edema of the optic nerve. Often signals serious disorders of the brain such as meningitis, subarachnoid hemorrhage, trauma and mass lesions.

Which of the following health problems necessitates the use of an ophthalmoscope during assessment?

Papilledema; swelling of the optic disc and bulging of the physiology cup.

Equipment used for objective data collection involving the eyes includes which of the following?

Penlight, ophthalmoscope, snellen chart and occlusive covers.

When testing near reason, what is an expected finding?

Pupillary constriction on near gaze; dilation on distant gaze.

Straight movements of the eye are controlled by

Rectus muscles

what part of the eye receives and transmits visual stimuli to the brain for processing?

Retina

Which of the following is a symptom of the eye?

Scotomas; Specks in the vision or areas where the client can't see.

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

There is no reaction in the opposite pupil to light.

Normal movement of the eye involves what cranial nerves?

2, 3, 4, 6.

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

Argus Senilis; no effect on vision.

A client has anisocoria on examination, pathological causes include?

Horner's syndrome. Disruption of nerve pathway from brain to face and eye which results in decreased pupil size and drooping eyelid.

The optic nerves from each eyeball cross at the

Optic Chiasma.

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?

The area around the sac is inflamed.

Nurse performs the confrontation test to assess the client's peripheral vision. Which test result should recognize as indication of normal peripheral vision?

The client and the examiner see the examiners finger at the same time.

Visual acuity.

The larger the bottom number, the worse the visual acuity.

A nurse is inspecting client's eyes to assess for possibility of detached retinas. The nurse is aware that which of the following is the function of the retina?

Transforms light rays into nerve impulses that are conducted to the brain.

A client recently diagnosed with Grave's diseases exhibits protruded eyeballs. Which eye care instruction should the nurse discuss with this client?

Wear an eyepatch and use moisturizing eye drops

Pinguecula

Yellowish nodules on the bulbar conjunctiva. These harmless nodules are common in older clients and appear first on the medial side of the iris and then on the lateral side.

The nurse should make it a priority to assess which client for papilledema?

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 nerves, causing edema of the optic never.

The client reports excessive tearing in his left eye. The nurse should access the client's eye for

lacrimal obstruction

Legally blind

severely impaired vision; having 20/200 acuity

The nurse should make it a priority to assess which client for papilledema?

A 45 YO suspected of experiencing a subarachnoid hemorrhage.

Client states "it is like one eye is moving faster than the other", what test would be appropriate for the nurse to use to assess this client?

Cardinal fields allow the nurse to detect muscle defects that cause misalignment or uncoordinated movement of the eye.

What information, acquired during an eye assessment and history, would the nurse document as lifestyle habits?

Has smoked for the last 12 years, uses protective eyewear when appropriate and uses sunglasses when outdoors.

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

Lacrimal Apparatus

A client is assigned a visual acuity of 20/100 in her left eye. Which is true?

She can see at 20 feet, what a normal person could see at 100 feet.

To examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?

Up

Nurse notes 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

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and

cleanse the cornea and the lens.

What is the open space between the eyelids called?

Palpebral tissue. Limbus is the border of the cornea and sclera.

Nurse assesses client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?

Ask the client about previous trauma to the eyes. Unequal pupil size is termed ANISOCORIA. It can indicated trauma to the parasympathetic nerve supply to the iris.

A nurse begins an eye examination on a client who comes 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, read from top to bottom. If the patient wears glasses they should be left on for the test.

A client is admitted after sustaining a crushing injury to the right eye. The nurse should anticipate abnormal results for which test?

Six cardinal positions of gaze; which test eye muscle strength and cranial nerve function. With an injury to the right eye, the client may experience weakness.

The tarsal plates of the upper eyelid contain

meibomian glands