NURS 235: PrepU Chapter 16 Assessing the Eyes
The meibomian glands secrete
an oily substance to lubricate the eyes.
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
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 nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?
presbyopia
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
vitamin A deficiency.
A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment?
Blunt-force trauma often results in fracture of the orbit
The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?
Conjunctiva
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.
The optic nerves from each eyeball cross at the
optic chiasma
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?
20/200 or less
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
What do retinal abnormalities include?
Age-related macular degeneration
What is a characteristic symptom of Graves hyperthyroidism?
Exophthalmos
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
The nurse asks the client to perform the action pictured. What is the nurse assessing?
Near vision
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?
Snellen E
The functional reflex that allows the eyes to focus on near objects is termed
accommodation.
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 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 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.
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
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
head trauma
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.
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
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 performs the test for distant visual acuity and scores 20/50. 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 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
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
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
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?
Lacrimal apparatus
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?
Medially toward the nose
A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?
Presbyopia
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
When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze; dilation on distant gaze
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
