(PrepU) Chapter 16: Assessing Eyes

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 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.

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 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. The Snellen chart tests distant visual acuity by seeing how far the client can read the letters standing 20 feet from the chart. The top number is how far the client is from the chart and the bottom number refers to the last line the client can read. A reading of 20/50 means the client sees at 20 feet what a person with normal vision can see at 50 feet. The minus number is the number of letters missed on the last line the client can distinguish.

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.

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 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.

A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should

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.

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.

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

Conjunctiva The conjunctiva is a thin mucous membrane that lines the inner eyelid (palpebral conjunctivae) and also covers the sclera (bulbar conjunctivae). The border between the cornea and the sclera is the limbus. The lacrimal apparatus protects and lubricates the cornea and the conjunctiva by producing and draining tears. The eyelid is a loose fold of skin that covers and protects the eye.

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?

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

entropion

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

The bony orbit and fat cushion of the eye serves as a

protector The eyeball is located in the eye orbit, a round, bony hollow formed by several different bones of the skull. In the orbit, a cushion of fat surrounds the eye. The bony orbit and fat cushion protect the eyeball.

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'." 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.

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.

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.

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?

Risk for Injury The only nursing diagnosis that can be confirmed with these data is Risk for Injury. The client is aware of the dangers of driving due to changes in his vision. There is not enough data to support the other diagnoses.

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 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 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 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.

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. 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.

The nurse tests the six cardinal directions to test extraocular movement of the eye.

True

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.