Ch. 16 health assessment -Assessing eyes

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?"

The nurse is assessing cranial nerves III, IV, and VI. Which instructions should the nurse provide to the client in order to perform this assessment?

"Follow my finger with only your eyes."

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?

"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

A patient comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse?

"You will need to see the doctor to have your eye checked."

The nurse is teaching about the importance of regular eye examinations and should include information about which conditions that place clients at highest risk for blindness? (Select all that apply.)

-Diabetes -Hypertension

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 -The external eye

Which vision acuity reading indicates blindness?

20/200

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

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

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

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

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

Accommodation

The meibomian glands secrete

An oily substance to lubricate the eyes

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 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

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

Conjunctiva

A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?

Consensual Reaction

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

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

Corrective lenses.

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

What eye function is the nurse preparing to assess when the patient is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

Distant vision

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

A client is diagnosed with glaucoma. When performing the ophthalmic exam, what changes should the nurse anticipate finding?

Enlarged physiologic cup that occupies more than half of disc's diameter

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

What is a characteristic symptom of Graves hyperthyroidism?

Exopthalamus

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 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

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 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 Jaeger card 14 inches from the face & read with one eye at a time

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

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 patient is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the patient's medical record supports this diagnosis?

Increased intraocular pressure

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test the near visual acuity using a Jaeger reading card?

Instruct the client hold the chart 14 inches from the eyes

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?

Instruct the client to hold the chart 14 inches from the eyes

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

Lacrimal apparatus

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

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?

Medially toward the nose

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

Muscular Degeneration

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 nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

Position the client 609.6cm (20ft) away from the chart

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 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.

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

Pupillary constriction on near gaze; dilation on distant gaze

Photoreceptors of the eye are located in the eye's

Retina

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states 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

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

Which of the following is a symptom of the eye?

Scotomas

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 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

What systemic diseases may cause nodular episcleritis? (Mark all that apply.)

Systemic lupus erythematosus Rheumatoid arthritis

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time

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?

The larger the bottom number, the worse the visual acuity

Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination?

Touch the cornea with a wisp of cotton

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

True

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?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?

Up

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

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

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

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 safety equipment

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.

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

lacrimal obstruction.

A 52-year-old patient 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""

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

The middle layer of the eye is known as the

Choroid layer

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

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses?

Corneal Damage

Normal movement of the eye involves what cranial nerves? (Mark all that apply.)

Correct response: • II • III • IV • VI

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

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 assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are clients most likely at increased risk for if a first-degree relative has it?

Glaucoma

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?

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.

On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear 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 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

Requires the covering of each eye separately.

On visual confrontation testing, a client with a recent stroke cannot see the examiner's fingers on the entire right side with either eye covered. Which of the terms would describe this finding?

Right homonymous hemianopsia

What do retinal abnormalities include?

age-related macular degeneration

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and cleanse the cornea and the lens. change refractory of the lens. maintain the retinal vessels. transmit light rays.

cleanse the cornea and the lens. Aqueous humor helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure.

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

entropion