Chapter 16- Assessing Eyes

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.

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

Which vision acuity reading indicates blindness?

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.

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 the contact lenses in place. The nurse should use the right eye to examine the right eye & the left hand 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 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 High-velocity injuries are typically penetrating. Blunt-force trauma often results in fracture of the orbit. Optic atrophy is atrophy of the optic nerve. Strabismus is the medical term for cross-eye.

A client presents at the clinic with a chief complaint of right ear pain. The nurse notes a rash in the right ear canal. What should the nurse know is a possible cause of these symptoms?

Chronic otitis media Unusually soft wax, debris from inflammation or rash in the ear canal, or discharge through a perforated eardrum may be secondary to acute or chronic otitis media.

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?

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

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 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.

What is a characteristic symptom of Graves hyperthyroidism?

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

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

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.

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

What features would most likely be noted on fundoscopic examination of someone with glaucoma?

Increased cup-to-disc ratio

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 Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor.

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

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

What are the glands that are located on the tarsal plates and open on the lid margins?

Meibomian glands

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

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.

OS vs OD

OS (oculus sinister) means the left eye OD (oculus dextrus) means the right eye.

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

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.

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 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.

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.

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 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 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.

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. The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger or a delay in seeing it indicates reduced peripheral vision. Client's consensual pupils constricting in response to indirect light as well as direct light shown into the client's pupils resulting in constriction are observed when testing the pupils for reaction to light. Eyes converging on an object as it is moved towards the nose is a normal result for accommodation.

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. 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.

What is the primary purpose of the health history in relation to the eyes?

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

The nursing instructor is discussing the difference between sensorineural and conductive hearing loss with his class. The discussion turns to evaluation for determining what kind of hearing loss a client has. What Weber test results would indicate the presence of a sensorineural loss?

The sound is better in the ear in which he has better hearing. A client with sensorineural hearing loss hears the sound better in the ear in which he has better hearing. The Weber test assesses bone conduction of sound and is used for assessing unilateral hearing loss. A tuning fork is used. A client with normal hearing hears the sound equally in both ears or describes the sound as centered in the middle of the head. A client whose hearing loss is conductive hears the sound better in the affected ear.

The meibomian glands secrete

an oily substance to lubricate the eyes.

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 SUBMIT ANSWER

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?

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.

What is the largest chamber of the eye?

Vitreous

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

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.

What do retinal abnormalities include?

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.

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 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

ask the client if he sees "halos."

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?

at bridge of 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 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 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.

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

bulbar 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 middle layer of the eye is known as the

choroid layer The middle layer contains both an anterior portion, which includes the iris and the ciliary body, and a posterior layer, which includes the choroid.

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.

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?

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.

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 consensual light response occurs when one eye is exposed to light and the pupil of the other eye constricts. Since the light was shined in the right eye, the left pupil constricted. The left eye was not exposed to direct light. There is not enough information to determine if the pupils are equal or reacting to accommodation.

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 accomodation 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.

A client asks a nurse if any foods promote eye health. What food would the nurse include as a response?

deep water meat 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?

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.

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 normal findings Inferior @ 70 degrees, superior @ 50 degrees, temporal @ 90 degrees, nasal @ 60 degrees

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.

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 With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision.

A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder?

glaucoma

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?

hold 14 inches away from face To test near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The Snellen chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arms length is an arbitrary length depending on the size of the client and is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client.

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 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.

When assessing the tympanic membrane, where would the nurse expect to visualize the malleus?

in the center The tympanic membrane adheres through its concave shape to the malleus near the center. The other options do not accurately describe the location of the malleus.

A 60-year-old client is concerned about developing cataracts in her eyes. She asks the nurse whether there is anything she can do to reduce her risk. Consumption of which of the following foods should the nurse recommend to the client for this purpose? Select all that apply.

kale, eggs, orange Lutein and zeaxanthin found in green leafy vegetables, eggs, and other foods reduce the risk of chronic eye diseases, including age-related macular degeneration and cataracts. Foods rich in these nutrients include kale, spinach, collards, turnip greens, corn, green peas, broccoli, romaine lettuce, green beans, eggs, and oranges. Consumption of red wine, turkey, and skim milk are not associated with a reduced risk for cataracts.

What structure in the inner ear senses the position and movements of the head and helps to maintain balance?

labrynth

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

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.

A client presents to the health care clinic with red, watery eyes and constant tearing. The nurse understands that which of the following is the organ that produces tears?

lacrimal gland

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 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.

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.

Straight movements of the eye are controlled by the

rectus The extraocular muscles are the six muscles attached to the outer surface of each eyeball. These muscles control six different directions of eye movement. Four rectus muscles are responsible for straight movement, and two oblique muscles are responsible for diagonal movement.

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 A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.

A 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should

tell the client that these often occur with aging. Spots or floaters are common among clients with myopia or in clients over age 40. In most cases, they are due to normal physiologic changes in the eye associated with aging and require no intervention.

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