HA Chapter 13: Vision
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 the Jaeger card 14 inches from the face and read with one eye at a time
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
As the nurse inspects and palpates the eye, he or she assesses for the sensory and motor functions of four cranial nerves:
II, III, IV, VI optic, oculomotor, trochlear, abducens
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
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 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.
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.
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
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.
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
A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following?
conjunctiva
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 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
When testing the near reaction, an expected finding includes which of the following?
constriction on near gaze dilation on distant gaze
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 can lead to
corneal damage
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?
corrective lenses
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 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 Snellen E chart
The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents
entropion
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
estropia
What is a characteristic symptom of Graves hyperthyroidism?
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 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
A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for?
glaucoma
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?
left temporal hemianopsia
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
The nurse asks the client to perform the action pictured. What is the nurse assessing?
near vision
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?
no reaction in opposite pupil to light
The optic nerves from each eyeball cross at the
optic chiasma
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
Photoreceptors of the eye are located in the eye's
retina
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 action by the nurse demonstrates correct assessment of the corneal reflex:
touch cornea with a wisp of cotton
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?"
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'."
A nurse performs the test to assess for proper alignment of the eyes. When uncovering the previously covered eye, the nurse observes which ABNORMAL response?
1. Eyes moving to any side to reestablish focus (muscle weakness) 2. Eyes turning toward the object to reestablish focus 3. Eyes moving upward or downward
How to test vision acuity using SNELLEN CHART:
20 feet away don't lean forward or backward cover eye with an opaque card
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.
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
A nurse performs the test to assess for proper alignment of the eyes. When uncovering the previously covered eye, the nurse observes which NORMAL response?
covered eye remains fixed and straight ahead
Glaucoma
damage to the optic nerve when fluid builds up in anterior part of eye
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
A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response?
deep-water fish
Snellen chart is used to test
distant visual acuity
A nurse assesses the distant vision acuity of a client using the Snellen chart. Which action should the nurse implement to perform the test with accuracy?
instruct patient to read without reading glasses
A nurse assesses the distant vision acuity of a client using the SNELLEN CHART. Which action should the nurse implement to perform the test with accuracy?
instruct patient to read without reading glasses.
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.
