Health Assessment Chapter 11 - 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'."

A client recently diagnosed with Grave's diseases exhibits protruded eyeballs. Which eye care instruction should the nurse discuss with this client?

"Wear an eyepatch and use moisturizing eye drops"

When visual acuity is tested using the Snellen eye chart, which result suggests better distance vision?

30/20

You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what?

A left temporal hemianopsia

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 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 has performed the corneal light reflex test during a client's eye examination. During this test, the nurse appraised the client's eye alignment in which way?

By comparing the reflection of the light on the client's eye surface

Dilated and fixed pupils typically result from

CNS injury, circulatory collapse, or deep anesthesia

The nurse is preparing to assess a client's visual fields to evaluate her gross peripheral vision. Which test would the nurse perform?

Confrontation test

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

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 nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following?

Consensual response

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 - if it is bilateral, it suggests the presence of Grave's disease - other causes would be a tumor and inflammation in the orbit

The nurse is assessing a client whose electronic health record notes a diagnosis of esotropia. When examining this client, the nurse should expect what finding?

Eye turning inward

What is vital in maintaining vision and a healthy outlook for clients?

Health education

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 causes a loss of central vision. Risk factors for macular degeneration are age, smoking history, obesity, family history, and female gender

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following?

Narcotic use

When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following?

Optic disc - round to oval with sharp, well-defined borders

You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document?

Papilledema

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 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

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

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 denotes an age-related deficit in close vision.

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

Pupillary construction on near gaze; dilation on distant gaze

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

RA, and Systemic lupus erythematosus

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

TRUE

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 assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?

Unequal pupil size is termed anisocoria. Often it is a normal finding but it can indicate trauma to the parasympathetic nerve supply to the iris. The nurse should ask the client about previous trauma to the eye to determine whether this is a new finding or new onset.

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 nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate?

When testing distant visual acuity, the nurse should have the client remove the reading glasses, because they blur distant vision. The client would wear his or her glasses during the test if they were not reading glasses.

Stabismus refers to

a constant malalignment of the eyes

The meibomian glands secrete

an oily substance to lubrications the eyes

Nystagmus refers to

an oscillating or a shaking movement of the eye

Exotropia refers to

an outward turning of the eyes

Arteriole retinal vessels appear

bright red

Allergies are usually indicated by

burning or itching pain in the eye

Cataracts are characterized by

cloudiness of the eye lenses

Ishihara cards are used to assess

color discrimination

Venules retinal vessels appear

darker red and larger, with progressively narrowing as they move away from the optic disc

The Snellen chart is used to assess

distant vision

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

entropion

The cover test, corneal light reflex test, and eye position test would be used to evaluate

extraocular muscle function

Hyphema would suggest recent

eye trauma

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

Double vision (diplopia) may indicate

increased intracranial pressure due to injury or a tumor

Glaucoma is an increase in

intraocular pressure that places pressure on eye structures and affecting vision

The client is using the Jaeger chart is is used to assess

near vision

Vitamin A deficiency is a cause of

night blindness

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

position the client 20 ft away from the chart

Viral infection is usually indicated by

redness or swelling of the eye

The physiologic cup appears on the optic disc as

slightly depressed and a lighter color than the disc

The fovea is a

small area of the retina that provides acute vision

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 optic nerves from each eyeball cross at the

optic chiasma