Health Assessment Chapter 16- Eyes
Exophthalmos
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? Ptosis Exophthalmos Ectropion Epicanthus
Lacrimal apparatus
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Vitreous chamber Aqueous chamber Lacrimal apparatus Sinus
20/200 or less
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? 20/100 or less 20/200 or less 20/300 or less 20/400 or less
conjunctivitis
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? hyphema anisocoria conjunctivitis exophthalmos
Conjuctiva
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? Retina Sclera Cornea Conjunctiva
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 of safety equipment Prevention of knee injuries Prevention of head injuries Use of correct foot gear
glaucoma.
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. increased intracranial pressure. bacterial infection. migraine headaches.
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.
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? cataracts glaucoma detached retina macular degeneration
III (oculomotor) IV (trochlear) VI (abducens)
Normal movement of the eye involves what cranial nerves? (Mark all that apply.) w II III IV V VI
retina
Photoreceptors of the eye are located in the eye's ciliary body. lens. retina. pupil.
b. have the client read newspaper print held 14 inches from the eyes
The nurse is planning to assess a client's near vision. Which technique should be used? a. shine a light on the bridge of the nose b. have the client read newspaper print held 14 inches from the eyes c. ask the client to move the eyes in the direction of a moving finger d. have the client stand 20 feet from a wall chart and read the letters after covering one eye
Exophthalmos
What is a characteristic symptom of Graves hyperthyroidism? Pterygium Exophthalmos Pinguecula Episcleritis
Extropia
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 Esotropia Strabismus Presbyopia
Vitreous
What is the largest chamber of the eye? Anterior Posterior Corneal Vitreous
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? Ineffective Individual Coping Disturbed Self Concept Self-Care Deficit Risk for Injury
Cardinal fields
A client tells the nurse that his eyes "are not working right." When the nurse asks what the client means, the client states, "It is like one eye is moving faster than the other." What test would be most appropriate for the nurse to use to assess this client? Cover Kinetic confrontation Cardinal fields Static confrontation
Iris
A nurse is testing a client's pupillary reaction to light, noting that the pupil constricts when shining light obliquely into it. The nurse understands that muscles in which of the following structures adjust to control the amount of light entering the eye through the aperture of the pupil? Lens Optic disc Iris Retina
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.
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 viral infection. lacrimal obstruction. double vision. allergic reactions.
d. The client and the examiner see the examiner's finger at the same time.
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? a. Client's consensual pupil constricts in response to indirect light. b. Eyes converge on an object as it is moved towards the nose. c. Direct light shown into the client's pupils results in constriction. d. The client and the examiner see the examiner's finger at the same time.
b. Perform both the distant and near visual acuity tests
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? a. Document the findings in the client's record b. Perform both the distant and near visual acuity tests c. Test the pupils for direct and consensual reaction to light d. Obtain a referral to the ophthalmologist for a complete eye exam
a. "Follow my finger with only your eyes."
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? a. "Follow my finger with only your eyes." b. "Rotate your head from side to side." c. "Shrug your shoulders as I push down on them." d. "Stand very still with your eyes closed."
Snellen E
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? Allen Snellen E Ishihara PERRLA
position the client 609.6 cm (20 ft) away from the chart.
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should a. position the client 609.6 cm (20 ft) away from the chart. b. ask the client to remove his glasses. c. ask the client to read each line with both eyes open. d. instruct the client to begin reading from the bottom of the chart.
entropion
The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents entropion ectropion ptosis exophthalmos
a 45-year-old suspected of experiencing a subarachnoid hemorrhage 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.
The nurse should make it a priority to assess which client for papilledema? an 80-year-old diagnosed with chronic open-angle glaucoma a 12-year-old demonstrating a deviated left eye a 45-year-old suspected of experiencing a subarachnoid hemorrhage a 56-year-old reporting double vision
To identify changes
What is the primary purpose of the health history in relation to the eyes? To identify a family history of ocular disease To identify if problems are unilateral or bilateral To test the acuity of central vision To identify changes
fundus is grayish brown with a purplish cast
When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals? slightly darker fovea is just discernible no light reflex is visible fundus is grayish brown with a purplish cast the lower field of the fundus has characteristic stripes
Medially toward the nose 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.
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? Medially toward the nose Laterally toward the ear Upward toward the forehead Downward toward the chin
c. Pupillary constriction on near gaze; dilation on distant gaze
When testing the near reaction, an expected finding includes which of the following? a. Pupillary dilation on near gaze; dilation on distant gaze b. Pupillary dilation on near gaze; constriction on distant gaze c. Pupillary constriction on near gaze; dilation on distant gaze d. Pupillary constriction on near gaze; constriction on distant gaze
a. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."
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? a. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." b. "Please come into the clinic right away so we can see what is wrong." c. "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." d. "I have an opening tomorrow at 2 in the afternoon. Can you come in then?"
d. refer the client to an optometrist.
A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should a. document the results in the client's record. b. ask the client to read a handheld vision chart. c. ask the client to return in 2 weeks for another examination. d. refer the client to an optometrist.
There is no reaction in the opposite pupil to light. When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict. An abnormal response to this test is if either or both pupils do not constrict in response to light.
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? Pupils dilate in response to a light shone in the eyes. Eyes do not converge to focus on a shining light. There is no reaction in the opposite pupil to light. Light reflection appears at different spots on both eyes.
c. She can see at 20 feet what a normal person could see at 100 feet.
A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? a. She obtains a 20% correct score at 100 feet. b. She can accurately name 20% of the letters at 20 feet. c. She can see at 20 feet what a normal person could see at 100 feet. d. She can see at 100 feet what a normal person could see at 20 feet.
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.
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? Vitamin A deficiency Brain tumor Allergies Viral infection
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.
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 Blepharitis Chalazion Iris nevus
an oily substance to lubricate the eyes.
The meibomian glands secrete an oily substance to lubricate the eyes. sweat. hormones. clear liquid tears.
document the findings in the client's records.
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 refer the client for further evaluation. examine the client for other signs of glaucoma. ask the client if there is a genetic history of blindness. document the findings in the client's records.
b. A client's extraocular movements are asymmetrical and she complains of diplopia.
Which of the following assessment findings suggests a problem with the client's cranial nerves? a. A client states that he has recently begun seeing lights flashing in his field of vision. b. A client's extraocular movements are asymmetrical and she complains of diplopia. c. Fundoscopic examination reveals intraocular bleeding. d. A client's lens appears cloudy and she claims that her visual acuity has recently declined.
d. Asks the client to fix the gaze upon an object and look straight ahead
Which technique by the nurse demonstrates proper use of the ophthalmoscope? a. Uses right eye to examine the client's left eye b. Moves the scope around so the entire optic disk may be seen c. Approaches the client directly in front of the pupil d. Asks the client to fix the gaze upon an object and look straight ahead
A left temporal hemianopsia
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 A homonymous hemianopsia A bitemporal hemianopsia A quadrantic defect
Covered eye remains fixed straight ahead. The covered eye should remain fixed straight ahead upon uncovering the eye. The eye moving to any side to reestablish focus indicates a deviation in alignment of the eyes and muscle weakness.
A nurse performs the cover test to assess for proper alignment of the eyes. When uncovering the previously covered eye, the nurse should observe for which response to indicate a normal finding? Covered eye remains fixed straight ahead Uncovered eye turns inward to establish focus Covered eye moves to establish focus Both eyes may turn either downward or upward
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 Cataract formation Loss of convergence Macular degeneration TAKE ANOTHER QUIZ
