Health Assessment Prep U Chapter 16 Assessing Eyes

macular degeneration

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

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? Client's consensual pupil constricts in response to indirect light. Eyes converge on an object as it is moved towards the nose. Direct light shown into the client's pupils results in constriction. The client and the examiner see the examiner's finger at the same time.

retina.

Photoreceptors of the eye are located in the eye's ciliary body. lens. retina. pupil.

accommodation.

The functional reflex that allows the eyes to focus on near objects is termed pupillary reflex. accommodation. refraction. indirect reflex.

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

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).

What do retinal abnormalities include? Age-related macular degeneration Mydriasis Argyll Robertson syndrome Horner's syndrome

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

Consensual reaction

While the nurse examines a client'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? Myopia Presbyopia Direct reaction Consensual reaction

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

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? Dacryocystitis Chalazion Stye Xanthelasma

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

Corrective lenses

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? Surgery Daily use of eye drops Corrective lenses No night driving

At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? Client did not wear his glasses for this test and therefore it is not accurate. When 50 feet from the chart, the client can see better than a person standing at 20 feet. Client can read the 20/50 line correctly and two other letters on the line above. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

Cardinal fields The cardinal fields of gaze allow the nurse to detect muscle defects that cause misalignment or uncoordinated movement of the eyes.

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

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? Place the chart 20 feet away from the client on the wall Instruct the client to hold the chart away from the body at arm's length Instruct the client hold the chart 14 inches from the eyes Place the chart on a table 17 inches away from the client

Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time

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 Sit the client in front of the examiner, extend one arm, and slowly move one finger upward Tell the client to remove glasses, if present, and read the Snellen card using both eyes Place the client 20 feet from the Snellen chart and record the smallest line the client can read

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

check the client's blood pressure.

An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should ask about the client's diet. determine whether there is a history of glaucoma. check the client's blood pressure. ask the client if he has any known allergies.

glaucoma. A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from 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.

Penlight Ophthalmoscope Snellen chart

Equipment used for objective data collection involving the eyes includes which of the following? Select all that apply. Penlight Ophthalmoscope Snellen chart Occlusive covers Protective mask

Use a Snellen E chart to perform the examination If a client does not speak English, is unable to read, or has a verbal communication problem, the Snellen E chart can be used to test the client's distant visual acuity. With this test, the client is asked to indicate by pointing which way the E is open on the chart

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking? Move an object through the six cardinal positions of gaze Use a Snellen E chart to perform the examination Have the client read from a Jaeger reading card Perform the confrontation test

an oily substance to lubricate the eyes.

The meibomian glands secrete an oily substance to lubricate the eyes. sweat. hormones. clear liquid tears.

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 position the client 609.6 cm (20 ft) away from the chart. ask the client to remove his glasses. ask the client to read each line with both eyes open. instruct the client to begin reading from the bottom of the chart.

Distant vision

What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall? Near vision Distant vision Peripheral vision External eye structures

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

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.

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

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 client states that he has recently begun seeing lights flashing in his field of vision. A client's extraocular movements are asymmetrical and she complains of diplopia. Fundoscopic examination reveals intraocular bleeding. A client's lens appears cloudy and she claims that her visual acuity has recently declined.

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? Uses right eye to examine the client's left eye Moves the scope around so the entire optic disk may be seen Approaches the client directly in front of the pupil Asks the client to fix the gaze upon an object and look straight ahead

esotropia.

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. strabismus. phoria. exotropia.