Prep U Ch 16
What do retinal abnormalities include
Age-related macular degeneration
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
What test would the nurse perform to test for strabismus
Corneal light reflex
A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response
Deep-water fish
An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible
Increased intracranial pressure
What are the glands that are located on the tarsal plates and open on the lid margins
Meibomian glands
Which of the following is a symptom of the eye
Scotomas
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
What is the largest chamber of the eye
Vitreous
An adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in vision are often associated with
head trauma.
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent
macular degeneration
The optic nerves from each eyeball cross at the
optic chiasma
The bony orbit and fat cushion of the eye serves as a
protector
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. Shetells 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 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye
"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." Explanation: Conjunctivitis usually has an infectious etiology. Severe pain and vision damage are not common consequences.
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. Correct Explanation: Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology.
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 seniles, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision.
A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding
At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.
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.
The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what
Conjunctiva Correct Explanation: The conjunctiva is a thin mucous membrane that lines the inner eyelid (palpebral conjunctivae) and also covers the sclera (bulbar conjunctivae).
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 Explanation: The conjunctiva is a thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion.
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 Explanation: The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object.
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition
Correct response: Corrective lenses Explanation: Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night.
Which data collected in a health history interview of a client should the nurse document as risk factors for the development of cataracts
Correct response: • Cigarette smoking• Works in lawn maintenance• Eats very few fruits or vegetables
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.
Snellen E chart
Does not speak English
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 eyes turns outward it is called 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 When testing the corneal light reflex the nurse should shine the light toward the bridge of the nose.
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 Jaeger card 14 inches from the face & 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 Explanation: Hyphema is blood in the anterior chamber of the eye, usually caused by blunt trauma.
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye
Lacrimal apparatus
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 observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from
Myopia Explanation: Myopia is nearsightedness, meaning the client can see objects better up close.
Which of the following health problems necessitates the use of an ophthalmoscope during assessment
Papilledema A (Papilledema is characterized by swelling of the optic disc and bulging of the physiologic cup. It is necessary to use an ophthalmoscope to view these parts of the eye.
You note anterior bulging of the physiologic cup when performing a funduscopic examination of your patient's eyes. What would you document
Papilledema Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup.
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
Perform both the distant and near visual acuity tests
In order to effectively examine a patient's eyes with an ophthalmoscope, the The nurse should follow which procedure related to this piece of equipment
Place the ophthalmoscope in the right hand and look through the right eye.
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 Correct Explanation: Prebyopia denotes an age-related deficit in close vision.
When testing the near reaction, an expected finding includes which of the following
Pupillary constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far gaze.
What information should the nurse include when documenting the data associated with the physical examination of a patient's eyes
Shape and size of the pupil Appearance of the optic disc
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 patient's vision
Snellen E
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 Explanation: A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.
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.
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 client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes
The is no reaction in the opposite pupil to light When light is shone into the eyes both the pupil the receives direct light & the consensual (opposite ) pupil should constrict (smaller).
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.
What is the open space between the eyelids called
The palpebral fissure
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes
There is no reaction in the opposite pupil to light. Nonreaction of the opposite pupil to light Explanation: When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict.
What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client
Thick, purulent drainage is noted at inner corner of both eyes.
When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction
Up
The functional reflex that allows the eyes to focus on near objects is termed
accommodation.
A nurse inspects the eyes of a young child and notices the inward turning of the eyes. What test should the nurse perform to assess whether this finding is normal or abnormal
corneal light reflex In young children the pupils will often appear at the inner canthus due to the epicanthic fold. To test for corneal light reflex the nurse shines a penlight about 12 inches from the face, directing it towards the bridge of the nose.
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. Explanation: 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 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
esotropia.
The nurse is using the ophthalmoscope to examine the patient's eyes. The nurse holds the scope
in the right hand for the right eye, and in the left hand for the left eye
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
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.
Photoreceptors of the eye are located in the eye's
retina.
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 retin
transform light rays into nerve impulses that are conducted the brain Visual perception occur as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve & interpreted.
An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is
ultraviolet light exposure
Which vision acuity reading indicates blindness
20/200 Correct Explanation: The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision.
A client presents to the clinic reporting sudden visual loss in the left eye. What is the nurse's priority action
Notify the healthcare provider immediately. Sudden visual loss is an emergency and should be immediately reported to the healthcare provider.
How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking
Correct response: Use a Snellen E chart to perform the examination Explanation: 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. The six cardinal positions of gaze test eye muscle function & cranial nerve function.
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
Correct response: Exophthalmos Explanation: 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 tumour and inflammation in the orbit.
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
Risk for Injury
