The Point Ch 16 Assessing the Eyes
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 The nurse shines a penlight about 12 inches from the face, directing towards the bridge of the nose
Which action by the nurse indicates the appropriate use of an ophthalmoscope?
employ the right eye to examine the clients right eye
Which data collected in a health history review of a client should the nurse document as rest factors for the development of cataracts?
-cigarette smoking -works in lawn maintenance -eats very few fruits or vegetables
Which vision acuity reading indicates blindness?
20/200
A white arc around the limbus of the clients eye is a condition common in older adults called...
Arcus seniles
A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask obtain more data about this condition?
Are the blind spots constant or intermittent? A scotoma is the presence of the blind spots can be constant or intermittent.
A nurse assess a client 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?
Ask the client about previous trauma to the eyes
Which technique by the nurse demonstrates proper use of the ophthalmoscope?
Asks the client to fix gaze upon an object and look straight ahead
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 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 eye. The nurse recognizes this membrane as which of the following?
Conjuctiva
A nurse examines a clients retina during the ophthalmic exam and notices light colored spots on the retinal background. The nurse should ask the client about a history of what disease?
Diabetes
An elderly client presents to the health acre clinic with reports of decreased tearing in both eyes. The nurse observes the presence of ectoprion. What is an appropriate action by the nurse?
Document the finding as a normal sign of aging.
A client is diagnosed with glaucoma. When performing the ophthalmic exam, what changes should the nurse anticipate finding?
Enlarged physiologic cup that occupies more than half of the disc's diameter
When performing the cover test, a nurse notices that the clients left eye turns outward. How should the nurse document this finding?
Exotropia
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 middle aged client reports difficulty in reading. Which action by the is appropriate to test near visual acuity using a Jaegar reading card?
Instruct the client hold the the chart 14 inches from the eyes
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
A nurse assess the pupillary reaction to light for a client. Which precaution should the nurse follow to get an accurate result of conceal response?
Place an opaque card between the eyes of the client.
A client is admitted to the health care facility after sustaining a crushing injury to the right eye. The nurse should anticipate abnormal results for which vision test?
Six cardinal positions of gaze
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 examiners fingers 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 clients vision based on these results?
The larger the bottom number, the worse the visual acuity
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the clients eyes?
There is no reaction in the opposite pupil to light. When a light is shone into the eyes, both the pupils should contract.
The nurse is aware that which of the following is the function of the retina?
Transforms light rays into nerve impulses that are conducted to the brain
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 biggest space inside the eyeball contains a clear, gelatinous substance that light passes through
Vitreous Humor
A nurse carers for a client with atopic atrophy. The nurse recognizes that an ophthalmoscope examination of the ye should reveal which characteristic finding in the optic disc?
White colored
a nurse assess the distant vision acuity of a client using the Snellen chart. Which action should the nurse implement to perform the test with accuracy?
c-instruct the client to read without reading glasses
Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye exam?
c-touch the cornea with a wisp of cotton
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?
d-covered eye remains fixed straight -eye should not turn toward the object to establish focus-move upward or downward
Yellowish nodules on the medial side of the iris.
document the finding and proceed with the exam --its normal part of aging
A nurse assess the parallel alignment of a clients 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 reports the appearance of rings around lights. A nurse sho
glaucoma
