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final Terms in this set (40)When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding is expected. (The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding) During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: stimulated by cranial nerves III, IV, and VI. The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? The outer layer of the eye is very sensitive to touch. When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: elevates the eyelid and dilates the pupil. The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The nurse is testing a patient's visual accommodation, which refers to which action? Pupillary constriction when looking at a near object A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: constriction of both pupils occurs in response to bright light. A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." The nurse is reviewing for a class in age-related changes in the eye. Which of these physiological changes is responsible for presbyopia? Loss of lens elasticity Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? A dark retinal background A 52-year-old patient describes the presence of occasional "floaters" or "spots" moving in front of his eyes. The nurse should: know that floaters are usually not significant and are caused by condensed vitreous fibers.
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? Use the Snellen chart positioned 20 feet away from the patient. A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that the patient can read at 20 feet what a person with normal vision can read at 30 feet. A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? Shorten the distance between the patient and the chart until it is seen and record that distance. A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: has poor vision. When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: consider this a normal finding. The nurse is performing the diagnostic positions test. Normal findings would be which of these results? Parallel movement of both eyes During an assessment of the sclera of an African-American patient, the nurse would consider which of these an expected finding? The presence of small brown macules on the sclera A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? Observe the distance between the palpebral fissures. During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? The absence of drainage from the puncta when pressing against the inner orbital rim When assessing the pupillary light reflex, the nurse should use which technique? Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? Convergence of the axes of the eyes In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would: consider this a normal reflection of the ophthalmoscope light off the inner retina. The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? An optic disc that is a yellow-orange color A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would: consider this a normal finding. The nurse is assessing color vision of a male child. Which statement is correct? The nurse should test for color vision once between the ages of 4 and 8. The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has "lazy eye" and should: test for strabismus by performing the corneal light reflex test. The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? Unequal pupillary constriction in response to light The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: ask the patient if he or she has a history of heart failure. When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for: the presence of shadows, which may indicate glaucoma. In a patient who has anisocoria, the nurse would expect to observe: pupils of unequal size. Unequal pupil size is termed anisocoria. It exists normally in 5% of the population but may also be indicative of central nervous system disease A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: shadow or diminished vision in one quadrant or one half of the visual field. A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is dacryocystitis. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: she may have macular degeneration. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision. A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? A shattered look to the light rays reflecting off the cornea An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: increased intracranial pressure. During an ophthalmoscopic examination of the eye, the nurse notices areas of exudate that look like "cotton wool" or fluffy gray-white cumulus clouds. This finding indicates which possible problem? Diabetes During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of: hyphema. During an assessment the nurse notices that an elderly patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct? Assess for other signs of ectropion. 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Using a penlight, approach the patient from the side, and shine the penlight on one pupil. Observe the response of the lighted pupil, which is expected to quickly constrict. Repeat by shining the light on the other pupil.
How would a nurse assess a client for pupillary accommodation quizlet?How would a nurse assess a client for pupillary accommodation? Ask the client to focus on an object as it is brought closer to the nose. During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks.
Where should you shine the light when checking for the corneal light reflex quizlet?When testing the corneal light reflex, the nurse should shine the light toward the bridge of the nose. At the same time, the client is instructed to stare straight ahead. This facilitates a parallel image on the cornea. The eye response upon shining the light toward the eye may interfere with the assessment.
When assessing the client's pupil the normal reaction to light would be?A normal, healthy adult patient is expected to have a 4+ response, which indicates a brisk, large response. A 3+ grading indicates a moderate response, 2+ is a small, slowed response, 1+ represents a tiny/just visible response, and a 0 indicates unresponsive pupils.
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Which technique should the nurse use to assess the pupillary light reflex on client quizlet?
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