Chapter 14: Eyes
Terms in this set (41)
When examining the eye, the nurse notices that the patient's eyelid margins approximate completely.
The nurse recognizes that this assessment 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
Amount of aqueous produced and resistance to its outflow at the angle of the
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
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
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse
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
Shorten the distance between the patient and the chart until it is seen and record
A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the
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 s
consider this a normal finding.
The nurse is performing the diagnostic positions test. Normal findings would be which of these
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
The absence of drainage from the puncta when pressing against the inner orbital
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
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
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
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
the presence of shadows, which may indicate glaucoma.
In a patient who has anisocoria, the nurse would expect to observe:
pupils of unequal size.
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
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
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.
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
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?
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:
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.
During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years
ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are
characteristics of open-angle glaucoma?
Select all that apply.
The patient experiences tunnel vision in late stages.
Vision loss begins with peripheral vision.
There are virtually no symptoms.