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NURSINGTB.COM Chapter15:Eyes MULTIPLECHOICE 1.Whenexaminingtheeye,thenursenoticesthatthepatientseyelidmarginsapproximatecompletely.The nurserecognizesthatthisassessmentfinding: a.Isexpected. b.Mayindicateaproblemwithextraocularmuscles. c.Mayresultinproblemswithtearing. d.Indicatesincreasedintraocularpressure. ANS:A Thepalpebralfissureistheellipticalopenspacebetweentheeyelids,and,whenclosed,thelidmargins approximatecompletely,whichisanormalfinding. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 2.Duringocularexaminations,thenursekeepsinmindthatmovementoftheextraocularmusclesis: a.Decreasedintheolderadult. b.Impairedinapatientwithcataracts. c.Stimulatedbycranialnerves(CNs)IandII. d. StimulatedbyCNsIII,IV,andVI. ANS:D MovementoftheextraocularmusclesisstimulatedbythreeCNs:III,IV,andVI. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 3.Thenurseisperforminganexternaleyeexamination.Whichstatementregardingtheouterlayeroftheeye istrue? a.Theouterlayeroftheeyeisverysensitivetotouch. b. Theouterlayeroftheeyeisdarklypigmentedtopreventlightfromreflectinginternally. c.Thetrigeminalnerve(CNV)andthetrochlearnerve(CNIV)arestimulatedwhentheouter TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)194 NURSINGTB.COM PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK Open Resources for Nursing (Open RN) Now that we have reviewed the anatomy of the eyes and ears and their common disorders, let’s discuss common eye and ear assessments performed by nurses. Subjective AssessmentNurses collect subjective information from the patient and/or family caregivers using detailed questions and pay close attention to what the patient is reporting to guide the physical exam. Focused interview questions include inquiring about current symptoms, as well as any history of eye and ear conditions. See Table 8.3a for suggested interview questions related to the eyes and ears. Table 8.3a Suggested Interview Questions for Subjective Assessment of the Eyes and Ears
Life Span ConsiderationsPediatricWhen collecting subjective data from children, information is also obtained from parents and/or legal guardians. Children aged 2-24 months commonly experience ear infections. Vision impairments may become apparent in school-aged children when they have difficulty seeing the board from their seats. Additional subjective data may be obtained by asking these questions:
Older AdultsThe aging adult experiences a general slowing in nerve conduction. Vision, hearing, fine coordination, and balance may also become impaired. Older adults may experience presbyopia (decreased near vision), presbycusis (hearing loss), cataracts, macular degeneration, or glaucoma. They may also experience feelings of dizziness or feeling off-balance, which can result in falls. Read more about these conditions in the “Eye and Ear Basic Concepts” section earlier in this chapter. Tip: Educate all patients to have yearly eye examinations.Objective AssessmentA routine assessment of the eyes and ears by registered nurses in inpatient and outpatient settings typically includes external inspection of eyes and ears for signs of a medical condition, as well as screening for vision and hearing problems. A vision screening test, whispered voice hearing test, and assessment of pupillary response are often included in the physical exam based on the setting.[1]Additional assessments may be performed if the patient’s status warrants assessment of the cranial nerves. InspectionEyesBegin the assessment by inspecting the eyes. The sclera should be white and the conjunctiva should be pink. There should not be any drainage from the eyes. The patient should demonstrate behavioral cues indicating effective vision during the assessment. EarsInspect the ears. There should not be any drainage from the ears or evidence of cerumen impaction. The patient should demonstrate behavioral cues indicating effective hearing. Vision TestsSee more information about procedures for assessing vision in the “Eye and Ear Basic Concepts” section earlier in this chapter. Assess far vision using the Snellen eye chart. In outpatient settings, near vision may be assessed using a prepared card or a newspaper. Color vision may be assessed using a book containing Ishihara plates. Hearing TestNurses perform a basic hearing assessment during conversation with the patient. For example, the following patient cues during normal conversation can indicate hearing loss:
Whisper TestThe whispered voice test is an effective screening test used to detect hearing impairment if performed accurately. Complete the following steps to accurately perform this test:[3]
Pupillary Response, Extraocular Movement, and Cranial NervesWhen a patient is suspected of experiencing a neurological disease or injury, their pupils are assessed to ensure they are bilaterally equal, round, and responsive to light and accommodation (PERRLA). Extraocular movement and other cranial nerves may also be assessed that affect vision, hearing, and balance. For more information about how to assess PERRLA, extraocular eye movement, and other cranial nerves, go to the “Assessing Cranial Nerves” section in the “Neurological Assessment” chapter. See Table 8.3b for a comparison of expected versus unexpected findings when assessing the eyes and ears. Table 8.3b Expected Versus Unexpected Findings on Eyes or Ears Assessment
What findings are expected when assessing the iris and pupils of the eyes quizlet?What findings are expected when assessing the iris and pupils of the eyes? (Select all that apply.) -Both pupils constrict when a light is shone directly into one eye. -When testing accommodation, the pupils constrict when looking at the far object.
Which nose assessment findings would be considered abnormal?Normal findings might be documented as: “External nose is symmetrical with no discolouration, swelling or malformations. Nasal mucosa is pinkish red with no discharge/bleeding, swelling, malformations or foreign bodies.” Abnormal findings might be documented as: “Bright red nasal mucosa with purulent discharge.”
When examining the eyes which finding is indicative of cataracts?Diagnosis is best made with the pupil dilated. Well-developed cataracts appear as gray, white, or yellow-brown opacities in the lens. Examination of the red reflex through the dilated pupil with the ophthalmoscope. History includes location... read more held about 30 cm away usually discloses subtle opacities.
When performing the Ophthalmoscopic examination which finding of the optic discs is abnormal?Chalky whiteness or erythema of the disk is abnormal, as are indistinct disk margins. Any sharp change in elevation that renders one area out of focus with the ophthalmoscope, while the remainder of the retina remains in focus, is abnormal. Tortuous blood vessels usually bespeak pathology.
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