Author Question: The nurse is assessing a client's eyes during a comprehensive health assessment. Which assessment ... (Read 54 times)

genevieve1028

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The nurse is assessing a client's eyes during a comprehensive health assessment. Which assessment finding would require immediate intervention?
 
  1. Acute glaucoma.
  2. Blepharitis.
  3. Periorbital edema.
  4. Anisocoria.

Question 2

The nurse is assessing a client's visual fields by confrontation. Which actions by the nurse indicate appropriate practice? Select all that apply.
 
  1. The nurse asks the client to cover one of her eyes with a card.
  2. The nurse uses a penlight to assist with performing the test.
  3. The nurse asks the client to sit 20 feet away.
  4. The client tells the nurse when she first sees the object.
  5. The nurse asks the client to stand 4 feet away.



upturnedfurball

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Answer to Question 1

Correct Answer: 1
Acute glaucoma results from a sudden increase in intraocular pressure caused by a blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate interventions to prevent further eye damage. Blepharitis is when the eyelid becomes inflamed. The eye burns, itches, and tears but does not require an immediate intervention. Periorbital edema is when the eyelid becomes puffy and swollen. It can be related to crying, infection, or systemic problems. It does not require an immediate intervention. Anisocoria refers to unequal pupil size, which may be a normal finding or it may indicate that the client has a central nervous system disease.

Answer to Question 2

Correct Answer: 1, 2, 4

Confrontation to test visual fields is done by asking the client to cover one eye with a card while the nurse covers the eye opposite to the client. The nurse and client sit 2-3 feet away from each other, at eye level. An object such as a pen or penlight is advanced from the periphery to the midline. Both the client and the nurse should be able to see the object at the same time. The client should tell the nurse when she first sees the object in her peripheral vision.



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