When assessing a patient's consensual pupil response, the nurse ...

[CQXA]

When assessing a patient's consensual pupil response, the nurse should
 
  a. have the patient cover one eye while facing the nurse.
  b. observe for a light reflection in the center of both corneas.
  c. instruct the patient to follow a moving object using only the eyes.
  d. shine a light into one pupil and observe the response of both pupils.

Question 2

The nurse is performing an eye examination on a 76-year-old patient. The nurse should refer the patient for a more extensive assessment based on which finding?
 
  a. The patient's sclerae are light yellow.
  b. The patient reports persistent photophobia.
  c. The pupil recovers slowly after responding to a bright light.
  d. There is a whitish gray ring encircling the periphery of the iris.

[aburgess]

Answer to Question 1

ANS: D
The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye, then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements.

Answer to Question 2

ANS: B
Photophobia is not a normally occurring change with aging, and would require further assessment. The other assessment data are common gerontologic differences and would not be unusual in a 76-year-old patient.