The nurse is assessing a patient for neurological changes after a ...

[lracut11]

The nurse is assessing a patient for neurological changes after a head trauma. Which eye assessment should the nurse perform?
 
  Select all that apply.
  1. ptosis
  2. extraocular movements
  3. accommodation
  4. color of iris
  5. nystagmus

Question 2

The nurse is assessing a 75-year-old patient. Which patient report would require immediate action by the nurse?
 
  1. occasional presence of floaters
  2. greater need for additional light and reading glasses
  3. development of a white circle around the iris
  4. frequent falls from tripping over items on the floor

[welcom1000]

Answer to Question 1

Correct Answer: 1, 2, 3, 5
Ptosis refers to the drooping one eyelid and may indicate cranial nerve damage. Failure of one or both eyes to follow an object in any given direction may reflect cranial nerve dysfunction. Accommodation is the bending of light rays at the lens so that they focus on one point on the retina. Failure of accommodation, along with lack of pupil response to light, may signal a neurologic problem. Nystagmus is the involuntary rhythmic movement of the eyes that occurs with neurologic disorders and the use of some medications. The color of the iris does not reflect neurologic changes or deficits in cranial nerves.

Answer to Question 2

Correct Answer: 4
Excessive falling down can represent changes in vision sufficient to alter the field of vision. Depth perception changes and adaptation to changes in light represent a need for immediate additional assessments. Floaters are often seen by older patients and are related to debris or condensation when the vitreous body pulls away from the retina. Unless excessive, with vision suddenly greatly impaired, floaters are not an urgent problem. Near vision accommodation is gradually lost as elasticity declines and presbyopia (a common problem in older patients) develops with aging. This is not an urgent problem. White circles around the iris of the eye (arcus senilis) are caused by lipid deposits through a gradual process that does not require immediate care.

[lracut11]

Gracias!

[kswal303]

Excellent