The nurse is performing a focused interview and eye assessment on a client
The nurse suspects that the client is experiencing problems associated with her vision based on which of the following pieces of data? Standard Text: Select all that apply. 1. The client is frowning and squinting while she is reading the Snellen chart.
2. The client exhibits a symmetrical pupillary light reflex response.
3. As the nurse checks for accommodation, the pupils remain dilated.
4. The client's near vision acuity is 14/14 bilaterally.
5. When the cornea is lightly touched in the right eye, both eyelids close.
1,3
Rationale 1: The client is frowning and squinting while she is reading the Snellen chart. If the client is frowning or squinting during the test of their ability to see distant objects, this is indicator that the client may be experiencing visual problems.
Rationale 2: The client exhibits a symmetrical pupillary light reflex response. Symmetrical pupillary responses are normal.
Rationale 3: As the nurse checks for accommodation, the pupils remain dilated. When checking accommodation, the eyes should converge and the pupils should constrict as the eyes focus on the penlight.
Rationale 4: The client's near vision acuity is 14/14 bilaterally. The normal result for near vision is 14/14 in each eye.
Rationale 5: When the cornea is lightly touched in the right eye, both eyelids close. When testing the corneal reflex, touch the eye gently and quickly with a wisp of cotton. The client will react by blinking both eyes. If one or both eyes fail to respond, there could be a problem.
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