The nurse conducting an eye examination notes that the client exhibits rapid, involuntary, oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as:
1. Nystagmus
2. Photophobia
3. Unequal pupils
4. Impaired consensual response
1
Rationale: Nystagmus is characterized by the presence of involuntary, rapid eye movements and is an abnormal finding caused by disease or as a side effect of some medications. Unequal pupils are noted by direct examination of pupil size and reaction to light and are abnormal in most cases. Consensual response is a normal finding that is noted when one pupil contracts, even though the other pupil has a light shone into it. Photophobia is an abnormal sensation and is seen as a sensitivity of the client to light.
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