The nurse is assessing extraocular eye movements (EOMs) in an older adult client and finds that the client is unable to sustain an upward gaze for longer than 2 seconds. What does the nurse do next?
a. Repeat the test while holding the client's head in a fixed position.
b. Perform a cover-uncover eye test.
c. Document the finding and continue as-sessing.
d. Assess for additional signs of impending brain attack.
C
In the older adult, decreased muscle tone impairs the ability to maintain an upward gaze and to sustain convergence. Therefore, this finding is normal for an older adult client. The nurse would not repeat the test or hold the client's head in a fixed position. The nurse would document the finding and continue to assess. This would not be a cause for concern, nor would it be a symptom of impending brain attack. The cover-uncover test is used for determining the degree of peri-pheral vision.
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