Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 21: Nursing Assessment: Visual and Auditory Systems Answer Guidelines 1. This is a new finding, so you should perform a comprehensive assessment of the visual system. 2. This finding is consistent with a cataract, for which he is at risk due to his age and his diagnosis of diabetes mellitus. 3. Other risk factors include blunt or penetrating trauma, congenital factors such as maternal rubella, radiation or ultraviolet (UV) light exposure, drugs such as systemic corticosteroids or long-term topical corticosteroids, and ocular inflammation. 4. You should investigate his concern about trouble with his vision using the eight questions on topics outlined in Table 3-2: Location Quality Quantity Chronology Setting Aggravating or alleviating factors Associated manifestations Meaning of the symptom to the patient 5. This problem is clearly related to his visual system, and the comprehensive assessment outlined in Table 3-5 includes the following: Visual acuity Eyebrows Position and movement of eyelids (CN VII) Visual fields Extraocular movements (CN III, IV, VI) Cornea, sclera, conjunctiva Pupillary response (CN III) Red reflex 6. The best way to assess the clarity of the lens is to illuminate the eye from the side, or obliquely, to see if the light passes through (or across) the eyeball.

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.