The nurse is assessing the client's eyes. For each finding, click to specify whether the finding is normal or abnormal
Explanation & Rationale
Squinting during the visual acuity exam – Abnormal Squinting may indicate visual impairment such as refractive errors (myopia, hyperopia, or astigmatism) or difficulty focusing. A normal response is being able to read the chart without compensatory behaviors. Yellowing of the sclera – Abnormal Yellow sclera indicates jaundice, which can result from liver dysfunction, hemolysis, or bile duct obstruction. Sclera should normally be white. Reflection of light in the same spot on each eye – Normal This demonstrates proper alignment of the eyes and normal corneal light reflex, indicating no strabismus or ocular misalignment. Gaze fixed and steady – Normal A fixed and steady gaze shows normal extraocular muscle function and cranial nerve integrity. Abnormal findings would include nystagmus or uncontrolled eye movements. Clear conjunctiva – Normal Normal conjunctiva should be pink and moist without redness, swelling, or discharge. Abnormal findings include pallor (anemia), redness (infection or irritation), or jaundice.