A nurse is performing preoperative assessments on a client who has a suspected detached retina. Which of the following should the nurse expect to find?

Tonometer intraocular pressure reading 8 mm Hg

Smooth retina edges identified on slit-lamp biomicroscope examination

Visual acuity of 20/20 using the Snellen eye chart

Lens and cornea appear intact during ophthalmoscope exam

Answer and Explanation

The Correct Answer is A

Tonometer intraocular pressure reading 8 mm Hg (Option A): A low intraocular pressure reading may indicate a detached retina. In a detached retina, the vitreous humor (gel-like substance in the eye) may leak into the space behind the retina, causing a decrease in intraocular pressure. However, it's important to note that intraocular pressure alone cannot definitively diagnose a detached retina, and further diagnostic tests, such as a dilated eye examination or retinal imaging, would be needed for confirmation.

Smooth retina edges identified on slit-lamp biomicroscope examination (Option B): In the case of a detached retina, the edges of the retina may appear irregular or undulating rather than smooth. This irregularity is often observed during a dilated eye examination rather than with a slit-lamp biomicroscope.

Visual acuity of 20/20 using the Snellen eye chart (Option C): Visual acuity may be affected in a detached retina, depending on the extent and location of the detachment. However, visual acuity alone cannot confirm a detached retina, as other factors such as refractive errors or cataracts can also affect visual acuity.

Lens and cornea appear intact during ophthalmoscope exam (Option D): While a detached retina may be visualized during an ophthalmoscope examination as a gray or whitish area behind the lens, the appearance of the lens and cornea being intact does not definitively diagnose a detached retina. A thorough dilated eye examination by an ophthalmologist is necessary for accurate diagnosis.

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Correct Answer is C

Explanation

A. Marfan's syndrome: Marfan's syndrome is a genetic disorder that affects the connective tissue in the body, predisposing individuals to various cardiovascular, skeletal, and ocular abnormalities. While Marfan's syndrome can present with certain cranial and intracranial manifestations, such as dural ectasia and intracranial aneurysms, it is not typically considered a direct risk factor for traumatic brain injury (TBI).

B. Hypercarbia: Hypercarbia refers to elevated levels of carbon dioxide (CO2) in the blood. While severe hypercarbia can lead to cerebral vasodilation and potentially exacerbate intracranial pressure in individuals with traumatic brain injury, it is not considered a direct risk factor for TBI itself.

C. Falls: Falls are a significant risk factor for traumatic brain injury (TBI), particularly in older adults and young children. Falls can occur due to various factors such as environmental hazards, impaired mobility, balance issues, or neurological conditions. Falls are a leading cause of TBI-related emergency department visits, hospitalizations, and fatalities.

D. Ventriculostomy: Ventriculostomy involves the placement of a catheter into the ventricular system of the brain to monitor intracranial pressure (ICP) or drain cerebrospinal fluid (CSF). While ventriculostomy is a procedure commonly performed in the management of severe traumatic brain injury to monitor and manage intracranial pressure, it is not a risk factor for TBI itself.

A. Dopamine B. Mannitol C. Nicardipine D. Phenytoin

Correct Answer is B

Explanation

A. Dopamine: Dopamine is a catecholamine often used to increase blood pressure and cardiac output in hypotensive states. It does not directly reduce intracranial pressure (ICP).

B. Mannitol: Mannitol is an osmotic diuretic commonly used to reduce intracranial pressure in clients with conditions such as subarachnoid hemorrhage, traumatic brain injury, or cerebral edema. It works by drawing fluid from brain tissue into the bloodstream, thereby reducing cerebral edema and ICP.

C. Nicardipine: Nicardipine is a calcium channel blocker used primarily to lower blood pressure in hypertensive emergencies. While it can indirectly impact intracranial pressure by reducing cerebral perfusion pressure, its primary mechanism of action is not targeted at reducing ICP.

D. Phenytoin: Phenytoin is an antiepileptic medication used to prevent and control seizures. While it may be indicated in clients who have experienced a subarachnoid hemorrhage to prevent seizures, it does not directly reduce intracranial pressure.

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A nurse is performing preoperative assessments on a client who has a suspected detached retina. Which of the following should the nurse expect to find?

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