The nurse is performing an admission assessment on a client with a diagnosis of detached retina.
Which of the following is associated with this eye disorder?
Sharp, stabbing acute pain in the affected eye.
Total loss of vision.
A curtain-like loss of vision in the affected eye.
Yellow discoloration of the sclera.
The Correct Answer is C
Choice A rationale
Detached retina typically does not present with sharp, stabbing pain. Instead, patients experience painless symptoms like vision abnormalities due to separation of the retina from supporting tissue.
Choice B rationale
Total vision loss is rare with a detached retina unless extensive damage occurs. Partial visual disruption, such as curtain-like vision loss, is a hallmark symptom.
Choice C rationale
A curtain-like loss of vision arises from retinal detachment, disrupting visual fields as the retina separates from its vascular supply and neural connections.
Choice D rationale
Yellow sclera discoloration is associated with jaundice due to bilirubin accumulation, unrelated to retinal detachment pathology, which affects visual symptoms and not scleral appearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering oxygen at 6 liters per minute via nasal cannula risks hypercapnia in a client with emphysema due to impaired CO2 elimination. Oxygen should be titrated to maintain safe saturation levels, usually 88–92%.
Choice B rationale
Ipratropium is a bronchodilator that safely alleviates airway constriction in emphysema without systemic cardiovascular effects, making it suitable for a client with coronary artery disease and chronic obstructive pulmonary conditions.
Choice C rationale
Propranolol is contraindicated in emphysema due to its beta-blocking effects, which may exacerbate bronchoconstriction and reduce respiratory function, posing a significant risk to the client’s health.
Choice D rationale
Organic herbal supplements lack evidence-based safety and efficacy, especially in complex medical conditions like coronary artery disease and emphysema. They can also interact adversely with prescribed medications.
Correct Answer is B
Explanation
Choice A rationale
Nitroprusside is a vasodilator for hypertensive crises but is contraindicated in elevated ICP because it increases cerebral blood volume and exacerbates intracranial pressure, worsening the patient's condition.
Choice B rationale
Hypertonic saline (3%) helps reduce ICP by drawing excess fluid from brain tissue into the bloodstream through osmosis, effectively lowering intracranial pressure while maintaining cerebral perfusion.
Choice C rationale
Furosemide is a loop diuretic that reduces fluid overload but does not specifically target ICP. It is less effective in managing the osmotic balance required for intracranial pressure reduction.
Choice D rationale
Norepinephrine is a vasopressor used to treat hypotension and improve perfusion but does not lower ICP and may increase cerebral vasoconstriction, exacerbating intracranial hypertension. .
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