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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Kaposi's Sarcoma is a vascular malignancy associated with AIDS caused by human herpesvirus 8. It presents as purple or brown skin lesions due to abnormal angiogenesis and endothelial proliferation in immunocompromised patients.

Choice B rationale

Candidiasis stomatitis typically manifests as white patches on the mucosa due to fungal overgrowth, not purple or brown spots. It is caused by Candida species, commonly seen in immunosuppressed individuals.

Choice C rationale

Cryptosporidiosis primarily leads to gastrointestinal symptoms such as watery diarrhea due to parasitic infection in AIDS patients, but does not cause purple or brown spots on the skin.

Choice D rationale

Meningitis causes inflammation of the meninges, leading to symptoms like headache, stiff neck, and fever. It does not present with purple or brown lesions on the skin.

A. Ensure bed alarm is on when leaving the patient's room. B. Clarify misinformation and reorient the patient when confused. C. Turn the patient every 2 hours to prevent skin breakdown. D. Vary the schedule to prevent memorization and boredom.

Correct Answer is A

Explanation

Choice A rationale

Cerebellar injury affects balance and coordination; ensuring bed alarm use prioritizes safety for patients who are at high fall risk due to impaired motor control and unsteady gait.

Choice B rationale

Reorientation addresses confusion, often linked to cognitive or frontal brain injuries, not cerebellar function, which mainly regulates coordination and balance rather than higher-order thinking.

Choice C rationale

Turning every 2 hours prevents skin breakdown but is more relevant to immobilized patients, not those with cerebellar injuries where mobility and fall prevention are the primary concerns.

Choice D rationale

Varying the schedule may stimulate engagement but does not directly address fall risks or coordination issues, which are critical for patients with cerebellar injuries.

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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?