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 C

Explanation

Choice A rationale

Monitoring and documenting findings without intervention ignores the critical need to manage intracranial pressure (ICP). Normal ICP is 7-15 mmHg, and 25 mmHg indicates a dangerous elevation requiring prompt corrective actions.

Choice B rationale

Suctioning can trigger a vagal response, further increasing ICP. Interventions should aim to decrease ICP, not exacerbate it. Careful suctioning is used when airway clearance is critical, not as a routine measure.

Choice C rationale

Raising the head of the bed to 35–45 degrees promotes venous drainage, reducing ICP. Alerting the physician ensures timely medical interventions. This is the primary recommended action for elevated ICP cases.

Choice D rationale

Lowering the head of the bed can worsen ICP by impairing venous outflow. Padded side rails are useful for seizure precautions but are irrelevant for managing elevated ICP in this situation.

A. By threading it through the femoral artery to the brain. B. To monitor intracranial pressure (ICP) and drain cerebral spinal fluid. C. After the patient has an electroencephalogram (EEG). D. Due to having minimal risk for infection.

Correct Answer is B

Explanation

Choice A rationale

Ventriculostomies are inserted directly through the skull into the ventricles, not via the femoral artery. This method provides direct access to cerebrospinal fluid for drainage and pressure monitoring.

Choice B rationale

Ventriculostomies are placed to monitor intracranial pressure and drain excess cerebrospinal fluid, managing conditions like hydrocephalus or elevated intracranial pressure following brain injury or surgery.

Choice C rationale

An EEG monitors electrical brain activity but is unrelated to ventriculostomy placement. Ventriculostomy focuses on fluid drainage and pressure management, not on electrical diagnostic procedures.

Choice D rationale

Ventriculostomies carry a significant risk of infection due to the invasive nature of the procedure. Proper aseptic technique is critical to minimizing, not eliminating, the risk of infection.

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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?

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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?