A nurse is admitting a client who has suspected retinal detachment.

Which of the following questions should the nurse include when gathering a client history? (Select All that Apply.)

A. "Vision changes occur when the retina begins to breakdown and collect bits of debris": This statement does not accurately describe the changes that occur in the eye during retinal detachment. Vision changes in retinal detachment primarily occur due to the separation of the retina from its underlying tissue layers, rather than the breakdown and collection of debris within the retina.

B. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye": Retinal detachment occurs when the retina, which is the light-sensitive layer at the back of the eye, pulls away from its normal position along the inner wall of the eye. This separation disrupts the blood supply to the retina, leading to vision changes. The most common symptom of retinal detachment is the sudden appearance of floaters or flashes of light in the visual field, followed by a shadow or curtain effect as the detachment progresses. Therefore, this statement accurately describes the pathophysiological mechanism underlying vision changes in retinal detachment.

C. "Vision changes occur when the cloudy lens alters the passage of light through the eye": This statement describes changes associated with cataracts, not retinal detachment. Cataracts involve clouding of the lens inside the eye, which can lead to vision changes such as blurriness or decreased visual acuity. However, cataracts are distinct from retinal detachment, which involves the separation of the retina from the inner wall of the eye.

D. "Vision changes occur suddenly due to complete obstruction of aqueous humor outflow": This statement describes the pathophysiology of acute angle-closure glaucoma, not retinal detachment. Acute angle-closure glaucoma is characterized by sudden elevation of intraocular pressure due to complete obstruction of the outflow of aqueous humor, leading to rapid onset of symptoms such as severe eye pain, blurred vision, and halos around lights. Retinal detachment, on the other hand, is characterized by the separation of the retina from its normal position, resulting in distinct vision changes such as floaters, flashes of light, and visual field defects.

Answer: A. Ensuring that the client and their family are kept informed about the client's care

Rationale:

A. Ensuring that the client and their family are kept informed about the client's care:
This action is the priority because communication is vital in managing a client with multiple organ dysfunction syndrome (MODS). Keeping the client and their family informed can help them understand the seriousness of the condition, the plan of care, and potential outcomes. It also fosters trust and ensures that the family can make informed decisions regarding the client's care.

B. Being aware of the client's wishes regarding care:
While being aware of the client’s wishes is important, especially in critical conditions like MODS, the priority lies in ensuring ongoing communication about the client's current status and treatment. Understanding the client's wishes can guide care but should follow the immediate need for clear communication about the evolving situation.

C. Scheduling periods of rest for the client:
Rest is essential for recovery, particularly in clients with MODS, but scheduling rest periods is a part of implementing care rather than a primary action. It can be planned based on the client’s needs and condition but does not take precedence over ensuring that the family is informed.

D. Discussing the client's resting times with the family:
While involving the family in discussions about the client's care is beneficial, the immediate priority is to ensure they are fully informed about the overall condition and care plan. This discussion can occur after establishing a solid communication foundation regarding the client's status and care approach.