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 D

Explanation

Cushing's Triad is a set of three classic signs associated with increased intracranial pressure (ICP). These signs include hypertension, bradycardia, and irregular respirations. The presence of Cushing's Triad indicates severe brain injury or increased ICP, often leading to brainstem compression.

A. Tachycardia (Option A): Increased intracranial pressure can initially lead to tachycardia as the body attempts to compensate for the changes. However, as ICP continues to rise and brainstem compression occurs, the sympathetic response diminishes, resulting in bradycardia rather than tachycardia. Therefore, Cushing's Triad is not associated with preventing tachycardia.

B. Agonal breathing (Option B): Agonal breathing, characterized by gasping, labored breathing, or irregular breathing patterns, may occur as a result of brainstem dysfunction or damage. Cushing's Triad, indicative of increased ICP and impending brainstem herniation, does not prevent agonal breathing. In fact, irregular respirations are part of Cushing's Triad.

C. Chest pain (Option C): Chest pain may occur due to various cardiac or respiratory conditions and is not directly related to Cushing's Triad or increased intracranial pressure. Therefore, Cushing's Triad does not prevent chest pain.

D. Brainstem ischemia (Option D): Increased intracranial pressure can lead to brainstem compression, compromising blood flow to the brainstem and resulting in brainstem ischemia. Cushing's Triad, characterized by hypertension, bradycardia, and irregular respirations, is a nervous system response indicative of severe brain injury or increased ICP, which can lead to brainstem ischemia if left untreated. Therefore, Cushing's Triad is associated with brainstem ischemia rather than preventing it.

A. The client who is out of work and has been experiencing increased stress. B. The client who is recovering from a recent illness that caused vomiting and diarrhea. C. The client whose mother and uncle were diagnosed with this same condition. D. The client who had a myocardial infarction and required stent placement.

Correct Answer is D

Explanation

A. Stress can contribute to the development of atrial flutter, but it is not the highest risk factor compared to other options.

B. While electrolyte imbalances resulting from vomiting and diarrhea can predispose someone to arrhythmias, they are not as significant a risk factor for atrial flutter as other conditions.

C. A family history of atrial flutter may increase the likelihood of developing the condition, but it is not as significant a risk factor compared to other options.

D. A history of myocardial infarction and stent placement indicates underlying heart disease, which is a significant risk factor for developing atrial flutter. Cardiac events like myocardial infarction can lead to structural changes in the heart, such as scarring or remodeling, which can predispose individuals to atrial flutter. Therefore, this client is at the highest risk for developing atrial flutter among the options provided.

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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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