Author Question: A client is diagnosed with a detached retina. Which is the priority nursing diagnosis for this ... (Read 80 times)

skymedlock · **on:** Jun 25, 2018

A client is diagnosed with a detached retina. Which is the priority nursing diagnosis for this client?

A) Risk for Infection
B) Anxiety
C) Ineffective Coping
D) Impaired Tissue Integrity

Question 2

A client recovering from a penetrating eye injury tells the nurse that some shadows and movement can be seen with the eye.

Based on this data, which conclusion by the nurse is appropriate?
A) A deterioration in vision
B) The need for artificial tears
C) An improvement in vision
D) An indication of poor nutrition

Alyson.hiatt@yahoo.com · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: D

Immediate intervention is required for a client with a detached retina to ensure effective tissue perfusion and preserve vision. The priority nursing diagnosis for the client would be Impaired Tissue Integrity: Ocular. The client will most likely demonstrate anxiety with the loss of vision; however, retinal tissue integrity is the priority. Risk for infection and ineffective coping would not be priorities until the retina is reattached.

Answer to Question 2

Answer: C

For the client with an eye injury, the goal of care is to preserve vision and prevent further damage. The client recovering from a penetrating eye injury is able to see shadows and movement, which would indicate an improvement in vision. Deterioration in vision would be indicated by a lack of sight. The client's ability to see shadows and movement would not indicate poor nutrition or the need for artificial tears.