A client is diagnosed with a detached retina. Which is the ...

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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]

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.

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Excellent

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TYSM