Retinal detachment

A nurse is caring for a client who reports sudden onset of flashing lights and a "curtain-like" shadow in the peripheral vision of the right eye. Which nursing action should be the priority?

1 Administer prescribed analgesic medication for eye pain
2 Apply bilateral eye patches to prevent eye movement
3 Position the client with head elevated and affected eye dependent ✓ 정답
4 Encourage the client to perform gentle eye exercises

해설

Positioning with head elevated and affected eye dependent is the priority to use gravity for reattachment and prevent further detachment. Immediate ophthalmologic consultation is essential.

같은 주제 다음 문제A nurse is assessing a client who reports sudden onset of visual disturbances. Which asses…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다69,000원

Understanding the Clinical Presentation
The client’s report of sudden onset flashing lights (photopsia) and a "curtain-like" shadow in the peripheral vision strongly suggests a retinal detachment. This is a medical emergency where the neurosensory retina separates from the underlying retinal pigment epithelium. The "curtain" or "shadow" represents the visual field defect corresponding to the area of detached retina, and the flashing lights are caused by mechanical stimulation of the retina by vitreous traction. As noted in the literature, floaters and related visual phenomena can be associated with retinal detachment, which if untreated can lead to permanent vision loss ^[2].

Priority Nursing Action Rationale
The priority nursing action is to position the client with the head elevated and the affected eye dependent. The physiological basis for this intervention is to utilize gravity to minimize further damage. By keeping the head elevated, intraocular pressure is reduced. Positioning the affected eye in a dependent position (e.g., if the detachment is in the right temporal periphery, positioning the client on their right side) allows the detached retina to fall back or settle against the choroid. This can help prevent the detachment from extending into the critical central vision area, the macula, thereby preserving visual acuity while the client awaits definitive surgical repair. This action directly addresses the risk of progression and permanent vision loss.

Analysis of Incorrect Options
- Administer prescribed analgesic medication for eye pain: While pain management is a nursing responsibility, retinal detachment is not typically a painful condition; the primary symptoms are visual. More importantly, administering an analgesic does not address the underlying pathophysiology or prevent progression of the detachment. Prioritizing comfort over a sight-saving positioning intervention would be incorrect.
- Apply bilateral eye patches to prevent eye movement: This action is not indicated and could be harmful. Patching both eyes can induce anxiety and disorientation. While minimizing rapid eye movements (saccades) is a goal, it is achieved more safely by advising the client to rest quietly. Bilateral patching does not provide the therapeutic gravitational benefit of specific positioning.
- Encourage the client to perform gentle eye exercises: This action is contraindicated. Any intentional eye movement will increase vitreous traction on the retina, potentially causing the tear to enlarge and the detachment to spread more rapidly. The priority is to minimize eye movement, not encourage it.

Clinical Safety and Urgency
This scenario mirrors the acute-onset eye problems seen in urgent eyecare settings, where timely and correct initial management is critical for safety and outcomes . The nurse’s role is to recognize the signs of a potential retinal detachment, initiate appropriate positioning to stabilize the condition, and prepare the client for an emergency ophthalmology consultation. Recognizing fundus abnormalities and understanding pre-dilation screening are part of comprehensive eye assessment, but the immediate, non-invasive positioning intervention takes precedence in the nursing plan of care .

References (research sources)

[2]
Patients with floaters: Answers from virtual assistants and large language models.Research articleWu G, Zhao W, Wong A, Lee DA. (2024) · DOI: 10.1177/20552076241229933

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A nurse is caring for a client who reports sudden onset of flashing lights and a "curtain-like" shadow in the peripheral vision of the right eye. Which nursing action should be the priority?

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