Retinal detachment

A nurse is caring for a client who underwent emergency retinal detachment repair surgery 6 hours ago. Which assessment finding requires the most immediate nursing intervention?

1 Client reports mild eye pain rated 4/10
2 Small amount of clear drainage from the surgical site
3 Sudden onset of severe eye pain with nausea and vomiting ✓ 정답
4 Slight decrease in visual acuity compared to pre-operative baseline

해설

Sudden onset of severe eye pain with nausea and vomiting indicates increased intraocular pressure, a vision-threatening emergency requiring immediate intervention. Mild pain, clear drainage, and slight vision changes are expected post-operative findings manageable with standard care.

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 Scenario
The client is 6 hours post-operative from emergency retinal detachment repair. This is a critical period where the retina is beginning to reattach, and the intraocular pressure (IOP) is stabilizing. The nurse must differentiate between expected post-surgical findings and signs of a serious complication that threatens vision.

Analysis of Assessment Findings
The correct answer is the sudden onset of severe eye pain with nausea and vomiting. This cluster of symptoms is a classic presentation of acute angle-closure glaucoma, a devastating complication that can occur after intraocular surgery. The underlying mechanism is a rapid, severe elevation in IOP. The provided research highlights that postoperative elevation of intraocular pressure (IOP) is a known adverse effect following vitreoretinal procedures ^[1]. When IOP rises abruptly, it stimulates the oculocardiac reflex and triggers intense pain and vagal symptoms like nausea and vomiting. This constitutes an ocular emergency requiring immediate intervention to prevent irreversible optic nerve damage and permanent vision loss.

Why the Other Options Are Less Urgent
- Mild eye pain rated 4/10: This is an expected finding after surgery. The sclera and surrounding tissues have been manipulated, and some degree of discomfort is normal. It requires ongoing monitoring and pain management but is not the priority.
- Small amount of clear drainage: A small amount of serous, clear drainage can be a normal post-operative finding, representing weeping of the conjunctival tissue. The nurse should note its characteristics and monitor for changes, but it does not signal an immediate threat.
- Slight decrease in visual acuity: Immediately after retinal surgery, vision is often worse than the pre-operative baseline due to surgical trauma, inflammation, gas or oil tamponade, and blood in the vitreous. The research notes that thinning of the ganglion cell complex (GCC) and other structural changes can adversely affect visual outcomes ^[1]. A slight decrease is expected and will be monitored over the recovery period; it does not require the same instantaneous response as a pressure crisis.

Pathophysiology and Clinical Priority
The sudden, severe pain is the body's direct response to a rapid IOP spike, which mechanically stresses the ocular structures. The accompanying nausea and vomiting are a systemic vagal response to this intense pain. This combination is a red flag for acute glaucoma, which can be triggered post-operatively by inflammation, pupillary block, or the use of intraocular gas or oil. The research confirms that altered ocular biomechanics and inflammation are key factors in post-vitrectomy IOP changes ^[1]. The nurse's immediate priority is to recognize this as an emergency, notify the surgeon, and prepare for interventions to rapidly lower the IOP, such as administering prescribed hyperosmotic agents or topical medications.

References (research sources)

[1]
Changes in Intraocular Pressure and Ganglion Cell Complex Thickness After Pars Plana Vitrectomy in Patients With and Without Diabetes Mellitus.Research articleN S, Mohanty G, Das MK, Mohanty S, Singhal A, Choudhary M. (2026) · DOI: 10.7759/cureus.107201

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A nurse is caring for a client who underwent emergency retinal detachment repair surgery 6 hours ago. Which assessment finding requires the most immediate nursing intervention?

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