A patient is admitted to the emergency department with complaints that indicate possible retinal detachment. Which nursing actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Contact the health care provider immediately.
2. Record what the patient has eaten today and the time of consumption.
3. Ask the patient to bear down to see if there are changes in vision.
4. Give the patient oral pain medications as ordered.
5. Keep the patient as quiet as possible.
1,2,5
Rationale 1: The nurse should immediately notify the health care provider of this assessment and the suspicion of retinal detachment. Time is a critical element in saving this patient's sight.
Rationale 2: This patient may have surgery today. A record of food and fluid consumption is important.
Rationale 3: The patient should not perform any action that would increase intraocular pressure.
Rationale 4: If retinal detachment is suspected, the patient should be kept NPO.
Rationale 5: The nurse should keep the patient as calm and still as possible, with no straining, heavy lifting, or bending over.
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