A nurse is collecting data on a client who has a suspected detached retina. Which of the following should the nurse expect to find?

Choice A rationale While the lens and cornea may appear intact, an ophthalmoscopic exam of a client with a detached retina usually reveals a gray, opaque, or wrinkled appearance of the retina rather than a normal red reflex. The classic finding is the retina floating in the vitreous humor. Simply noting that the lens and cornea are intact is a non-specific finding and does not help in confirming a detachment. Detailed visualization of the posterior segment is required. Choice B rationale A client with a suspected detached retina is highly unlikely to have 20/20 visual acuity. Retinal detachment typically causes sudden, painless vision loss, often described as a curtain or shadow being pulled across the field of vision. The loss of contact between the sensory retina and the underlying pigment epithelium disrupts the neural signals to the brain. Therefore, impaired visual acuity or significant field deficits are the expected findings during a Snellen chart assessment. Choice C rationale In a detached retina, the edges are typically not smooth; instead, the nurse or ophthalmologist would see folds, tears, or a billowing effect where the retina has pulled away from the choroid. A smooth retinal edge would indicate a healthy, attached state. During a slit-lamp or indirect ophthalmoscopy exam, the clinical expectation is to see a displaced or elevated section of the retina, which is the hallmark of this medical emergency requiring surgical intervention. Choice D rationale Low intraocular pressure, such as a tonometer reading of 8 mm Hg, can be an expected finding in some cases of retinal detachment because fluid may leak through the retinal tear and out of the eye's posterior compartment. Normal intraocular pressure ranges from 10 to 21 mm Hg. While pressure can sometimes be normal, a lower-than-normal reading is a recognized clinical sign associated with the loss of retinal integrity. This finding supports the suspicion of a detachment.