The client's plan of care is created by the nurse using which guideline for nursing practice?

Choice A reason: Visual acuity measures the clarity of vision, typically tested using a Snellen chart to assess retinal and optic nerve function. Testing cardinal fields of vision evaluates eye muscle coordination, not visual sharpness. This assessment involves cranial nerves III, IV, and VI, not the retina’s ability to resolve fine details, making it irrelevant here.

Choice B reason: Extraocular movements are assessed by testing the cardinal fields of vision, evaluating the coordinated movement of eyes in six directions. This tests cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye muscles. Misalignment or uncoordinated movement may indicate neurological or muscular issues, making this the correct characteristic being assessed.

Choice C reason: Peripheral vision is tested using confrontation tests, assessing the visual field’s outer edges, mediated by retinal rod cells. Cardinal fields of vision testing focuses on eye muscle coordination, not the extent of the visual field. This assessment does not evaluate peripheral retinal function, making peripheral vision an incorrect choice for this procedure.

Choice D reason: Existence of cataracts is assessed via lens opacity examination, often using an ophthalmoscope. Cardinal fields of vision testing evaluates eye movement coordination, not lens clarity. Cataracts impair light transmission to the retina, but this test targets extraocular muscle function and cranial nerve integrity, making cataract assessment irrelevant to this procedure.

Choice A reason: Assessing blood pressure is important but does not directly confirm an irregular pulse. An irregular radial pulse may indicate arrhythmias like atrial fibrillation, affecting cardiac output. Blood pressure measurement assesses hemodynamic status but cannot verify pulse rhythm accuracy, as it relies on arterial pressure, not direct cardiac electrical activity, making it a secondary step.

Choice B reason: Checking the apical pulse, auscultated at the heart’s apex, directly assesses cardiac rhythm and rate, confirming an irregular radial pulse. Irregular rhythms, like atrial fibrillation, disrupt normal atrial-ventricular conduction, detectable via auscultation. This step ensures accurate assessment of cardiac electrical activity and stroke volume, critical for identifying arrhythmias and guiding further interventions.

Choice C reason: Obtaining the pulse in the other arm may detect peripheral inconsistencies but does not confirm cardiac rhythm. An irregular radial pulse likely reflects a cardiac arrhythmia, not a localized vascular issue. Apical pulse assessment directly evaluates heart activity, making it more relevant than bilateral radial checks for verifying rhythm disturbances and planning appropriate interventions.

Choice D reason: Notifying the healthcare provider is premature without confirming the irregular rhythm. An irregular pulse may indicate an arrhythmia, requiring validation via apical pulse to assess cardiac electrical activity. Immediate notification bypasses critical assessment steps, potentially leading to misdiagnosis or delayed care, as the nurse must first gather accurate data to inform the provider.