A nurse is planning care for a client who has worsening heart failure and is experiencing arrhythmias. Which of the following procedures should the nurse anticipate the client will require to regulate the rhythm?

A. "Vision changes occur when blood vessels leak fluid or blood under a portion of the retina": This statement describes a symptom of diabetic retinopathy, not open-angle glaucoma. In open-angle glaucoma, vision changes primarily result from increased intraocular pressure (IOP) due to impaired drainage of aqueous humor, not leakage of fluid or blood under the retina.

B. "Vision changes occur when the cloudy lens alters the passage of light through the eye": This statement describes a symptom of cataracts, not open-angle glaucoma. Cataracts involve clouding of the lens inside the eye, which affects the passage of light and leads to visual disturbances. Open-angle glaucoma, however, primarily affects the optic nerve and visual field due to increased intraocular pressure.

C. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye": This statement describes a symptom of retinal detachment, not open-angle glaucoma. Retinal detachment occurs when the retina detaches from the underlying layers of the eye, leading to vision changes and potentially vision loss. Open-angle glaucoma, on the other hand, primarily involves increased intraocular pressure and optic nerve damage.

D. "Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor": This statement is accurate. In open-angle glaucoma, vision changes occur due to increased intraocular pressure resulting from inadequate drainage of aqueous humor from the eye. This increased pressure can lead to damage of the optic nerve, resulting in peripheral vision loss and potentially blindness if left untreated.

A. Apply soft restraints to wrists and chest: Using restraints should only be considered as a last resort and should not be the first intervention for managing delirium. Restraints can exacerbate agitation and increase the risk of complications such as skin breakdown, musculoskeletal injury, and psychological distress. Therefore, applying restraints should not be the first action taken by the nurse.

B. Administer antipsychotic medications as prescribed: While antipsychotic medications may be used to manage symptoms of delirium in some cases, they should not be the first intervention for preventing client injury. Additionally, the use of antipsychotics in the ICU requires careful consideration due to potential adverse effects, such as sedation, hypotension, and prolongation of the QT interval. The decision to administer antipsychotic medications should be based on a comprehensive assessment and in consultation with the healthcare team.

C. Administer sedative medications as prescribed: Administering sedative medications may help calm an agitated client with delirium, but it should not be the first intervention for preventing client injury. Sedatives can further impair cognition and increase the risk of falls or other complications. Like antipsychotic medications, the use of sedatives should be based on a thorough assessment and in collaboration with the healthcare team, rather than being the initial action taken by the nurse.

D. Arrange for one-on-one observation for the client: Delirium in the intensive care unit (ICU) is a serious condition that can lead to confusion, disorientation, and an increased risk of injury to the client. The priority intervention for preventing client injury in this situation is to ensure constant monitoring and supervision. By arranging for one-on-one observation, the nurse can provide continuous monitoring of the client's behavior, assess for changes or signs of agitation, and intervene promptly to prevent falls or other injuries.