A client you are assigned is experiencing arrhythmia. What sign is the client exhibiting?
Heart rate is less than expected reference range.
Irregular heart rate.
Respiratory rate is less than expected range.
Decrease in blood pressure that occurs upon standing, especially from a lying or sitting position.
The Correct Answer is B
Choice A reason: A heart rate below normal (e.g., <60 bpm) indicates bradycardia, not necessarily arrhythmia, which is characterized by irregular rhythm. Irregular heart rate defines arrhythmia. Assuming low rate risks misdiagnosis, potentially missing treatments like antiarrhythmics, critical for stabilizing rhythm and preventing complications in arrhythmic patients.
Choice B reason: Irregular heart rate is the hallmark of arrhythmia, reflecting disrupted electrical conduction (e.g., atrial fibrillation). This sign, detected via pulse or ECG, guides diagnosis and treatment like anticoagulants or cardioversion. Accurate identification ensures timely intervention, critical for preventing stroke or heart failure in patients with cardiac rhythm disturbances.
Choice C reason: Low respiratory rate is unrelated to arrhythmia, which affects heart rhythm, not breathing. Irregular heart rate is the key sign. Assuming respiratory rate misdirects focus, risking neglect of cardiac monitoring or treatment, potentially delaying management of arrhythmia and increasing risks of thromboembolism or hemodynamic instability.
Choice D reason: Decreased blood pressure upon standing (orthostatic hypotension) is unrelated to arrhythmia, which involves irregular heart rhythm. Misidentifying this risks overlooking cardiac signs like irregular pulse, delaying ECG or antiarrhythmic therapy, critical for managing arrhythmia and preventing complications like syncope or heart failure in affected patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Head protrusions are not expected in older adults; they may indicate abnormal growths or trauma, requiring investigation. Thinning hair is a normal aging change. Assuming protrusions are expected risks missing serious conditions like tumors, delaying diagnosis and treatment critical for ensuring safety in elderly patients.
Choice B reason: Asymmetry of facial features is not a normal aging variation; it may suggest stroke or Bell’s palsy, needing urgent evaluation. Thinning hair is expected due to hormonal changes. Assuming asymmetry is normal risks overlooking neurological issues, delaying interventions critical for older adults’ health and functional outcomes.
Choice C reason: Thinning hair is an expected aging variation, resulting from reduced hair follicle activity and hormonal changes in older adults. Unlike vertigo or asymmetry, it’s benign and doesn’t require intervention unless cosmetic. Recognizing this ensures accurate assessment, focusing on abnormal findings like vertigo that need medical attention in elderly patients.
Choice D reason: Vertigo is not an expected aging variation; it may indicate inner ear disorders or neurological issues, requiring evaluation. Thinning hair is a normal change. Assuming vertigo is expected risks delaying diagnosis of treatable conditions like BPPV, compromising safety and quality of life in older adults.
Correct Answer is A
Explanation
Choice A reason: Taking retirement checks and limiting access to funds is financial abuse, exploiting the patient’s resources. This violates elder rights, requiring reporting and social service intervention. Accurate identification ensures protection, critical for restoring financial autonomy and preventing further exploitation, enhancing safety and well-being in vulnerable elderly patients.
Choice B reason: Emotional abuse involves psychological harm like humiliation, not directly indicated by taking retirement funds, which is financial abuse. Assuming emotional risks misclassification, delaying financial protection measures, critical for addressing exploitation and ensuring the patient’s economic security, essential for elder abuse prevention and support.
Choice C reason: Neglect involves failure to provide care, like food or medical needs, not specifically taking funds, which is financial abuse. Misidentifying as neglect risks overlooking financial exploitation, delaying interventions like legal guardianship, critical for protecting the patient’s assets and ensuring safety in elder care settings.
Choice D reason: Physical abuse involves bodily harm, not indicated by financial exploitation like taking retirement checks. Assuming physical risks missing financial abuse, delaying reporting or social services, critical for stopping exploitation, restoring financial control, and ensuring the patient’s safety and dignity in elder abuse scenarios.
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