A nurse analyzes a rhythm strip for a patient who has had a myocardial infarction and observes the following: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, QRS complex wide and distorted, and QRS duration of 0.18 second.
How should the nurse interpret this cardiac rhythm?
Sinus tachycardia.
Ventricular tachycardia.
Ventricular fibrillation.
Atrial flutter.
The Correct Answer is B
Choice A rationale
Sinus tachycardia is a regular, rapid heart rate caused by rapid firing of the sinoatrial node. It is characterized by a heart rate of greater than 100 beats per minute, and P waves are present before each QRS complex. This does not match the description given.
Choice B rationale
Ventricular tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or for much longer. In this condition, the ventricular rate is often between 120 and 200 beats per minute, and P waves are not associated with the QRS complexes. This matches the description given.
Choice C rationale
Ventricular fibrillation is a severe condition in which the heart beats with rapid, erratic electrical impulses. This causes the ventricles to quiver uselessly instead of pumping blood. The description does not match this condition.
Choice D rationale
Atrial flutter is a condition that shares similarities with atrial fibrillation, both involve an irregular heartbeat. However, atrial flutter is more organized and less chaotic than atrial fibrillation, which can make it more manageable. The description does not match this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Promoting a diet high in saturated fats is not a recommended strategy for preventing cardiovascular disease. Saturated fats can raise the level of cholesterol in your blood and increase your risk of heart disease and stroke.
Choice B rationale
Advising smoking cessation is a crucial intervention in preventing cardiovascular disease. Chemicals in tobacco can damage the heart and blood vessels, leading to narrowing of the arteries (atherosclerosis). Atherosclerosis can ultimately lead to a heart attack.
Choice C rationale
Regular blood pressure monitoring is important because high blood pressure is a significant risk factor for heart disease. It can cause the arteries that supply blood to your heart muscle to harden and narrow, leading to a heart attack.
Choice D rationale
Regular cholesterol screenings are essential because high levels of cholesterol can lead to the buildup of plaques in your arteries, increasing your risk of heart disease.
Choice E rationale
Encouraging regular physical exercise is a key strategy in preventing cardiovascular disease. Regular exercise helps control your weight and reduce your chances of developing other conditions that may put a strain on your heart, such as high blood pressure, high cholesterol, and diabetes.
Correct Answer is B
Explanation
Choice A rationale
A pleural friction rub, which is a grating sound caused by the inflammation of the pleural surfaces during respiration, is not typically associated with cardiac tamponade. It is more commonly associated with conditions affecting the lungs, such as pneumonia or pleurisy.
Choice B rationale
Distended neck veins are a classic sign of cardiac tamponade. This occurs due to increased pressure in the right atrium as a result of the impaired filling of the ventricles. This is a critical sign that should be reported immediately.
Choice C rationale
Widening pulse pressure (an increase in the difference between systolic and diastolic blood pressure) is not typically associated with cardiac tamponade. In fact, cardiac tamponade more commonly presents with a narrowed pulse pressure.
Choice D rationale
Bradycardia, or a slow heart rate, is not typically a sign of cardiac tamponade. More commonly, tachycardia, or a fast heart rate, is observed in response to decreased cardiac output.
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