A nurse is analyzing a client's electrocardiogram (ECG) strip and identifies the following information:

Heart rate: 92/min

Rhythm: Irregular

P wave: Unable to identify

PR interval: Unable to measure

QRS duration: O. 1 0 seconds
Based upon this information, the nurse should interpret the client's rhythm as indicating which of the following?

Atrial fibrillation

Sinus bradycardia

Supraventricular tachycardia

First-degree heart block

Answer and Explanation

The Correct Answer is A

A. Atrial fibrillation: Atrial fibrillation is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and irregular ventricular response. The heart rate in atrial fibrillation can be variable, and the absence of identifiable P waves indicates disorganized atrial electrical activity.

B. Sinus bradycardia: Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute (bpm) and normal P waves preceding each QRS complex. In sinus bradycardia, the PR interval and QRS duration are typically within normal limits.

C. Supraventricular tachycardia: Supraventricular tachycardia (SVT) is characterized by a regular rhythm with a heart rate greater than 100 bpm. SVT typically presents with narrow QRS complexes and may or may not have discernible P waves.

D. First-degree heart block: First-degree heart block is characterized by a prolonged PR interval (>0.20 seconds) but maintains a regular rhythm with normal QRS duration. In first-degree heart block, P waves are typically identifiable, and the rhythm is not irregular.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["B","C"]

Explanation

A. Limit exercise to 10 min, 2 days per week. This recommendation is incorrect. Regular physical activity is essential for heart health. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity aerobic exercise per week, spread throughout the week.

B. Monitor blood pressure This recommendation is correct. Monitoring blood pressure is an essential aspect of heart disease prevention. High blood pressure (hypertension) is a significant risk factor for heart disease, so regular monitoring allows for early detection and management.

C. Lose weight if necessary. This recommendation is correct. Maintaining a healthy weight or losing weight if overweight or obese is important for heart disease prevention. Excess weight, especially around the abdomen, increases the risk of heart disease and other health conditions.

D. Eat a diet high in saturated fats. This recommendation is incorrect. A diet high in saturated fats is associated with an increased risk of heart disease. Instead, the nurse should encourage a heart-healthy diet that includes fruits, vegetables, whole grains, lean proteins, and healthy fats.

E. Maintain current cholesterol level This recommendation is not entirely accurate. While maintaining healthy cholesterol levels is important for heart health, individuals with high cholesterol levels may need to take steps to lower their cholesterol through lifestyle modifications and, in some cases, medication. Therefore, simply maintaining current cholesterol levels may not be sufficient for heart disease prevention.

A. An abdominal aortic aneurysm is commonly found in the suprarenal aorta. B. An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery. C. An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter. D. Abdominal aortic aneurysms might rupture if blood pressure is too low.

Correct Answer is C

Explanation

A. An abdominal aortic aneurysm is commonly found in the suprarenal aorta: This statement is incorrect. Abdominal aortic aneurysms (AAAs) are most commonly found infrarenally, below the level of the renal arteries, rather than in the suprarenal region.

B. An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery: This statement is incorrect. An abdominal aortic aneurysm typically occurs due to weakening of the arterial wall, rather than thickening. The weakened wall allows the arterial wall to bulge or balloon out, forming an aneurysm.

C. An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter: This statement is correct. An abdominal aortic aneurysm is defined as a localized dilation of the abdominal aorta that exceeds 50% of the normal vessel diameter, typically greater than 30 mm in diameter. This dilation occurs due to weakening of the arterial wall, which can result from various factors such as atherosclerosis, hypertension, and genetic predisposition.

D. Abdominal aortic aneurysms might rupture if blood pressure is too low: This statement is incorrect. Abdominal aortic aneurysms are more likely to rupture when blood pressure is too high, rather than too low. Hypertension increases the pressure within the weakened arterial wall, potentially leading to rupture. Therefore, controlling blood pressure is crucial in managing abdominal aortic aneurysms to reduce the risk of rupture.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to teach a community group about preventative measures for heart disease. Which of the following recommendations should the nurse include in the teaching plan? (Select All that Apply.)

Correct Answer is ["B","C"]

Explanation

A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is assessing a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?

A nurse is instructing a client who is experiencing episodes of tinnitus on lifestyle modifications to make. Which of the following statements should the nurse include in the teaching?

A nurse is providing teaching to a group of clients about the changes that occur when clients experience cataracts. Which of the following statements should the nurse include in the teaching?

A nurse is collecting neurologic data on a client who has a neurological injury and notes changes suggestive of Cushing's Triad. The nurse understands that Cushing's Triad is a nervous system response that might prevent which of the following conditions?

A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a possible treatment for brain herniation?

A nurse is providing care to a client who has spent several weeks in the intensive care unit because of complications related to shock. What adverse psychological outcomes should the nurse educate the client about prior to transfer to the medical unit?

A nurse is preparing to administer medications to a client who has pericarditis. Which of the following medications should the nurse anticipate administering to this client? (Select All That Apply)