A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring.
The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate.
The nurse should identify the cardiac rhythm as which of the following?
Atrial fibrillation.
Ventricular asystole.
Second-degree heart block.
Sinus tachycardia.
The Correct Answer is A
Choice A rationale:
The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the absence of distinct P waves on the ECG.
Choice B rationale:
Ventricular asystole is a flatline on the ECG, indicating the absence of electrical activity in the heart. It is a life-threatening arrhythmia and requires immediate intervention with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) protocols.
Choice C rationale:
Second-degree heart block is characterized by intermittent failure of atrial electrical impulses to conduct to the ventricles. This results in occasional dropped beats and a varying heart rate. It is not consistent with the described ECG findings in the question.
Choice D rationale:
Sinus tachycardia is a regular, fast heart rate originating from the sinoatrial (SA) node. In sinus tachycardia, P waves are present, indicating that the electrical impulses originate in the SA node. The described ECG findings do not match the characteristics of sinus tachycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"}}
No explanation
Correct Answer is D
Explanation
Choice A rationale:
Borderline personality disorder is characterized by impulsivity, unstable relationships, and mood swings. While individuals with this disorder may have concerns about details, it is not the primary characteristic of the disorder. The impulsivity exhibited by these clients is a more prominent feature.
Choice B rationale:
While individuals with borderline personality disorder may struggle with interpersonal relationships and may sometimes display seductive behavior, this is not a defining characteristic of the disorder. The primary concern lies in their impulsivity and emotional instability.
Choice C rationale:
Clinginess can be a feature of borderline personality disorder, but it is not the defining characteristic. The disorder is more accurately characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affects, marked impulsivity that begins by early adulthood and is present in various contexts.
Choice D rationale:
Borderline personality disorder is indeed marked by impulsive behavior, one of the key diagnostic criteria according to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). This impulsivity often leads to self-damaging behaviors, such as reckless driving, substance abuse, and unsafe sex. Including this information in the in-service is crucial for an accurate understanding of the disorder.
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