A nurse is caring for a client who suddenly develops atrial fibrillation with a ventricular rate of 150 beats per minute. The nurse should assess the client for which of the following priority signs and symptoms associated with this dysrhythmia?
Nausea and vomiting
Hypertension and headache
Flattened neck veins
Hypotension and dizziness
The Correct Answer is D
Choice A reason: Nausea and vomiting can occur in cardiac conditions due to reduced perfusion to the gastrointestinal system. However, in atrial fibrillation with a rapid ventricular rate, the priority is assessing for symptoms of reduced cardiac output, such as hypotension and dizziness, which are more immediate and life-threatening.
Choice B reason: Hypertension and headache are not typical of rapid atrial fibrillation, which usually causes reduced cardiac output due to ineffective atrial contractions. These symptoms are more associated with hypertensive crises or other conditions, making them less relevant for this dysrhythmia.
Choice C reason: Flattened neck veins suggest hypovolemia or low venous pressure, not typical in acute atrial fibrillation, where jugular vein distension may occur due to heart failure. Hypotension and dizziness are more direct indicators of compromised cardiac output in this scenario.
Choice D reason: Rapid atrial fibrillation impairs atrial filling, reducing cardiac output and causing hypotension. Dizziness results from decreased cerebral perfusion due to low blood pressure. These are critical symptoms to assess, as they indicate hemodynamic instability, requiring immediate intervention to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.44"]
Explanation
Step 1: Calculate the total units to be given per hour: 18 × 90 = 1620 units/hour Result = 1620 units/hour
Step 2: Determine the concentration of Heparin in 1 mL: 25000 ÷ 250 = 100 units/mL Result = 100 units/mL
Step 3: Calculate the required volume in mL/hr using total units per hour: (1620 ÷ 100) = 16.2 mL/hr Result = 16.2 mL/hr
Final answer 16.2 mL/hr
Question 47
Calculate the initial bolus of Heparin. Heparin is ordered as 80 units/kg. The client weighs 90 kg. How many mL would you administer using a vial of Heparin labeled Heparin 5000 units/mL?
The correct answer is 1.44 mL
Explanation:
Step 1: Calculate the total number of units required for the bolus: 80 × 90 = 7200 units Result = 7200 units
Step 2: Use the vial concentration to find out how many mL deliver 7200 units: (7200 ÷ 5000) = 1.44 mL Result = 1.44 mL
Final answer 1.44 mL
Correct Answer is B
Explanation
Choice A reason: Increased sleep may occur with sertraline due to its sedative effects, but it is not the priority assessment. Early in treatment, SSRIs can increase energy before mood improvement, heightening suicide risk, making suicidal ideation a more urgent concern.
Choice B reason: Sertraline, an SSRI, can initially increase energy in severe depression before fully improving mood, potentially increasing suicide risk. Assessing suicidal ideation is the priority to ensure safety, as this risk is highest early in treatment, requiring immediate intervention if present.
Choice C reason: Emotional changes are expected with sertraline as it improves mood over weeks. However, this is less urgent than assessing suicidal ideation, which poses an immediate safety risk, especially in severe depression during the early phase of SSRI treatment.
Choice D reason: Increased socialization may indicate improved depressive symptoms but is a secondary outcome. The priority is assessing suicidal ideation, as SSRIs can paradoxically increase suicide risk early in treatment due to improved energy without full mood stabilization, requiring vigilant monitoring.
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