The nurse is analyzing a rhythm strip.
What component of the ECG corresponds to the resting state of the client’s heart?

Choice A rationale:

Blocking impulse transmission to the AV node is not the primary function of an ICD. This is typically achieved through medications such as beta blockers or calcium channel blockers, or through a procedure called AV node ablation.

While ICDs can sometimes have a secondary effect of slowing AV node conduction, their primary purpose is to actively monitor heart rhythm and deliver electrical shocks when necessary to restore normal rhythm.

Choice B rationale:

Assuming the function of the SA node is not the primary function of an ICD. The SA node, located in the right atrium, is the natural pacemaker of the heart, responsible for initiating electrical impulses that trigger each heartbeat.

While ICDs can sometimes pace the heart if the SA node is not functioning properly, their primary purpose is to intervene when life-threatening arrhythmias occur, rather than to continuously regulate heart rate.

Choice C rationale:

Triggering electrical impulses to the heart is the core function of an ICD. It continuously monitors heart rhythm and can deliver electrical shocks to restore normal rhythm when it detects potentially dangerous arrhythmias, such as ventricular tachycardia or ventricular fibrillation.

These shocks are designed to interrupt chaotic electrical activity in the heart and allow the natural pacemaker to regain control, preventing cardiac arrest and sudden cardiac death.

Choice D rationale:

Increasing ventricular conduction is not the primary function of an ICD. In fact, in some cases, ICDs may actually slow down ventricular conduction to prevent certain types of arrhythmias.

Medications or procedures such as cardiac resynchronization therapy (CRT) are specifically designed to improve ventricular conduction in patients with heart failure.

correct answer is Choice B.

Choice B rationale:

Orthostatic hypotension is a significant drop in blood pressure that occurs when a person stands up from a lying or sitting position. It's characterized by a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing.

The client's assessment data clearly demonstrates orthostatic hypotension, with a systolic blood pressure drop of 23 mmHg and a diastolic drop of 13 mmHg upon standing.

Orthostatic hypotension is a major risk factor for falls, especially in older adults. This is because the sudden decrease in blood pressure can lead to lightheadedness, dizziness, blurred vision, weakness, and even fainting.

Falls in older adults can result in serious injuries, such as fractures, head trauma, and even death. Therefore, it's crucial to identify and address orthostatic hypotension to prevent falls and their associated complications.

Rationales for other choices:

Choice A: Ineffective breathing pattern is not directly related to orthostatic hypotension. While hypotension can cause shortness of breath in some cases, it's not the primary concern in this scenario.

Choice C: Ineffective role performance can be a consequence of frequent falls, but it's not the most immediate or pressing nursing diagnosis in this case.

Choice D: Risk for imbalanced fluid balance is a potential concern in some cases of orthostatic hypotension, but it's not the most likely diagnosis based on the client's assessment data.