The nurse is assessing the cardiac rhythm of a client who is admitted with coronary artery disease. The nurse notes that the PR interval is 0.24 and the QRS interval is 0.10. Which interpretation would be appropriate for the nurse to make
First degree heart block
Second degree heart block
Bundle branch block
Sinus arrhythmia
The Correct Answer is A
A. First-degree heart block: A prolonged PR interval greater than 0.20 seconds, as seen in this case, indicates first-degree heart block, which is a delay in conduction at the AV node.
B. Second-degree heart block. Second-degree heart block is characterized by some PR intervals being prolonged with occasional dropped beats (non-conducted P waves).
C. Bundle branch block. Bundle branch block causes a wide QRS complex (greater than 0.12 seconds), which is not seen here.
D. Sinus arrhythmia. Sinus arrhythmia involves changes in heart rate due to respiratory cycles, not prolonged PR intervals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Have you had any immunizations recently?: Immunizations are not associated with a significant risk of infectious endocarditis.
B. Have you had any dental work done recently?: Dental procedures can introduce bacteria into the bloodstream, posing a risk for endocarditis, especially in clients with prosthetic valves.
C. Do you have a family history of endocarditis?: Endocarditis is not typically hereditary; risk factors are more related to procedures, infections, or valve abnormalities.
D. Have you ever suffered a heart attack?: While a history of a heart attack is relevant to cardiac health, it does not directly increase the risk for infectious endocarditis.
Correct Answer is A
Explanation
A. “Brain death has occurred if there is no spontaneous breathing or brainstem reflexes.” Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of spontaneous breathing and brainstem reflexes (such as pupillary response, gag reflex, and eye movements) are critical criteria used to confirm brain death.
B. “If respiratory efforts cease and no apical pulse is audible, brain death is present.” While the cessation of respiratory efforts is a key component of brain death, the presence or absence of an apical pulse alone is not sufficient for determining brain death. Brain death is determined based on the complete absence of brain function, including brainstem reflexes.
C. “Brain death has occurred if a person has flaccid muscles and does not awaken.” Muscle flaccidity and lack of consciousness may be signs of severe brain injury, but they do not necessarily confirm brain death. Brain death is diagnosed based on the absence of brainstem reflexes and spontaneous breathing.
D. “CPR does not restore a heartbeat, the brain cannot function.” While it is true that CPR may not restore circulation in brain-dead patients, this statement is incomplete and not a precise definition of brain death. Brain death is determined by the irreversible cessation of all brain activity, not just by the failure of CPR to restore circulation.
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