The nurse is caring for a client on a telemetry unit. The client's cardiac monitor exhibits the rhythm below. How should the nurse document this rhythm?

Sinus rhythm with first-degree heart block

ST-segment elevation myocardial infarction (STEMI)

Atrial fibrillation

Ventricular tachycardia

Answer and Explanation

The Correct Answer is B

A. Sinus rhythm with first-degree heart block: This rhythm is characterized by a regular sinus rhythm with a prolonged PR interval (greater than 0.20 seconds), indicating a first-degree heart block.

B. ST-segment elevation myocardial infarction (STEMI): STEMI is indicated by significant ST-segment elevation in specific leads, showing acute myocardial infarction.

C. Atrial fibrillation: Atrial fibrillation shows an irregularly irregular rhythm without distinct P waves.

D. Ventricular tachycardia: Ventricular tachycardia is a rapid heart rhythm originating from the ventricles, with wide QRS complexes and no preceding P waves.

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Correct Answer is A

Explanation

A. BP 170/64, pulse 58: Cushing's triad includes increased systolic blood pressure with widened pulse pressure, bradycardia, and irregular respirations, indicating increased intracranial pressure.

B. BP 180/90, pulse 96: Hypertension is present, but the elevated pulse does not align with bradycardia seen in Cushing's triad.

C. BP 110/70, pulse 100: These values do not reflect the classic signs of Cushing's triad.

D. BP 100/60, pulse 54: While bradycardia is present, hypotension does not align with Cushing’s triad.

A. Inability to see objects on one side of the visual field B. Inability to perform a previously learned action C. Inability to repeat a simple sentence D. Inability to hear from the ear on the affected side

Correct Answer is B

Explanation

A. Inability to see objects on one side of the visual field: This describes hemianopsia, not apraxia.

B. Inability to perform a previously learned action: Apraxia is the loss of the ability to perform skilled movements or gestures despite having the desire and physical ability to do so.

C. Inability to repeat a simple sentence: This describes aphasia, specifically expressive or receptive aphasia.

D. Inability to hear from the ear on the affected side: This describes hearing loss, which is unrelated to apraxia.

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The nurse is caring for a client on a telemetry unit. The client's cardiac monitor exhibits the rhythm below. How should the nurse document this rhythm?

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Naxlex Comprehensive Predictor Exams

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Explanation

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