The nurse is caring for a client with a heart rate of 143 beats/min with atrial fibrillation. Which assessment data will the nurse anticipate? Select all that apply:
Cool, clammy skin
Respiratory rate 20
Flushing of the skin
Hypotension
Chest discomfort
Correct Answer : A,D,E
Choice A Reason:
Cool, clammy skin is a common symptom in patients with atrial fibrillation, especially when the heart rate is very high. This symptom occurs due to decreased cardiac output, which leads to poor perfusion of the skin. When the heart is beating too fast, it doesn’t have enough time to fill properly, resulting in less blood being pumped out to the body. This can cause the skin to feel cool and clammy as the body tries to compensate for the reduced blood flow.
Choice B Reason:
Respiratory rate of 20 is within the normal range for adults, which is typically 12-20 breaths per minute. While it is important to monitor respiratory rate in patients with atrial fibrillation, a rate of 20 does not indicate any immediate distress or abnormality. Therefore, this choice is not particularly relevant to the assessment of a patient with a heart rate of 143 beats/min due to atrial fibrillation.
Choice C Reason:
Flushing of the skin is not a typical symptom associated with atrial fibrillation. Flushing can occur due to various reasons such as fever, anxiety, or certain medications, but it is not directly linked to the high heart rate or the irregular rhythm seen in atrial fibrillation. Therefore, this choice is not applicable in this context.
Choice D Reason:
Hypotension (low blood pressure) is a significant concern in patients with atrial fibrillation, especially when the heart rate is very high. The rapid heart rate can lead to decreased cardiac output, as the heart does not have enough time to fill properly between beats. This can result in lower blood pressure, which can cause symptoms such as dizziness, fainting, and fatigue. Monitoring blood pressure is crucial in managing patients with atrial fibrillation to prevent complications.
Choice E Reason:
Chest discomfort is a common symptom in patients with atrial fibrillation, particularly when the heart rate is very high. The irregular and rapid heart rate can cause the heart to work harder, leading to increased oxygen demand and potentially reduced oxygen supply to the heart muscle. This imbalance can result in chest pain or discomfort, which is a warning sign that the heart is under stress. It is important to assess and address chest discomfort promptly to prevent further cardiac complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Consuming a high-protein diet is not typically recommended for clients with hepatitis B. While protein is essential for overall health, excessive protein intake can put additional strain on the liver. Instead, a balanced diet with adequate carbohydrates, fruits, and vegetables is advised to support liver function.
Choice B reason: Resting frequently throughout the day is crucial for clients with hepatitis B. The liver is responsible for many vital functions, including detoxification, protein synthesis, and the production of biochemicals necessary for digestion. When the liver is inflamed or damaged, as in hepatitis B, it needs ample rest to recover and function properly.
Choice C reason: Clients with hepatitis B should not donate blood. Hepatitis B is a bloodborne virus, and donating blood can transmit the infection to others. Blood donation guidelines strictly prohibit individuals with hepatitis B from donating blood, regardless of the time elapsed since completing medication.
Choice D reason: Taking acetaminophen every 4 hours for discomfort is not advisable for clients with hepatitis B. Acetaminophen is metabolized by the liver, and excessive use can lead to liver damage. Clients with liver conditions should use acetaminophen sparingly and under medical supervision to avoid exacerbating liver damage.
Correct Answer is C
Explanation
Choice A Reason:
Telling his wife what the client needs is not the most effective discharge action. While it is important for the wife to understand the client’s needs, this approach is too passive and does not actively engage the client or his wife in the care process. Effective management of Parkinson’s disease requires active participation from both the client and the caregiver to ensure adherence to the care plan and to address any concerns or preferences they may have.
Choice B Reason:
Setting up visitations by a home health nurse can be beneficial, but it is not the most effective discharge action on its own. Home health nurses can provide valuable support and monitoring, but the success of the management plan also depends on the involvement and commitment of the client and his wife. Without their active participation, the care plan may not be fully effective.
Choice C Reason:
Involving the client and his wife in developing a plan of care is the most effective discharge action. This approach ensures that both the client and his wife are fully engaged in the care process, understand the management plan, and are more likely to adhere to it. Collaborative care planning allows for the consideration of the client’s and caregiver’s preferences, needs, and concerns, leading to a more personalized and effective care plan. This active involvement can also empower the client and his wife, improving their confidence in managing the disease.
Choice D Reason:
Writing up a detailed plan of care according to standards is important, but it is not the most effective discharge action if done in isolation. A standardized care plan may not address the unique needs and preferences of the client and his wife. Without their involvement in the development of the plan, there may be a lack of understanding or commitment to the care plan, reducing its effectiveness. Personalizing the care plan through active involvement of the client and his wife is crucial for successful management.
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