While assessing a client diagnosed with angina, the patient asks, “What causes this pain in my heart?” What is the nurse’s BEST response?

Choice A rationale:

Sinus bradycardia with a heart rate of 48 is a potentially life-threatening condition that requires immediate assessment and intervention. The heart rate is significantly below the normal range of 60-100 beats per minute, which means that the heart is not pumping enough blood to meet the body's needs. This can lead to symptoms such as dizziness, lightheadedness, fatigue, shortness of breath, chest pain, and even syncope (fainting). In severe cases, it can progress to cardiac arrest and death.

The patient is awaiting pacemaker placement, indicating that the bradycardia is severe and not responding to other treatment measures. This further underscores the urgency of assessment and intervention.

The nurse needs to assess the patient immediately for signs of hemodynamic instability, such as hypotension, altered mental status, and decreased urine output. The nurse should also obtain a 12-lead ECG to confirm the diagnosis of sinus bradycardia and to rule out other potential causes of the bradycardia, such as AV block or medication effects.

Prompt intervention is crucial to prevent further deterioration of the patient's condition and to avoid potentially lifethreatening complications.

Choice B rationale:

Atrial fibrillation is a common heart rhythm disorder that is characterized by rapid and irregular beating of the heart's upper chambers (atria). It can cause symptoms such as palpitations, shortness of breath, fatigue, and lightheadedness.

Diltiazem is a calcium channel blocker that is often used to control the heart rate in patients with atrial fibrillation. While it is important to monitor patients who are newly started on diltiazem for potential side effects, such as hypotension and bradycardia, it is not as urgent as assessing a patient with severe sinus bradycardia.

Choice C rationale:

Thrombophlebitis is an inflammation of a vein that is often caused by a blood clot. It can cause pain, redness, swelling, and warmth in the affected area.

IV heparin is an anticoagulant medication that is used to prevent blood clots from forming or getting larger. While it is important to monitor patients who are receiving IV heparin for potential side effects, such as bleeding, it is not as urgent as assessing a patient with severe sinus bradycardia.

Choice D rationale:

End-stage, right-sided heart failure is a serious condition that is characterized by the inability of the heart to pump blood effectively from the right ventricle to the lungs. It can cause symptoms such as shortness of breath, fatigue, edema, and abdominal swelling.

Hospice care is a type of care that focuses on providing comfort and quality of life for patients who are nearing the end of life. While it is important to provide supportive care for patients who are on hospice care, it is not as urgent as assessing a patient with severe sinus bradycardia.

Choice A rationale:

Atrial flutter is characterized by a rapid, regular atrial rate of around 250-350 beats per minute with a "sawtooth" pattern on the ECG. It typically presents with a 2:1 or 4:1 atrioventricular (AV) block, resulting in a ventricular rate of around 150 beats per minute or less. However, the rhythm in question does not exhibit the characteristic sawtooth pattern or rapid atrial rate of atrial flutter.

Choice B rationale:

Normal Sinus Rhythm (NSR) is the typical heart rhythm in healthy individuals. It is characterized by the following features on the ECG:

Regular rhythm: The R-R intervals (the distance between consecutive QRS complexes) are relatively constant.

Rate: The heart rate is typically between 60-100 beats per minute.

P waves: Each QRS complex is preceded by a P wave, representing atrial depolarization.

PR interval: The PR interval (the distance between the P wave and the QRS complex) is normal, measuring between 0.12-0.20 seconds.

QRS complex: The QRS complex is narrow (less than 0.12 seconds), representing normal ventricular depolarization.

ST segment: The ST segment is usually isoelectric (flat).

T wave: The T wave is typically upright, representing ventricular repolarization.

Choice C rationale:

Atrial Fibrillation (AFib) is characterized by a rapid, irregular atrial rate (usually over 400 beats per minute) with no discernible P waves on the ECG. The ventricular rate is also irregular, often ranging between 100-175 beats per minute.

However, the rhythm in question does not exhibit the characteristic irregular pattern of AFib.

Choice D rationale:

Ventricular Tachycardia (VT) is a rapid heart rhythm originating from the ventricles. It is characterized by a wide QRS complex (greater than 0.12 seconds) and a rate typically over 100 beats per minute. However, the rhythm in question does not exhibit the wide QRS complex characteristic of VT.