A client with the rhythm below has been admitted into the cardiac icu. What assessment finding does the nurse expect to find in this client?

Hypertension

Indigestion

Eupnea

Irregular palpitations

Answer and Explanation

The Correct Answer is D

A. Hypertension:

Hypertension is not directly related to the rhythm displayed in the image. The rhythm is suggestive of atrial fibrillation (AF), characterized by irregular and chaotic electrical activity, leading to irregular heartbeats. Hypertension can be a risk factor for AF but is not a typical presenting symptom.

B. Indigestion:

Indigestion is a non-specific symptom that may occur in cardiac events like myocardial infarction but is not a hallmark of atrial fibrillation. The rhythm strip does not indicate myocardial ischemia.

C. Eupnea:

Eupnea refers to normal breathing, which is not commonly associated with atrial fibrillation. Clients with AF may experience symptoms such as shortness of breath or fatigue rather than normal, unlabored breathing.

D. Irregular palpitations:

This is the most expected finding. Atrial fibrillation leads to an irregularly irregular pulse, which patients often describe as palpitations. This rhythm strip demonstrates the hallmark chaotic atrial activity and irregular ventricular response seen in AF.

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Correct Answer is A

Explanation

A) Prepare the client for mechanical ventilation:
A myasthenic crisis is a medical emergency characterized by severe weakness of the respiratory muscles, leading to respiratory failure. This can result from insufficient levels of acetylcholine due to insufficient medication (e.g., pyridostigmine) or from an infection. In such cases, airway support is the priority. The nurse should first prepare the client for potential mechanical ventilation to ensure they can breathe properly and to prevent respiratory arrest.

B) Instruct the client to perform pursed-lip breathing:
While pursed-lip breathing is a useful technique to help with shortness of breath and improve ventilation in certain respiratory conditions (like COPD), it is not the first action in managing a myasthenic crisis. The immediate priority is to ensure the client can breathe and maintain oxygenation, which may require mechanical ventilation if the respiratory muscles are too weak to support breathing effectively.

C) Prepare to administer IVIG:
IV immunoglobulin (IVIG) can be used in the treatment of myasthenic crisis by suppressing the immune response and increasing acetylcholine receptor activity. However, IVIG is not typically the first intervention. Respiratory support and stabilization should take precedence, especially if there is significant respiratory distress.

D) Administration of an immunosuppressant:
Immunosuppressive therapy, such as corticosteroids or azathioprine, may be used to manage myasthenia gravis over the long term, but it is not an acute intervention for a myasthenic crisis. The immediate priority in a crisis situation is to manage respiratory distress and ensure airway protection.

A. Associated with recent vaccination B. Associated with tobacco use C. Recent surgical experience D. Presence of a thymus gland E. Associated with exposure to a recent viral infection

Correct Answer is ["A","C","E"]

Explanation

A) Associated with recent vaccination:
Vaccinations, particularly those for influenza and other viral infections, have been linked to an increased risk of GBS in some cases. This association is believed to be due to an immune response that may trigger the autoimmune attack on the peripheral nervous system, leading to GBS.

B) Associated with tobacco use:
While smoking has been associated with various health conditions, including respiratory and cardiovascular diseases, there is no established direct link between tobacco use and the development of GBS. The pathophysiology of GBS is more strongly related to infections and certain immune responses rather than lifestyle factors like smoking.

C) Recent surgical experience:
It is believed that the stress from surgery, particularly in the presence of an infection or immune response, may trigger the development of GBS. Infections, especially bacterial infections like those caused by Campylobacter jejuni, which is a common antecedent of GBS, can sometimes occur after surgery.

D) Presence of a thymus gland:

The thymus is involved in the immune system, particularly in the development of T-cells, but there is no direct correlation between the thymus gland and the onset of GBS. GBS is more closely related to infections (viral or bacterial), recent vaccinations, or surgery rather than anatomical features like the thymus.

E) Associated with exposure to a recent viral infection:
Viral infections such as Zika virus, Epstein-Barr virus, cytomegalovirus (CMV), influenza, and others can trigger an autoimmune response that leads to the development of GBS. Infections are the most common precipitating factor for GBS, and the immune system’s response to the viral infection may cause the body to mistakenly attack its own peripheral nerves, leading to the symptoms of GBS.

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A client with the rhythm below has been admitted into the cardiac icu. What assessment finding does the nurse expect to find in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse prepare to take first?

Correct Answer is A

Explanation

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Correct Answer is ["A","C","E"]

Explanation

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