A nurse assesses a client with a brain injury. The client opens his eyes when the nurse calls his name, does not understand questions, and brings his arm up in response to a trapezius squeeze by the nurse. How would the nurse document this client's assessment using the Glasgow Coma Scale shown below

A. Atrial fibrillation is consistent with the symptoms described. It causes irregular palpitations and dizziness due to the rapid and irregular ventricular rate. The significant pulse deficit can occur because the irregular rhythm may lead to intermittent weak or absent pulses. The ECG typically shows an irregular rhythm with no identifiable P waves and an irregularly irregular ventricular response.
B. Sinus bradycardia does not usually cause a rapid and irregular heart rate. It is characterized by a regular rhythm with a slow heart rate. While it can cause fatigue and dizziness, it does not typically present with an irregular rhythm or a significant pulse deficit. Therefore, it is less consistent with the symptoms described.
C. Sinus tachycardia is characterized by a rapid but regular heart rate. It does not typically present with an irregular rhythm or significant pulse deficit. While it may cause symptoms such as palpitations and

dizziness, the regular rhythm and absence of irregularity in the ECG make it less likely to be the cause of the significant irregular pulse deficit described.
D. First-degree AV block does not usually cause a rapid and irregular heart rate. It typically presents with a regular rhythm but with a prolonged PR interval. It is not typically associated with irregular palpitations or a significant pulse deficit. The symptoms described are not characteristic of first-degree AV block.

A. The normal P-R interval ranges from 0.12 to 0.20 seconds. A P-R interval longer than 0.20 seconds is considered prolonged and may indicate a first-degree AV block.
B. The T wave represents ventricular repolarization. Normally, the T wave is upright in most leads. An inverted T wave can indicate various conditions, including ischemia, electrolyte imbalances, or other abnormalities
C. The normal QRS duration ranges from 0.06 to 0.10 seconds. A QRS duration greater than 0.10 seconds indicates a delay in ventricular conduction, which could be due to a bundle branch block or other conduction abnormalities.
D. In a normal sinus rhythm, the P wave should consistently appear before each QRS complex. This reflects proper atrial depolarization followed by ventricular depolarization. This pattern indicates that the heart's electrical impulses are originating from the sinus node and are being properly conducted through the AV node to the ventricles.