A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?
Sinus bradycardia
Sinus tachycardia
Atrial fibrillation
First-degree AV block
The Correct Answer is C
Choice A Reason: This is incorrect. Sinus bradycardia is a slow and regular heart rate that originates from the sinus node. It does not cause irregular palpitations, fatigue, or dizziness, unless the heart rate is very low or the client has underlying cardiac disease.
Choice B reason: This is incorrect. Sinus tachycardia is a fast and regular heart rate that originates from the sinus node. It may cause fatigue or dizziness, but not irregular palpitations or pulse deficit.
Choice C Reason: This is correct. Atrial fibrillation is a fast and irregular heart rate that originates from multiple foci in the atria. It causes irregular palpitations, fatigue, dizziness, and pulse deficit due to ineffective atrial contractions and variable ventricular response.
Choice D Reason: This is incorrect. First-degree AV block is a delay in the conduction of impulses from the atria to the ventricles. It does not affect the heart rate or rhythm, and does not cause any symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is correct. The nurse should remove both of the elastic bandages from the leg, as they can impair blood flow and increase tissue damage. The nurse should also elevate the leg and keep it immobile to reduce venom absorption.
Choice B Reason: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.
Choice C Reason: This is incorrect. The nurse should not obtain a prescription for the appropriate anti-venom, as this is not within their scope of practice. The nurse should notify the physician and provide supportive care until the physician arrives and decides whether to administer anti-venom or not.
Choice D Reason: This is incorrect. The nurse should not obtain a prescription for pain medication, as this may mask the symptoms of venom toxicity or cause adverse reactions with anti-venom. The nurse should use non- pharmacological methods to relieve pain, such as ice packs or distraction.
Correct Answer is ["A","C","D","F"]
Explanation
Choice A: A cervical spinal cord injury can impair the function of cranial nerves, leading to a weakened gag reflex and an increased risk of aspiration.
Choice B:Patients with spinal cord injuries are more likely to experience poikilothermia (difficulty regulating body temperature), but this often results in hypothermia, not hyperthermia, due to the loss of autonomic temperature control.
Choice C:Spinal shock, which often follows a spinal cord injury, can cause decreased or absent bowel sounds due to a temporary loss of autonomic function and decreased peristalsis.
Choice D:Depending on the level and severity of the injury, paralysis can occur, affecting motor function below the injury site. A cervical spinal cord injury may lead to quadriplegia (tetraplegia).
Choice E:Clients with spinal cord injuries are more likely to experience urinary retention, rather than polyuria, due to loss of bladder control and autonomic dysfunction. A foley catheter may be needed initially, followed by intermittent catheterization.
Choice F:Neurogenic shock, a potential complication of cervical spinal cord injuries, can cause hypotension due to the loss of sympathetic nervous system control over blood vessel tone, leading to vasodilation and bradycardia.
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