A nurse is analyzing a client's electrocardiogram (ECG) strip and identifies the following information:

Heart rate: 92/min

Rhythm: Irregular

P wave: Unable to identify

PR interval: Unable to measure

QRS duration: O. 1 0 seconds
Based upon this information, the nurse should interpret the client's rhythm as indicating which of the following?

Atrial fibrillation

Sinus bradycardia

Supraventricular tachycardia

First-degree heart block

Answer and Explanation

The Correct Answer is A

A. Atrial fibrillation: Atrial fibrillation is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and irregular ventricular response. The heart rate in atrial fibrillation can be variable, and the absence of identifiable P waves indicates disorganized atrial electrical activity.

B. Sinus bradycardia: Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute (bpm) and normal P waves preceding each QRS complex. In sinus bradycardia, the PR interval and QRS duration are typically within normal limits.

C. Supraventricular tachycardia: Supraventricular tachycardia (SVT) is characterized by a regular rhythm with a heart rate greater than 100 bpm. SVT typically presents with narrow QRS complexes and may or may not have discernible P waves.

D. First-degree heart block: First-degree heart block is characterized by a prolonged PR interval (>0.20 seconds) but maintains a regular rhythm with normal QRS duration. In first-degree heart block, P waves are typically identifiable, and the rhythm is not irregular.

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Correct Answer is C

Explanation

A. "Since my parent suffered from Alzheimer's disease, I know that I am at an increased risk for developing the disease myself." This statement is accurate. Family history is a significant risk factor for Alzheimer's disease. Individuals with a first-degree relative (such as a parent or sibling) with Alzheimer's disease are at a higher risk of developing the condition themselves.

B. "The cause of Alzheimer's disease is still not fully known or understood." This statement is also accurate. While there are theories about the underlying causes of Alzheimer's disease, such as genetics, brain changes, and environmental factors, the exact cause is still not fully understood. Research into the etiology of Alzheimer's disease is ongoing.

C. "I do not have to worry about this because I do not have Down syndrome and I have never had a stroke." This statement indicates a need for further teaching. While it is true that individuals with Down syndrome and those who have had a stroke are at increased risk for developing Alzheimer's disease, they are not the only populations at risk. Alzheimer's disease can affect individuals without Down syndrome or a history of stroke. Other risk factors include age, family history, genetics, and lifestyle factors.

D. "My child is at risk for developing Alzheimer's disease because they have trisomy 21." This statement is accurate. Trisomy 21, also known as Down syndrome, is associated with an increased risk of developing Alzheimer's disease. Individuals with Down syndrome have three copies of chromosome 21, which contains the gene for amyloid precursor protein (APP). Overproduction of amyloid beta protein, derived from APP, is thought to contribute to the development of Alzheimer's disease in individuals with Down syndrome.

A. Lower back or groin pain B. Hunger after eating C. Pain in the chest D. Presence of Cullen's sign

Correct Answer is A

Explanation

A. Lower back or groin pain: Lower back or groin pain can be an early manifestation of an abdominal aortic aneurysm (AAA). This pain may result from pressure exerted by the enlarging aneurysm on surrounding structures or from irritation of nerves as the aneurysm expands. As the aneurysm enlarges, the pain may become more severe and persistent.

B. Hunger after eating: Hunger after eating is not typically associated with an abdominal aortic aneurysm. This symptom may be indicative of various gastrointestinal issues such as peptic ulcer disease or gastritis, but it is not a characteristic manifestation of AAA.

C. Pain in the chest: While AAA can lead to compression of nearby structures, resulting in referred pain, chest pain is not a common early manifestation of an abdominal aortic aneurysm. Chest pain is more commonly associated with cardiac issues such as angina or myocardial infarction.

D. Presence of Cullen's sign: Cullen's sign refers to periumbilical bruising, which can occur due to retroperitoneal hemorrhage from a ruptured AAA. However, Cullen's sign is not an early manifestation of an AAA; it is typically observed in more advanced cases or after rupture has occurred.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching clients at a senior center about the etiology of Alzheimer's disease. Which of the following statements by a client indicates the need for further teaching?

Correct Answer is C

Explanation

A nurse is assessing a client who has a possible abdominal aortic aneurysm (AAA). Which of the following is an early manifestation of an AAA?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a severe traumatic brain injury (TBI). Which of the following should the nurse include in the plan of care? (Select All that Apply.)

A nurse is providing care for a client following a cardiac arrest due to pulseless electrical activity (PEA). Which of the following alterations are causes of PEA? (Select All that Apply.)

A nurse is teaching a client who has cardiomyopathy about the side effects of their new prescription beta blocker, carvedilol. Which of the following client statements should indicate to the nurse that the client understands the teaching? (select all that apply)

A nurse is teaching a client who has arrhythmogenic cardiomyopathy about the risk for sudden cardiac death. Which of the following client statements indicates to the nurse an understanding of the teaching?

A nurse is teaching a group of clients about lifestyle modifications that could decrease risk factors for developing hearing loss. Which of the following risk factors should the nurse include in the teaching?

A nurse is assessing a client who is experiencing a change in vision. Which of the following statements indicates that the client might be developing cataracts?

A nurse is developing a plan of care for a client who has Meniere’s disease. Which of the following medications should the nurse anticipate administering?

A nurse is providing discharge teaching to a client who has heart failure. Which of the following lifestyle modifications should the nurse include in the discharge teaching?