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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Endolymph fluid provides protection to the structures of the inner ear": Endolymph is a fluid found within the membranous labyrinth of the inner ear. It plays a crucial role in maintaining the balance of ions necessary for proper sensory function of the auditory and vestibular systems. Endolymph helps protect the delicate sensory structures of the inner ear, including the hair cells responsible for hearing and balance.

B. "Aqueous humor provides protection to the structures of the inner ear": Aqueous humor is a clear fluid that fills the anterior chamber of the eye, maintaining intraocular pressure and nourishing the cornea and lens. It is not involved in protecting the structures of the inner ear.

C. "Vitreous humor provides protection to the structures of the inner ear": Vitreous humor is a gel-like substance that fills the posterior chamber of the eye, providing structural support to the eyeball and maintaining its shape. It is not associated with protecting the structures of the inner ear.

D. "Sanguineous fluid provides protection to the structures of the inner ear": Sanguineous fluid refers to blood or a blood-like fluid, which does not directly provide protection to the structures of the inner ear. While the circulatory system supplies oxygen and nutrients to the inner ear structures, blood itself does not serve as a protective fluid within the inner ear.

A. "You can have 2 to 3 cups of coffee throughout the day." B. "You should practice deep breathing exercises:' C. "You can use at least 2,300 mg of sodium daily." D. "You should avoid exercising."

Correct Answer is B

Explanation

A. "You can have 2 to 3 cups of coffee throughout the day": Caffeine consumption can exacerbate tinnitus symptoms in some individuals. Therefore, advising the client to limit caffeine intake, rather than specifying a quantity, would be more appropriate.

B. "You should practice deep breathing exercises": Deep breathing exercises and relaxation techniques can help reduce stress and anxiety, which may contribute to tinnitus symptoms. Stress management strategies can be beneficial in managing tinnitus-related distress.

C. "You can use at least 2,300 mg of sodium daily": High sodium intake may exacerbate tinnitus symptoms in some individuals. Advising the client to limit sodium intake would be more appropriate to potentially alleviate symptoms.

D. "You should avoid exercising": Regular exercise is generally beneficial for overall health and well-being, including stress reduction, which can help manage tinnitus symptoms. Therefore, advising the client to avoid exercising is not appropriate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is instructing a client who is experiencing episodes of tinnitus on lifestyle modifications to make. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is teaching a group of clients about risk factors for developing atrial fibrillation. Which of the following should be included in the teaching?

A nurse is teaching a client who has symptomatic atrial fibrillation about manifestations to expect. Which of the following should the nurse include in the teaching? (Select All that Apply.)

A nurse is caring for a client who had a traumatic brain injury (TBI). Which of the following manifestations indicate a mild TBI?

A nurse is collecting data from a client related to changes in vision. Which of the following statements indicates that the client might be developing a cataract?

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 care for a group of clients who have coronary artery disease who are all scheduled for coronary artery bypass grafts (CABG). Which of the following clients is at the highest risk for complications following the surgical procedure?

A nurse is teaching the caregiver of a client who has dementia. Which of the following behaviors should the nurse identify as increasing with the progression of the disorder? (Select All that Apply.)

A nurse is teaching a group of nursing students about brain herniation. Which of the following interventions should the nurse include as a possible treatment for brain herniation?