A nurse is assessing a client who has a heart rate of 56/min.
Which of the following findings should the nurse expect?
Temperature of 39°C (102.2°F).
History of cigarette smoking.
Report of dizziness.
Hypoglycemia.
The Correct Answer is C
Choice A rationale:
A heart rate of 56 beats per minute is within the normal range for an adult, so a high temperature of 39°C (102.2°F) is not directly related to the heart rate. While elevated body temperature can increase heart rate, the given temperature does not indicate a significant fever.
Choice B rationale:
History of cigarette smoking may be a risk factor for cardiovascular issues, but it does not directly correlate with the current heart rate of 56 beats per minute. The low heart rate is more likely related to other factors.
Choice C rationale:
A heart rate of 56 beats per minute is considered bradycardia, which can lead to dizziness, fatigue, and other symptoms. Dizziness is a common finding in individuals with a slow heart rate, and addressing this symptom is essential for patient safety.
Choice D rationale:
Hypoglycemia (low blood sugar) can cause symptoms like dizziness, but the heart rate is not typically affected directly by hypoglycemia. It is important to address both the bradycardia and the reported dizziness to determine the underlying cause and provide appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Health promotion is the correct concept demonstrated by the nurse. Health promotion refers to activities and strategies that aim to enhance an individual's overall health and well-being. Educating the client with heart disease about the importance of eating a heart-healthy diet is a proactive step towards improving their health.
Choice B rationale:
Holistic health is a broader approach that considers the whole person, including physical, mental, and social aspects. While it is an important concept, the nurse, in this scenario, is primarily focused on educating the client about a specific aspect of their health, which is heart disease management.
Choice C rationale:
Health education is a component of health promotion, but it specifically refers to the process of providing individuals with knowledge and skills to make informed decisions about their health. In this case, the nurse is providing education as a means of promoting the client's health.
Choice D rationale:
Primary prevention involves measures to prevent the development of a disease or condition before it occurs. While promoting a heart-healthy diet is a form of prevention, it does not specifically align with the concept of primary prevention, which typically involves actions taken to avoid the initial occurrence of a health problem.
Correct Answer is D
Explanation
The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.
Choice A rationale:
Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).
Choice B rationale:
Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.
Choice C rationale:
Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.
Choice D rationale:
Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.
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