A nurse is assisting with collecting data on a client who is on a continuous ECG monitor. The client's ECG tracing shows no identifiable P waves and an irregular ventricular rate. The nurseshould recognize the client is experiencing which of the following cardiac dysrhythmias?
Complete heart block
Atrial fibrillation
Sinus tachycardia
First-degree AV block.
The Correct Answer is B
a. Complete heart block: Complete heart block would typically present with a regular ventricular rate, but with no association between P waves and QRS complexes.
b. Atrial fibrillation: Atrial fibrillation is characterized by the absence of identifiable P waves and an irregular ventricular rate. The atria fibrillate, leading to chaotic electrical activity and an irregular ventricular response.
c. Sinus tachycardia: Sinus tachycardia is characterized by a regular ventricular rate and identifiable P waves. It is not associated with the absence of P waves.
d. First-degree AV block: First-degree AV block is characterized by a prolonged PR interval, but it does not result in the absence of P waves. The relationship between P waves and QRS
complexes is maintained.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. A sensory warning that a seizure is imminent: An aura is a subjective sensation or warning that a seizure is about to occur. It can manifest as visual, auditory, or other sensory experiences.
b. A brief loss of consciousness accompanied by staring: This describes an absence seizure, not an aura. Absence seizures are characterized by a brief loss of consciousness without convulsions.
c. A continuous seizure state in which seizures occur in rapid succession: This describes status epilepticus, not an aura. Status epilepticus is a medical emergency characterized by prolonged or rapidly recurring seizures.
d. A period of sleepiness following the seizure during which arousal is difficult: This describes the postictal state, not an aura. The postictal state is a period of altered consciousness or
sleepiness that may follow a seizure.
Correct Answer is C
Explanation
a. Battle's sign: Battle's sign is bruising over the mastoid process and is not a direct manifestation of increased intracranial pressure.
b. Nuchal rigidity: Nuchal rigidity (stiff neck) is associated with irritation of the meninges and is not a specific sign of increased intracranial pressure.
c. Lethargy: Lethargy or altered level of consciousness is a common manifestation of increased intracranial pressure. It can range from mild drowsiness to severe impairment of consciousness.
d. Polyuria: Polyuria is not a typical manifestation of increased intracranial pressure. Increased urine output may be associated with other conditions, such as diabetes or diuretic use.
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