A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?

Elective cardioversion

CPR

Radiofrequency catheter ablation

Defibrillation

Answer and Explanation

The Correct Answer is A

A.   Elective cardioversion is a procedure used to restore a normal heart rhythm by delivering a controlled electrical shock to the heart. It is generally used for patients with stable atrial or ventricular arrhythmias who do not respond to medication. In the case of stable VT, elective cardioversion might be considered if the arrhythmia is causing symptoms or if the patient’s condition changes
B.   CPR is an emergency procedure used when a person’s heart has stopped beating (cardiac arrest) or when they are not breathing. It is not indicated for a stable VT because the patient is still stable and conscious, and CPR is not used for arrhythmias like VT in a stable patient.
C.   Radiofrequency catheter ablation is a procedure used to destroy abnormal electrical pathways in the heart that cause arrhythmias. This is often used as a treatment for recurrent or persistent VT, especially if medication or cardioversion fails to manage the condition effectively. For a stable patient with VT, this treatment might be considered in the long-term management plan rather than as an immediate intervention.
D.   Defibrillation is the use of an electrical shock to the heart to restore a normal rhythm in cases of life- threatening arrhythmias such as ventricular fibrillation or pulseless VT. It is not used for stable VT because the patient still has a pulse and is not in immediate danger of cardiac arrest

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Correct Answer is C

Explanation

A. This client is at risk for other complications such as electrolyte imbalances or heart failure, but not specifically neurogenic shock.
B. This client is experiencing respiratory distress, which is a different type of shock (anaphylactic or septic shock might be considered, but not neurogenic).

C. Guillain-Barré syndrome is an autoimmune disorder that affects the nervous system, often leading to paralysis. It can cause a rapid loss of muscle function, which can result in neurogenic shock due to loss of sympathetic nervous system tone.
D. This client is at risk for hypovolemic shock due to fluid loss, not neurogenic shock.

A. Ability to self-feed with the use of adaptive equipment B. Ability to achieve independent transfer from bed to wheelchair C. Use of a wheelchair with a chin or mouth stick D. Independent control of bowel and bladder function

Correct Answer is A

Explanation

A. This is a realistic goal for a C5 injury. Patients can often develop the strength and coordination in their arms to use adaptive equipment like a mobile arm support or a built-up spoon to feed themselves.
B. This goal is generally not achievable with a C5 injury. Independent transfers require significant lower body strength and coordination, which are completely absent in this case.
C. This is a potential option, but it's not a rehabilitation goal. It's more of an adaptive equipment recommendation to assist with mobility and independence in tasks like operating computer or phone.

D. This is not a realistic goal for a complete spinal cord transection at C5. Bowel and bladder function are typically impaired below the level of injury.

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A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock?

Correct Answer is C

Explanation

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

Correct Answer is A

Explanation

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