A nurse is caring for an adolescent client who has cystic fibrosis.
Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

Choice A rationale:

The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the absence of distinct P waves on the ECG.

Choice B rationale:

Ventricular asystole is a flatline on the ECG, indicating the absence of electrical activity in the heart. It is a life-threatening arrhythmia and requires immediate intervention with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) protocols.

Choice C rationale:

Second-degree heart block is characterized by intermittent failure of atrial electrical impulses to conduct to the ventricles. This results in occasional dropped beats and a varying heart rate. It is not consistent with the described ECG findings in the question.

Choice D rationale:

Sinus tachycardia is a regular, fast heart rate originating from the sinoatrial (SA) node. In sinus tachycardia, P waves are present, indicating that the electrical impulses originate in the SA node. The described ECG findings do not match the characteristics of sinus tachycardia.

Choice A rationale:

Asking the client directly about the hallucinations is essential in understanding the nature and content of the hallucinations. This information is crucial for the nurse to assess the client's mental state accurately and plan appropriate interventions. Direct communication helps establish trust and rapport with the client, making them more likely to share their experiences.

Choice B rationale:

Avoiding eye contact can create a sense of disconnection and may increase the client's anxiety. Establishing eye contact, on the other hand, communicates empathy and attentiveness, which are essential in therapeutic communication.

Choice C rationale:

Encouraging the client to lie down in a quiet room might not be the most appropriate action, as it does not address the hallucinations directly. It's important to address the hallucinations and help the client cope with them effectively.

Choice D rationale:

Referring to the hallucinations as if they are real might validate the client's experience but can also perpetuate the hallucinations. The nurse should acknowledge the client's feelings without reinforcing the false beliefs. Providing reality-based perspectives and encouraging the client to explore the origin of these hallucinations can be more beneficial.