A nurse is collecting data from a client who is receiving continuous cardiac monitoring that is indicating premature ventricular contractions (PVCs). Which of the following findings should the nurse expect when assessing the client?
S3 heart sounds
Irregular pulsations
Bradycardia
Increase in point of maximum impulse (PMI)
The Correct Answer is B
A) S3 heart sounds:
S3 heart sounds are typically associated with heart failure and are not directly related to premature ventricular contractions (PVCs). S3 heart sounds occur during the early diastolic phase and are heard immediately after S2.
B) Irregular pulsations:
This is the correct choice. Premature ventricular contractions (PVCs) can cause irregular pulsations in the pulse. PVCs are premature contractions originating from the ventricles, which can interrupt the normal rhythm of the heart and lead to irregularities in the pulse.
C) Bradycardia:
Premature ventricular contractions (PVCs) can lead to various rhythm disturbances, but bradycardia (slow heart rate) is not typically associated with PVCs. In fact, PVCs often occur in the context of tachycardia (rapid heart rate).
D) Increase in point of maximum impulse (PMI):
An increase in the point of maximum impulse (PMI) is not typically associated with premature ventricular contractions (PVCs). The PMI refers to the location where the apex of the heart is palpated during systole and is not directly affected by PVCs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
(A) Lean back in the chair: Leaning back in the chair can be perceived as a relaxed posture, but it might also convey disinterest or detachment in the conversation. Active listening involves being engaged and showing interest in what the client is saying.
(B) Use intermittent eye contact: This is the most appropriate answer. Maintaining eye contact is an important part of active listening as it shows that the nurse is focused and interested in what the client is saying. However, constant eye contact can be intimidating or uncomfortable for some clients, so intermittent eye contact is often more appropriate.
(c) Have a pen and paper: Having a pen and paper can be useful for note-taking, but it is not a direct action of active listening. It’s important to maintain focus on the client during the conversation, and excessive note-taking can be distracting.
(D) Sit side-by-side with the client: While sitting side-by-side with the client can create a more relaxed and equal atmosphere, it is not a direct action of active listening. The nurse should face the client and maintain appropriate eye contact to show engagement and interest.
Correct Answer is C
Explanation
A. Cerebral edema:
Cerebral edema is not typically associated with hyperkalemia. It is more commonly seen in conditions such as hyponatremia or cerebral trauma.
B. Hypoactive bowel sounds:
Hypoactive bowel sounds are not typically associated with hyperkalemia. They may occur in conditions such as paralytic ileus or intestinal obstruction.
C. Decreased deep tendon reflexes:
Decreased deep tendon reflexes (hyporeflexia) are a common manifestation of hyperkalemia. High potassium levels can impair neuromuscular function, leading to decreased reflexes.
D. Wheezing:
Wheezing is not typically associated with hyperkalemia. It may occur in conditions such as asthma or chronic obstructive pulmonary disease (COPD).
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