A nurse is collecting data on a client who has a heart rate of 44/min.
Which of the following findings should the nurse expect?

Temperature of 39°C (102.2°F)

History of cigarette smoking.

Patient reports they feel that they are going to pass out.

Hypoglycemia.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Temperature of 39°C (102.2°F) A temperature of 39°C (102.2°F) is elevated, but it is not directly related to a heart rate of 44/min. Elevated temperature can be caused by various factors, such as infection, and would not be an expected finding solely due to the heart rate.

Choice B rationale:

History of cigarette smoking. A history of cigarette smoking may be a risk factor for certain cardiovascular conditions, but it does not directly explain a heart rate of 44/min. The heart rate can be influenced by factors such as medications, cardiac conditions, and autonomic nervous system activity.

Choice D rationale:

Hypoglycemia. Hypoglycemia (low blood sugar) can cause various symptoms, including shakiness, confusion, and sweating, but it is not the primary cause of a heart rate of 44/min. Hypoglycemia is more likely to cause symptoms related to altered mental status and autonomic nervous system activation.

Choice C rationale:

Patient reports they feel that they are going to pass out. A heart rate of 44/min is significantly lower than the normal range for adults, which is typically between 60-100 beats per minute. Such a low heart rate, known as bradycardia, can lead to decreased blood flow to vital organs, including the brain. Feeling like they are going to pass out is a concerning symptom associated with bradycardia because it suggests inadequate cardiac output and perfusion. This finding should prompt immediate assessment and intervention to address the underlying cause of the slow heart rate.

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Correct Answer is C

Explanation

Choice A rationale:

Rigid abdomen. A rigid abdomen is not typically associated with placenta previa. Placenta previa is a condition in which the placenta partially or completely covers the cervix, and it is more likely to present with painless vaginal bleeding rather than abdominal rigidity.

Choice B rationale:

Persistent uterine contractions. Persistent uterine contractions are not a characteristic finding in placenta previa. In fact, uterine contractions can be concerning in the presence of placenta previa as they may increase the risk of bleeding.

Choice C rationale:

Bright red vaginal bleeding. Bright red vaginal bleeding is a common and hallmark symptom of placenta previa. This bleeding typically occurs without pain and can be intermittent or continuous. It is essential to recognize this symptom promptly because it can lead to significant maternal and fetal complications.

Choice D rationale:

Increased fetal movement. Increased fetal movement is not a typical finding in placenta previa. The presence or absence of fetal movement should always be monitored during pregnancy, but it is not a specific indicator of placenta previa.

A. A client who has psychomotor retardation. B. A client who reports an inability to concentrate. C. A client who exhibits an increase in energy. D. A client who experiences persistent insomnia.

Correct Answer is C

Explanation

The correct answer is: c. A client who exhibits an increase in energy.

Choice A reason: A client with psychomotor retardation may experience a visible slowing of physical and emotional reactions. This symptom is associated with major depressive disorder and can manifest as slowed speech, decreased movement, and impaired cognitive function. While psychomotor retardation is a significant symptom of depression, it is not typically identified as the highest risk factor for suicide when compared to other symptoms such as a sudden increase in energy, which can indicate a potential for acting on suicidal thoughts.

Choice B reason: An inability to concentrate is another symptom that can be present in individuals with major depressive disorder. It refers to difficulty in focusing, making decisions, or remembering things. Although this can contribute to the overall severity of depression, it is not directly linked to an increased risk of suicide as strongly as some other symptoms like changes in sleep patterns or behavior.

Choice C reason: An increase in energy in a client with major depressive disorder, especially if it occurs suddenly, can be a warning sign of potential suicidal behavior. This change can indicate that the individual has decided about suicide and may now have the energy to act on these thoughts. It is important for healthcare providers to closely monitor such changes in energy levels, as they can be indicative of an increased risk for suicide.

Choice D reason: Persistent insomnia is a common symptom in individuals with major depressive disorder and can exacerbate other symptoms of depression. Lack of sleep can lead to irritability, cognitive impairment, and can affect overall health. While it is a concerning symptom and can affect a person’s risk for suicide, it is not considered the single highest risk factor when compared to a sudden increase in energy.

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A nurse is collecting data on a client who has a heart rate of 44/min.Which of the following findings should the nurse expect?

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Correct Answer is C

Explanation

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Correct Answer is C

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A nurse is collecting data on a client who has a heart rate of 44/min.
Which of the following findings should the nurse expect?