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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
"Instruct the client to take a brisk walk." Rationale: This action is not appropriate for a pregnant client experiencing dizziness, a racing heart, and pallor while lying on their back. It may exacerbate their symptoms and is not recommended.
Choice B rationale:
"Position the client on their left side." Rationale: This is the correct action to take. The client's symptoms, such as dizziness, racing heart, and pallor, suggest that they may be experiencing supine hypotensive syndrome, a common issue in pregnancy. Placing the client on their left side helps relieve pressure on the inferior vena cava, improving blood flow to the fetus and reducing symptoms.
Choice C rationale:
"Check the client's temperature." Rationale: Checking the client's temperature is not the most relevant action to address the reported symptoms. Dizziness, racing heart, and pallor are not typically associated with fever.
Choice D rationale:
"Provide the client with a glass of orange juice." Rationale: While providing orange juice can be helpful in some cases of low blood sugar (hypoglycemia), it is not the primary intervention for a pregnant client with the reported symptoms. These symptoms are more indicative of supine hypotensive syndrome, and the priority is to change the client's position to alleviate the condition.
Correct Answer is D
Explanation
The correct answer is choiced. “Limit the number of choices for the client.”
Choice A rationale:
Using written signs to assist the client with locating the bathroom can be helpful, but it is not the most critical strategy for managing Alzheimer’s disease.
Choice B rationale:
Providing a stimulating environment for the client can sometimes lead to overstimulation, which may increase confusion and agitation in clients with Alzheimer’s disease.
Choice C rationale:
Using confrontation to manage the client’s behavior is not recommended as it can lead to increased agitation and aggression.
Choice D rationale:
Limiting the number of choices for the client helps reduce confusion and anxiety, making it easier for them to make decisions and feel more in control.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.