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A client with sepsis has a temperature of 40°C. Which dysrhythmia is most likely to occur in this client?
- A. Bradydysrhythmia
- B. Tachydysrhythmia
- C. Wolff-Parkinson-White dysrhythmia
- D. Long QT dysrhythmia
Correct Answer: B
Rationale: A client with sepsis and a temperature of 40°C is likely experiencing a systemic inflammatory response, which can lead to a variety of dysrhythmias. In this case, the client is more likely to develop a tachydysrhythmia (fast heart rate) due to the body's response to the infection. Sepsis can result in an increase in heart rate as the body tries to maintain adequate perfusion to vital organs in response to the inflammatory process. Tachydysrhythmias such as supraventricular tachycardia or atrial fibrillation are commonly observed in septic patients with high fevers.
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A 14-year-old child was recently diagnosed with hypertrophic cardiomyopathy. During a follow-up appointment, the mother asks the nurse, "How will this affect my child's ability to play football in the fall?" How should the nurse respond?
- A. "This shouldn't affect his ability to play football."
- B. "Children with cardiomyopathy should not play football."
- C. "He could participate in flag football but not tackle football."
- D. "This may actually make him a better, stronger football player."
Correct Answer: B
Rationale: Children diagnosed with hypertrophic cardiomyopathy should not participate in competitive sports such as football due to the potential risk of sudden cardiac events. Physical activity and sports with lower intensity may be allowed, but organized competitive sports with high intensity (such as football) are generally contraindicated. It is important for the health care team to prioritize the child's safety and well-being over sports participation in cases of cardiomyopathy. The nurse should communicate this information to the mother to help her understand the importance of limiting the child's physical activities to reduce the risk of complications related to hypertrophic cardiomyopathy.
During an assessment, the nurse decides to assess a patient’s calcium level. Which action will the nurse take to identify a low calcium level?
- A. Palpate turgor of skin
- B. Observe the color of the skin
- C. Conduct a Trousseau’s sign test
- D. Save urine to measure 17-ketosteroids
Correct Answer: C
Rationale: The Trousseau’s sign test is used to identify low calcium levels in a patient. This test involves inflating a blood pressure cuff on the patient's arm above systolic pressure for a few minutes, which can trigger a carpal spasm (wrist and hand flexion) in patients with low calcium levels (hypocalcemia). This is due to increased neuromuscular irritability caused by low calcium levels. Therefore, conducting a Trousseau’s sign test is the appropriate action to identify a low calcium level in a patient. Palpating turgor of skin, observing the color of the skin, and saving urine to measure 17-ketosteroids are not relevant actions for assessing calcium levels.
A patient has been vomiting for 4 hours. Which hormone will increase secretion in response to the physiologic changes caused by the vomiting?
- A. ADH
- B. Renin
- C. Thyroxin
- D. Aldosterone
Correct Answer: D
Rationale: Vomiting can lead to dehydration and electrolyte imbalances due to the loss of fluids and electrolytes. In response to these physiologic changes caused by vomiting, aldosterone secretion will increase. Aldosterone is a hormone produced by the adrenal glands that acts on the kidneys to increase reabsorption of sodium and water, helping to maintain blood pressure and electrolyte balance. By increasing aldosterone secretion, the body aims to retain more sodium and water to counteract the effects of vomiting and prevent dehydration.
The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?
- A. P wave smooth and round
- B. Absent U wave
- C. PR interval 0.30 seconds
- D. ST segment isoelectric
Correct Answer: D
Rationale: An isoelectric ST segment on an electrocardiogram can indicate myocardial ischemia or injury, which can lead to a decrease in perfusion to the heart muscle. This finding suggests an increased risk of inadequate blood flow to the heart, potentially resulting in further complications such as a myocardial infarction or altered perfusion to other organs. In a client with lower extremity edema and shortness of breath, identifying this ECG finding is crucial for early intervention and monitoring to prevent further deterioration in perfusion status.
The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?
- A. Blood pressure of 142/92 mmHg
- B. Pulse of 92 beats per minute
- C. Respiratory rate of 24 per minute
- D. Weight gain of 16 oz per week
Correct Answer: A
Rationale: A blood pressure of 142/92 mmHg in a client in the third trimester of pregnancy is elevated and could indicate the development of preeclampsia, a serious hypertensive disorder that can have adverse effects on both the mother and the fetus. Preeclampsia is characterized by high blood pressure accompanied by signs of organ damage, such as proteinuria and changes in other laboratory values. Immediate intervention is required in this situation, as preeclampsia can lead to complications such as seizures (eclampsia), stroke, and placental abruption. It is essential for the nurse to further assess the client and notify the healthcare provider promptly for appropriate management.