Nokea
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown below (see figure). The nurse identifies this rhythm as:
- A. Atrial fibrillation.
- B. Atrial tachycardia.
- C. Premature ventricular contractions.
- D. Ventricular tachycardia.
Correct Answer: C
Rationale: Premature ventricular contractions (PVCs) are characterized by early, wide QRS complexes on an ECG, common post-myocardial infarction. The other rhythms have distinct ECG patterns not described here.
You may also like to solve these questions
A client has nephrotic syndrome. To aid in the resolution of the client's edema, the physician orders 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome?
- A. Crackles in the lung bases.
- B. Blood pressure elevation.
- C. Cerebral edema.
- D. Cool skin temperature in lower extremities.
Correct Answer: B
Rationale: Albumin increases oncotic pressure, pulling fluid into the vascular space, which may elevate blood pressure. Crackles, cerebral edema, or cool extremities would indicate complications.
The nurse is assessing a client with suspected appendicitis. Which test should the nurse perform to confirm the diagnosis?
- A. Rovsing's sign
- B. Murphy's sign
- C. Psoas sign
- D. Both A and C
Correct Answer: D
Rationale: Rovsing's sign (pain in the right lower quadrant with left-sided pressure) and psoas sign (pain with leg extension) support an appendicitis diagnosis.
A client with schizophrenia is responding well to risperidone (Risperdal) and is no longer psychotic. After teaching the client about managing his illness, which of the following statements reflects a need for further education?
- A. I just don't know if I can afford to keep taking medicines every day
- B. When my thoughts start racing, I know I need to relax more
- C. I can name the side effects of Risperdal, but I'm not having any
- D. I don't listen to my mom's religious beliefs about not using medicines
Correct Answer: A
Rationale: Concern about affording daily medication suggests a need for further education on resources or adherence strategies, as non-adherence risks relapse. Other statements reflect appropriate understanding.
A family has taken home their newborn and later received a call from the pediatrician that the PKU levels for their newborn daughter are abnormally high. Additional testing confirmed the diagnosis of phenylketonuria. The parents refuse to believe the results as no one else in their family has the disease. The nurse explains that the disease:
- A. Is carried on recessive genes contributed by each parent.
- B. Is caused by a recessive gene contributed by either parent.
- C. Is cured by eliminating dietary protein for this child.
- D. Will not impact future childbearing for the family.
Correct Answer: A
Rationale: Phenylketonuria is an autosomal recessive disorder, requiring both parents to contribute a defective gene. It is not caused by a single parent's gene, cannot be cured by diet alone (though managed by low-phenylalanine diet), and may impact future childbearing as parents are carriers.
A client with a diagnosis of Parkinson's disease is prescribed ropinirole (Requip). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Drowsiness.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Ropinirole, a dopamine agonist, commonly causes drowsiness, which the nurse should monitor in Parkinson's clients.