A nurse is analyzing a client's electrocardiogram (ECG) strip and identifies the following information: Heart rate: 92/min Rhythm: Irregular P wave:
Unable to identify PR interval:
Unable to measure QRS duration:
0.10 seconds Based upon this information,
thenurse should interpret the client's rhythm as indicating which of the following?
Supraventricular tachycardia
Atrial fibrillation
Sinus bradycardia
First-degree heart block
The Correct Answer is B
A. Supraventricular tachycardia (SVT) typically has identifiable P waves; the absence of P waves suggests a different condition.
B. Atrial fibrillation is characterized by an irregular rhythm, inability to identify P waves, and varying intervals. This interpretation aligns with the client's ECG findings.
C. Sinus bradycardia would show identifiable P waves and a regular rhythm with a heart rate less than 60 bpm, which does not match the provided information.
D. First-degree heart block would also show identifiable P waves and regularity in the rhythm with a prolonged PR interval, which is not indicated here.
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Correct Answer is C
Explanation
A. The meningococcal (MCV4) vaccine is typically recommended for preteens and adolescents, usually starting at age 11.
B. The hepatitis B vaccine is typically administered at birth, 1-2 months, and 6-18 months, so a 4-year-old may already have received this vaccine.
C. The varicella (VAR) vaccine is recommended for children at ages 12-15 months and again at 4-6 years, making it appropriate for a 4-year-old child.
D. The Haemophilus influenza type b (Hib) vaccine is usually given to children in a series before 5 years of age, but it is more commonly completed by age 2-3 years. The 4-year-old may already be up to date with this vaccine.
Correct Answer is D
Explanation
A. While anxiety and withdrawal are concerning, they may not require immediate intervention compared to behaviors that pose risks to the child or others.
B. A stable child with a concerned parent may benefit from reassurance and support, but they do not require urgent intervention.
C. Stomach pain without an apparent cause should be assessed, but it may not be as urgent as aggressive behavior that can harm others.
D. A child exhibiting aggressive behavior poses a risk to themselves and others, necessitating immediate assessment and intervention to ensure safety and manage the behavior effectively.