A nurse is caring for a client in a cardiac unit. Using the five criteria for ECG analysis information, the nurse interprets the client's ECG as which of the following rhythm interpretations?Heart Rate: 59 bpmRhythm: RegularPresence of P waves: One P wave for every QRS complexPR interval: 0.20 secondsQRS complex duration: 0.10 seconds
Ventricular tachycardia
Sinus tachycardia
Sinus bradycardia
Normal sinus rhythm
The Correct Answer is C
A) Ventricular tachycardia: Ventricular tachycardia is characterized by a rapid heart rate exceeding 100 bpm, typically arising from abnormal ventricular activity. In this case, the heart rate is 59 bpm, which does not support this interpretation. Additionally, ventricular tachycardia usually presents with wide QRS complexes and no discernible P waves, neither of which is true in this scenario.
B) Sinus tachycardia: Sinus tachycardia is defined by a heart rate exceeding 100 bpm originating from the sinoatrial (SA) node, with a regular rhythm and normal P waves. The heart rate of 59 bpm in this client is too low for a diagnosis of sinus tachycardia, making this option incorrect.
C) Sinus bradycardia: Sinus bradycardia occurs when the heart rate is less than 60 bpm, with a regular rhythm and a normal PR interval and QRS duration. The provided data shows a heart rate of 59 bpm, a regular rhythm, one P wave for every QRS complex, a PR interval of 0.20 seconds, and a QRS duration of 0.10 seconds, which aligns perfectly with the criteria for sinus bradycardia.
D) Normal sinus rhythm: Normal sinus rhythm typically presents with a heart rate of 60-100 bpm, a regular rhythm, and appropriate P waves for each QRS complex. Given the heart rate of 59 bpm, this does not meet the criteria for normal sinus rhythm, as it falls below the acceptable range.
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Correct Answer is A
Explanation
A. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on 2 or more separate occasions.": This statement accurately reflects the criteria for diagnosing hypertension. According to guidelines, a diagnosis is typically confirmed when blood pressure readings consistently exceed normal levels (usually defined as 130/80 mm Hg) on two or more separate visits.
B. "For confirmed diagnosis of hypertension, BP readings should be lower than normal on only one occasion.": This statement is incorrect. A single low reading does not confirm a diagnosis of hypertension. In fact, it contradicts the concept of hypertension, which involves consistently high readings.
C. "For confirmed diagnosis of hypertension, BP readings should be higher than normal on more than three separate occasions.": This statement is misleading. While multiple readings are often taken, the threshold for diagnosis is two or more elevated readings, not three.
D. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on only one occasion.": This statement is inaccurate, as a single elevated reading is not sufficient for diagnosis. Consistent elevations over multiple occasions are necessary for a confirmed diagnosis.
Correct Answer is D
Explanation
A. Low fat diet: While a low-fat diet can be beneficial for overall cardiovascular health, it is not the most critical intervention for a client with Buerger's Disease. The primary concern is addressing the underlying causes of the disease rather than just dietary modifications.
B. Blood glucose control: This is important for clients with diabetes but is not specific to Buerger's Disease. Effective management of blood glucose levels does not directly address the primary issues associated with this condition.
C. Blood pressure control: Managing blood pressure is important for overall cardiovascular health; however, it is not the most immediate concern for a client with Buerger's Disease compared to smoking cessation.
D. Smoking cessation: This is the most critical intervention. Buerger's Disease is strongly associated with tobacco use, and smoking cessation is essential to halt the progression of the disease and improve symptoms. Educating the client about the importance of quitting smoking can lead to significant improvements in their condition and overall vascular health.