How should the nurse identify the rhythm shown in the diagram?
ventricular tachycardia
asystole
normal sinus rhythm
ventricular fibrillation
The Correct Answer is A
A. Ventricular tachycardia: Ventricular tachycardia (VT) is identified by a regular, fast rhythm with wide QRS complexes, typically without visible P waves. This rhythm often appears as consecutive, large, uniform waves, which is consistent with what is seen in the diagram.
B. Asystole: Asystole is characterized by a flat line, indicating no electrical activity, which is not present in this strip.
C. Normal sinus rhythm: Normal sinus rhythm would show identifiable P waves, a normal QRS complex, and a regular rate, which are not observed here.
D. Ventricular fibrillation: Ventricular fibrillation appears as chaotic, irregular waveforms with no clear QRS complexes or organization, which does not match the rhythm shown.
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Correct Answer is B
Explanation
A. The palm is not the best part of the hand to assess lymph nodes, as it lacks the sensitivity needed for palpation.
B. The parts of the fingers, particularly the pads of the fingers, are used to assess lymph node size. This allows for a more precise and sensitive examination of the lymph nodes.
C. The dorsal side of the hand is not typically used for palpation because it is less sensitive.
D. The ulnar surface of the hand is not commonly used for this purpose, as the fingertips provide better tactile sensation for assessing lymph node size.
Correct Answer is C
Explanation
A. This description relates more to a sensory discrimination test, not graphesthesia.
B. This option does not accurately describe the graphesthesia test, which involves identifying shapes or numbers rather than just touch location.
C. In the graphesthesia test, the client closes their eyes while the nurse uses a blunt object to write a number or shape in the client's palm, and the client must identify what was written. This assesses the ability to recognize letters or numbers drawn on the skin.
D. This option describes a two-point discrimination test rather than graphesthesia, which focuses on identifying drawn shapes or numbers.