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 ["A","C","D"]
Explanation
A. Decreased urine output: While not a direct sign of pneumonia, decreased urine output can be an objective finding indicative of dehydration, which often accompanies infections like pneumonia.
B. Headache: Although the client has a headache, it is a subjective symptom rather than an objective finding and is not a primary indicator of pneumonia.
C. Respiratory assessment: The respiratory assessment reveals shortness of breath, crackles in the right lower lobe, and tachypnea, which are commonly associated with pneumonia.
D. Chest X-ray: The chest X-ray shows areas of increased density and infiltrates in the right lower lobe, a hallmark finding that indicates pneumonia.
E. Religion: This does not relate to the clinical findings associated with pneumonia.
F. Bowel sounds: Normal bowel sounds are not indicative of pneumonia.
G. Perception of needles: This is irrelevant to the diagnosis of pneumonia.
Correct Answer is C
Explanation
A. A BMI of 26 is not classified as obese; obesity typically starts at a BMI of 30.
B. Underweight is defined as a BMI less than 18.5, which does not apply to this client.
C. A BMI of 26 falls within the overweight category, which is defined as a BMI between 25 and 29.9.
D. A healthy weight is classified as a BMI between 18.5 and 24.9, which does not include a BMI of 26.