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How should the nurse identify the rhythm shown in the diagram?

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A.

ventricular tachycardia

B.

asystole

C.

normal sinus rhythm

D.

ventricular fibrillation

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

A. The severity of the condition may correlate with pain but is not a direct measure of the individual's pain experience.

B. Vital signs can change due to pain but are not specific indicators of pain intensity or presence.

C. Nonverbal behavior can provide clues about pain but is subjective and can vary greatly between individuals.

D. Self-rating of pain is considered the most reliable indicator of pain because it reflects the individual's personal experience and perception of their pain, making it the gold standard for assessing pain intensity.

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.

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