What is the rate on the rhythm strip in the image below?
90
110
73
50
The Correct Answer is A
A. To determine the heart rate from a rhythm strip, you can count the number of R-R intervals in a set time frame (typically 6 seconds) and multiply by 10 to convert to beats per minute. If the rhythm is regular, you can also use the 300 method by dividing 300 by the number of large squares between R waves. In this case, the rate is calculated to be 90 beats per minute.
B. A heart rate of 110 beats per minute would be classified as tachycardia and is not supported by the observed intervals.
C. A heart rate of 73 beats per minute would be a normal resting heart rate but does not match the calculation from the rhythm strip.
D. A heart rate of 50 beats per minute would indicate bradycardia, which is not reflected in this rhythm strip.
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Correct Answer is B
Explanation
A. The planning phase involves setting goals and determining interventions based on the assessment data.
B. The assessment phase is where the nurse gathers information about the client's health history, including potential allergies, which is essential for safe care and diagnostic testing.
C. The implementation phase involves carrying out the planned interventions, which would include considerations for allergies but not the initial questioning about them.
D. The evaluation phase assesses the effectiveness of the interventions and the client's response to care, which is not the appropriate time to inquire about allergies.
Correct Answer is A
Explanation
A. Presbyopia is a common age-related condition that affects the ability to see close objects clearly, which aligns with the client's difficulty in reading, sewing, and seeing faces up close.
B. While some vision changes are expected with aging, the specific difficulties the client is experiencing suggest a more definitive condition rather than "normal" vision changes.
C. While cataracts can cause vision issues, the specific symptoms described (trouble reading and seeing objects up close) are more characteristic of presbyopia.
D. Glaucoma typically involves peripheral vision loss rather than difficulty with near vision, so this option is not supported by the findings.