Author Question: A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate ... (Read 112 times)

CBme · **on:** Jun 25, 2018

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?

a. Mid-sternal chest pain
b. Increased urine output
c. Mild orthostatic hypotension
d. P wave touching the T wave

Question 2

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge?

a. Medication reconciliation
b. Immunization history
c. Religious beliefs
d. Nutrition preferences

CourtneyCNorton · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

Answer to Question 2

ANS: A
The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.