A patient with an implantable cardioverter-defibrillator (ICD) experiences a shock.
Which of the following should the nurse assess first?
The patient's medication history.
The ICD insertion site.
The patient's emotional state.
The patient's hemodynamic status.
The Correct Answer is D
Choice A rationale
The patient's medication history is important to review after a shock to determine if any drugs (e.g., antiarrhythmics) need adjustment or if a proarrhythmic drug could have contributed to the episode. However, this is a secondary assessment; the immediate priority is determining if the shock restored stable circulation.
Choice B rationale
The ICD insertion site should be assessed for signs of infection, swelling, or hematoma, especially following a shock which can indicate a device malfunction or lead fracture. While necessary for device integrity and infection control, it is not the immediate priority over assessing the patient's cardiac function and stability.
Choice C rationale
The patient's emotional state, including anxiety or fear following a high-voltage shock, requires therapeutic support and debriefing. While critical for holistic care, addressing the psychosocial impact is not the first step; immediate focus must be placed on the physical stability and circulatory status.
Choice D rationale
The patient's hemodynamic status (e.g., blood pressure, heart rate, rhythm, O_2 saturation, level of consciousness) must be assessed first. A shock indicates a potentially life-threatening arrhythmia; the nurse must immediately confirm if the shock was effective in terminating the arrhythmia and whether the patient is now stable or requires further intervention. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
MRI generates powerful magnetic fields and radiofrequency pulses that can potentially interfere with the function of a pacemaker, reprogram it, heat the lead tips, or damage the device's circuitry. Patients must confirm if their pacemaker is specifically MRI-conditional or MRI-safe before undergoing the imaging procedure to prevent serious complications, a vital component of patient education.
Choice B rationale
Post-procedurally, patients should be instructed to keep the incision site clean and dry for a specified period, typically several days to a week, to promote healing and prevent infection. Showering is usually permitted but the site should be kept dry, or sponge bathing is recommended initially. The restriction is usually on submerging the site (baths, hot tubs, swimming), making the blanket "no restrictions on showering" advice unsafe.
Choice C rationale
Infection is a serious potential complication following any surgical procedure, including pacemaker insertion. Patients and caregivers must be taught to recognize the classic signs of a localized infection, which include erythema (redness), warmth, pain, and any type of purulent or non-purulent drainage from the incision site, necessitating prompt medical attention.
Choice D rationale
To prevent lead dislodgement from the endocardium before sufficient tissue growth secures it, patients are advised to restrict movement of the arm on the insertion side. Specifically, they should avoid vigorous activity, lifting more than a few pounds, and raising the arm above the shoulder for several weeks as directed by their cardiologist. —. ##.
Correct Answer is B
Explanation
Choice A rationale
Dyspnea (shortness of breath) is a common symptom of heart failure or pulmonary congestion, which can be related to poor cardiac function, but it is not a direct, specific sign of diaphragmatic pacing. This symptom is generally too non-specific to pinpoint lead misplacement to the diaphragm.
Choice B rationale
The diaphragm is innervated by the phrenic nerve, which passes close to the heart. When a pacemaker lead is positioned incorrectly and stimulates the phrenic nerve, it causes rhythmic, involuntary contractions of the diaphragm, which clinically manifest as persistent hiccups. This is a classic and specific sign of lead migration or perforation causing extracardiac stimulation.
Choice C rationale
Coughing up blood (hemoptysis) suggests damage to the pulmonary or tracheobronchial system, which is a serious but rare complication, and not the primary clinical manifestation associated with stimulation of the diaphragm or the phrenic nerve by an incorrectly positioned pacemaker lead.
Choice D rationale
Chest pain can occur after a pacemaker insertion due to irritation of the surrounding tissues or a complication like pneumothorax, but it is a general symptom. It is not a direct consequence of phrenic nerve stimulation and diaphragmatic contraction, which specifically causes hiccups.
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