A client in the emergency department complains of chest pain, diaphoresis, shortness of breath, lightheadedness, and dizziness
The cardiac monitor displays ventricular tachycardia at 180 beats per minute. What is the nurse's most immediate concern for this client?
1. The client may be experiencing a posterior myocardial infarction.
2. The client may suffer a cerebral vascular accident.
3. The client is at risk for development of a pulmonary embolism.
4. The client is at risk for cardiac death.
Correct Answer: 4
Rationale 1: While a myocardial infarction may occur, this is not the most immediate concern.
Rationale 2: A cerebral vascular accident may occur, but this is not the most immediate concern.
Rationale 3: Prevention of an embolism is not first priority.
Rationale 4: The most vital concern is deterioration into cardiac arrest. If not treated quickly, the client will die due to lack of circulation of oxygen.
Global Rationale: The most vital concern is deterioration into cardiac arrest. If not treated quickly, the client will die due to lack of circulation of oxygen. While a myocardial infarction and cerebral vascular accident may occur, these are not the most immediate concern. Prevention of an embolism is not first priority.
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