A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes with a heart rate of 35 beats/min on the monitor. What physical as-sessment parameter would be important to incorporate for this client?
A. Assess for pulmonary rales.
B. Assess for acute hypertension.
C. Assess for confusion or syncope.
D. Assess for the presence of a gallop rhythm.
C
A heart rate of 40 beats/min or below, with widened QRS complexes, should alert the nurse to the possibility that the AV block is infranodal and a ventricular escape focus is pacing the ven-tricles. This could have hemodynamic consequences and the client is at risk of inadequate cere-bral perfusion. The nurse should assess for lightheadedness, confusion, syncope, and seizure ac-tivity.
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