A patient with a pacemaker is ambulating in the room with the assistance of nurse. The patient complains of dizziness and shortness for breath. The initial action by the nurse should be?

1. A

   Reassure the patient that you will stay with him

2. B

   Have him rest in bed immediately

3. C

   Monitor his vital signs every hour

4. D

   Do nothing because this is normal after surgery

Appeared in: AIIMS Bhatinda NO - 2019

Explanation

• The patient's symptoms of dizziness and shortness of breath during ambulation indicate a potential decrease in cardiac output or a pacemaker malfunction.
• The most immediate priority is patient safety. Dizziness significantly increases the risk of a fall, which could lead to serious injury.
• Stopping the activity and having the patient rest immediately reduces the heart's workload and oxygen demand, which can help alleviate the symptoms.
• This action places the patient in a safe position, allowing the nurse to proceed with a focused assessment of vital signs and cardiac rhythm.

Why Other Options Were Wrong

• Option A: While therapeutic communication is important, reassuring the patient does not address the immediate physiological problem or the significant safety risk of falling due to dizziness.
• Option C: Monitoring vital signs is a crucial assessment, but it should be performed only after the patient's immediate safety is secured. The frequency of 'every hour' is also inappropriate for an acute event; monitoring should be more frequent until the patient is stable.
• Option D: Dizziness and shortness of breath in a cardiac patient during exertion are never considered normal. These are warning signs of a potentially serious complication that requires immediate attention.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prioritization of nursing actions for a patient with a pacemaker experiencing complications to guide bedside assessment, documentation, and the next nursing action.
• Nurses must be able to rapidly identify signs of cardiac decompensation or pacemaker malfunction (e.g., dizziness, dyspnea, palpitations) and prioritize safety interventions above all else.
• The nursing principle of 'safety first' is paramount. When a patient is dizzy, the immediate risk of a fall must be addressed before proceeding to other assessments or interventions.
• This scenario underscores the importance of early ambulation post-procedure while also being vigilant for complications. The nurse's role is to promote mobility safely.

How to Approach the Question

• First, identify the key elements of the clinical scenario: a patient with a pacemaker, an activity (ambulation), and acute symptoms (dizziness, shortness of breath).
• Recognize that the question asks for the 'initial action,' which means you must determine the absolute first priority.
• Analyze the symptoms. Dizziness is a major safety concern because it indicates a risk for syncope (fainting) and falls. Shortness of breath indicates a potential cardiac or respiratory issue.
• Apply the nursing principle of prioritizing patient safety. The most immediate threat is a fall due to dizziness.
• Evaluate the options based on which one best addresses the immediate safety threat and the physiological stressor. Stopping the activity and having the patient rest is the only option that directly mitigates the fall risk and reduces cardiac workload.
• Differentiate between initial actions and subsequent, necessary actions. Assessing vital signs is essential but must come after ensuring the patient is physically safe.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing actions for a patient with a pacemaker experiencing complications.
• Stem keywords: pacemaker, ambulating, dizziness, shortness for breath, initial action
• Lead-in keywords: initial action
• Negative lead-in flag: false

Question ID

QNYRlVT1MgHbr9MzH79aeA

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 pp. 121-123, 128-130

E6 Nursing Fundamentals Potter Perry 12e Part 1 p. 245-247