A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client’s blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?
A. Flat jugular vein distention (JVD) at 45 degrees.
B. Abnormal level of consciousness.
C. Nausea with vomiting.
D. Headache with sudden onset.
The correct answer and explanation is:
The most important finding to report to the healthcare provider is B. Abnormal level of consciousness.
Explanation:
Atrial fibrillation (AF) with a high ventricular rate, such as 150 beats per minute, can significantly affect cardiac output, leading to hypotension, as indicated by the client’s blood pressure of 80/40 mm Hg. The heart is not able to pump blood efficiently at such a high rate, reducing perfusion to vital organs like the brain. This may cause altered mental status, which could manifest as confusion, disorientation, or an abnormal level of consciousness.
An abnormal level of consciousness is critical to report because it may indicate insufficient cerebral perfusion, which is a serious condition that can result from poor cardiac output. The brain requires a continuous supply of oxygen and nutrients, which is facilitated by adequate cardiac output. When perfusion is compromised, as in this case, neurological symptoms may be the first signs of impending organ failure.
Other options:
- A. Flat jugular vein distention (JVD) at 45 degrees is not an immediate concern. In fact, flat JVD typically suggests normal venous pressure, which does not warrant urgent attention in this scenario.
- C. Nausea with vomiting could be related to the AF or low blood pressure, but it is not as immediately concerning as altered mental status. It may be a secondary symptom of poor perfusion but does not require immediate intervention in the same way as an abnormal level of consciousness.
- D. Headache with sudden onset could indicate a variety of issues, including a possible stroke or other neurological events, but it is not as directly related to the current findings of atrial fibrillation and hypotension as altered mental status.
Therefore, any changes in the client’s level of consciousness should be reported immediately, as they can signify a critical decrease in cerebral perfusion that requires rapid medical intervention.