A heart murmur should be assessed for which of the following? Select all that apply.

Timing

Radiation

Fremitus

Egophony

Location

Answer and Explanation

Correct Answer : A,B,E

A.   The timing of the murmur (systolic or diastolic) is an essential component of murmur assessment. It
helps in determining the cause of the murmur, whether it’s related to heart valves or flow.
B.   Radiation refers to where the murmur can be heard best, or if it radiates to other parts of the chest or neck, helping to indicate the origin of the murmur.
C.   Fremitus is a term used to describe the vibrations felt on the chest wall when a person speaks, which is unrelated to heart murmurs.
D.   Egophony refers to an abnormal lung sound heard during auscultation and is not relevant to the assessment of a heart murmur.
E.   The location where the murmur is heard best on the chest wall is crucial in determining its origin, such as whether it is coming from the aortic or mitral valve.

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Correct Answer is ["A","D","E","G"]

Explanation

A. Client's blood pressure is relevant as it can help correlate the murmur with potential cardiac conditions.
B. Client's weight is not directly related to documenting a heart murmur.
C. Client's respiratory rate is also not relevant to the murmur documentation unless respiratory symptoms are present.
D. Intensity of the murmur is important to document, as it helps assess the severity.
E. Location of the murmur is important for identifying which valve or area of the heart is involved.
F. Client's temperature is not directly related to documenting a heart murmur.
G. Timing of the murmur helps in identifying whether it occurs during systole or diastole, aiding in diagnosis.

A. Cyst B. Nodule C. Zosteriform D. Ulcer

Correct Answer is C

Explanation

A. Cyst refers to a fluid-filled sac, which does not present as a linear arrangement.
B. Nodule refers to a solid, raised lesion, not linear or along a nerve route.
C. Zosteriform refers to a rash or lesion arranged along a unilateral nerve distribution, often seen with shingles (herpes zoster).
D. Ulcer refers to a loss of skin or mucous membrane, not a linear pattern along a nerve route.

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A heart murmur should be assessed for which of the following? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating heart sounds and hears a murmur. What should be included in the nurse's documentation? Select all that apply.

Correct Answer is ["A","D","E","G"]

Explanation

A nurse is examining a patient and finds a lesion that is a linear arrangement along a unilateral nerve route. The nurse would document this finding as

Correct Answer is C

Explanation

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