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

Client's blood pressure

Client's weight

Client's respiratory rate

Intensity of the murmur

Location of the murmur

Client's temperature

Timing of the murmur

Client's medication history

Answer and Explanation

Correct Answer : A,D,E,G

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.

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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.

A. Improper positioning B. Fatigue or weakness C. Respiratory distress D. Increased comfort and relaxation

Correct Answer is C

Explanation

A. Improper positioning does not apply in this case; the position described is often associated with respiratory distress.
B. Fatigue or weakness may be present, but the described position is more indicative of difficulty breathing.
C. Respiratory distress is suggested by the patient leaning forward, which is a common position for patients with shortness of breath as it helps expand the lungs and ease breathing.
D. Increased comfort and relaxation is unlikely; this position is more often associated with discomfort and difficulty breathing.

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

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