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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 A

Explanation

A. Ulcer refers to a wound with a loss of epidermis and dermis, often irregular and deeper, potentially bleeding.
B. Erosion involves a shallow loss of the epidermis only, not extending into the dermis.
C. Nodule is a solid, raised lesion that is typically firm and not ulcerated.
D. Cyst is a sac-like structure containing fluid or semi-solid material, not a wound with loss of tissue.

A. Assess the forearm and hand for infection B. Assess the lower extremities C. Assess the dorsalis pedis pulses D. None of the above

Correct Answer is B

Explanation

A. Assess the forearm and hand for infection would be relevant if the swollen lymph node were in the upper extremity, but the inguinal node would be more associated with a lower extremity infection.
B. Assess the lower extremities is the correct next step since the inguinal lymph nodes drain the lower body, including the legs and genital area.
C. Assess the dorsalis pedis pulses is not the next step, though it may be important if vascular concerns are suspected.
D. None of the above is incorrect because assessing the lower extremities is the next logical step.

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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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Naxlex Comprehensive Predictor Exams

The nurse is assessing a lesion on a patient and observes a focal loss of epidermis and dermis, a depression extending into the dermis, irregularly shaped, and bleeding. This type of wound is known as a/an

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

The nurse has just completed a lymph node assessment on a healthy 40-year-old female patient. Which of the following is an expected finding?

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