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
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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Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A change in the size of a mole is a significant red flag and should be concerning for potential skin cancer, particularly melanoma. A mole that enlarges over time, especially if it changes size rapidly, can indicate the development of malignant melanoma.
Color changes in a mole, such as darkening, lightening, or developing multiple colors, should raise concern for melanoma. Melanomas often present with uneven pigmentation, where the mole may become more than one color, such as black, blue, red, or brown. This change in color is abnormal and requires further investigation.
Itching and burning are abnormal symptoms associated with skin lesions and can be indicative of skin cancer. These sensations can occur when the skin becomes irritated or inflamed due to a growing malignancy such as melanoma.
Bleeding from a mole is a red flag and is concerning for skin cancer, especially melanoma. A mole that bleeds or oozes may be ulcerating or eroding, which are signs of more advanced skin cancer.
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.
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