A nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

A) A heart murmur is a high-pitched sound caused by a narrowing of a heart valve:
While it's true that a narrowing of a heart valve (stenosis) can cause a murmur, the description of a heart murmur as a "high-pitched sound" due to this narrowing is overly specific and does not fully explain what a murmur is. A murmur is not always high-pitched, and it is caused by turbulent blood flow, which may occur for various reasons beyond just valve stenosis.

B) A heart murmur is an extra sound heard from blood entering a rigid heart chamber:
This description is somewhat inaccurate. While murmurs can result from turbulent blood flow through the heart chambers or valves, the idea that murmurs are "extra sounds from blood entering a rigid heart chamber" is misleading. A murmur occurs when there is turbulent blood flow, which can happen in both rigid and non-rigid chambers. The key point is that it's the turbulent flow, not just rigidity, that causes the sound.

C) A heart murmur is a sound generated by inflammation around the heart muscle:
This is incorrect. Inflammation around the heart muscle, such as in pericarditis, can cause chest pain or other symptoms but does not generate a heart murmur. A murmur is caused by turbulent blood flow, which can result from various heart valve issues (e.g., stenosis, regurgitation) or defects in the heart's structure (e.g., septal defects), not from inflammation around the heart muscle.

D) A heart murmur indicates turbulent blood flow through a valve in the heart:
This is the most accurate description. A heart murmur is typically caused by turbulent or irregular blood flow through a heart valve. This can occur for several reasons, such as valve stenosis (narrowing), valve regurgitation (leakage), or congenital heart defects that cause abnormal flow patterns. The turbulent flow disrupts the normal laminar (smooth) blood flow, creating the characteristic sound that can be heard with a stethoscope. Murmurs can vary in timing, pitch, and intensity depending on the nature of the flow disturbance.

A) Kyphosis: While kyphosis is an important physical finding that could impact a client's respiratory and musculoskeletal health, it is typically assessed during the general physical examination and postural assessment rather than as part of the anterior chest assessment. Therefore, kyphosis is not directly part of the anterior chest examination, though it could be a factor influencing respiratory mechanics.

B) Gastrointestinal sounds: Gastrointestinal sounds are assessed during the abdominal examination, not the chest examination. The anterior chest exam focuses on respiratory and cardiac assessments, which do not involve auscultating bowel sounds. Hence, gastrointestinal sounds are not part of the chest examination.

C) Heart sounds: Auscultation of heart sounds is a crucial part of assessing the anterior chest, as it helps the nurse evaluate cardiac function. The nurse listens to heart sounds at specific areas on the chest (e.g., aortic, pulmonic, tricuspid, and mitral areas) to identify any abnormalities such as murmurs, arrhythmias, or other issues.

D) Breath sounds: Breath sounds are an essential component of the chest assessment. By auscultating the lungs, the nurse can identify normal or abnormal breath sounds, such as wheezes, crackles, or decreased breath sounds, which may indicate respiratory issues like pneumonia, asthma, or emphysema.

E) Symmetric expansion: Symmetric expansion refers to the even movement of both sides of the chest during inhalation and exhalation. Assessing symmetric chest expansion helps the nurse identify any respiratory abnormalities, such as atelectasis, pneumonia, or other lung pathologies that may cause uneven chest expansion, signaling a potential underlying issue.