A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur.

Which of the following best describes the sound of a heart murmur?

A. Adequacy of circulation:

This assessment is the highest priority for a client who has undergone a procedure to bypass arteries in the right leg. Monitoring for signs of adequate blood flow, such as color, temperature, capillary refill, and pulses in the operated leg, is critical to identify and address any circulation issues early.

B. Patency of airway:

While maintaining a patent airway is always a priority in postoperative care, it is not the immediate concern in a client who has just undergone a leg bypass procedure. Airway management is essential, but assessing circulation in the operated limb takes precedence.

C. Movement of lower leg:

Assessing movement of the lower leg is important for detecting signs of impaired motor function or complications. However, it is secondary to assessing the adequacy of circulation, which is critical for preventing ischemia and other circulatory issues.

D. Neurovascular status of the left leg:

While monitoring the neurovascular status of the left leg is a valid aspect of the overall assessment, the priority in the immediate postoperative period is to assess the surgical site (right leg) to ensure that blood flow is adequate and that there are no immediate complications.

A. "Do you want to talk about your health concerns?"

While this question acknowledges the client's option to discuss health concerns, it is somewhat closed-ended and might not prompt the client to share specific details.

B. "Would it help to discuss your feelings about this hospitalization?"

This question addresses the client's feelings about the hospitalization, which is important for emotional well-being, but it might not directly elicit information about the client's primary health issues.

C. "Would you tell me about all of your medical issues?"

This question is somewhat open-ended but might be overwhelming for the client. It is more effective to start with a focused question about the reason for seeking care.

D. "What brought you to the hospital?"

This open-ended question encourages the client to share their primary reason for seeking healthcare and allows for a comprehensive discussion about the client's health concerns. It gives the client an opportunity to express their own perspective and share the relevant information about their medical condition or symptoms.