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. Auscultating lung sounds:

Auscultating lung sounds is essential to assess for any abnormal sounds such as wheezing, crackles, or diminished breath sounds, which can provide information about the extent and nature of lung congestion.

B. Obtaining the client’s temperature:

Obtaining the client's temperature is important to assess for the presence of fever, which is a common symptom associated with respiratory infections.

C. Assessing the strength of peripheral pulses:

Assessing peripheral pulses is not directly related to cold, cough, and lung congestion symptoms. This type of assessment is more relevant in cardiovascular or peripheral vascular assessments.

D. Obtaining information about the client’s respirations:

Assessing the rate, depth, and rhythm of respirations is crucial when dealing with respiratory symptoms. This information helps determine the severity and nature of the respiratory distress.

E. Asking the client about a family history of any illness or disease:

Family history is important for a comprehensive health assessment, but for the focused assessment of a cold, cough, and lung congestion, obtaining information about the current symptoms and associated factors takes precedence.

A. Redo the initial assessment and document current findings:

This option suggests repeating the entire initial assessment. While reassessment is important, redoing the entire initial assessment may not be necessary. Instead, a focused assessment on the specific area of concern (skin integrity) is more appropriate.

B. Perform and document a focused assessment of skin integrity:

This is the recommended choice. If unexpected findings are observed during care, such as reddened areas over bony prominences, it is important to conduct a focused assessment on the skin to identify any issues and document the findings accurately.

C. Correct the initial assessment form:

Simply correcting the initial assessment form may not address the immediate need for assessing and addressing the reddened areas. It is more crucial to perform a focused assessment on the skin.

D. Conduct and document an emergency assessment:

Reddened areas over bony prominences may not necessarily indicate an emergency. However, addressing the issue promptly is important. A focused assessment would be more appropriate than conducting a full emergency assessment.