While Performing a Physical Assessment on an Adult Client, the Nurse

question 7

Multiple Choice

While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. Which nursing action is most appropriate?

• A) Informing the client of "the abnormality."
• B) Stopping the assessment and referring the client to the healthcare provider immediately.
• C) Bring in another examiner to assess the finding.
• D) Documenting the finding and reassessing at the client's next visit.

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Definitions:

Sympathetic Nervous System

Part of the autonomic nervous system that prepares the body for action by triggering the fight or flight response.

Cerebellum

A region of the brain that plays an important role in motor control, and also contributes to coordination, precision, and timing of movements.

Electrical Impulses

These are rapid, short signals that travel along the nerves, allowing for communication throughout the body.

Ethnicity

Social groups with a shared culture, ancestry, language, or national origin.