65. A nurse is caring for a client who had a recent myocardial infarction (MI). During the cardiac assessment, a new murmur is noted. What question should the nurse ask the client first?
65. A nurse is caring for a client who had a recent myocardial infarction (MI). During the cardiac assessment, a new murmur is noted. What question should the nurse ask the client first?
. "Are you currently having chest pain?"
. "Did you recently walk to the bathroom?"
. "Have you ever been told you had a murmur?"
. "Do you feel short of breath?"
Test-Taking Tip
Focus on activity as a cause for a murmur that was not previously present.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
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Answer 1 is incorrect because murmurs are created by turbulent flow of blood. They do not cause chest pain. Answer 2 is correct because murmurs occur when blood flow through a normal cardiac structure is increased with activity. Answer 3 is incorrect because the answer to the question would not explain the development of the murmur. Answer 4 is incorrect because murmurs are not associated with shortness of breath.