Author Question: A nurse is auscultating an older patient's heart and notes a systolic murmur (heard between the S1 ... (Read 51 times)

cdr_15 · **on:** Jul 11, 2018

A nurse is auscultating an older patient's heart and notes a systolic murmur (heard between the S1 and S2 heart sounds. The first action by the nurse is to:

a. question the patient about the presence of the murmur.
b. note it in the chart as this is always a nor-mal finding for an older adult.
c. contact the medical provider as this is an abnormal finding.
d. immediately implement emergency inter-ventions.

Question 2

The role of a nurse caring for an older patient who is in the stable phase of a chronic illness may include which of the following? (Select all that apply.)

a. Coordinating care with members of the interdisciplinary team
b. Administering medications to the patient
c. Providing assistance with bathing and dressing
d. Ensuring that the patient's immunizations are up to date
e. Providing emergency care

cascooper22 · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

ANS: A
In normal aging, the heart valves separating the chambers thicken and stiffen as a result of lipid deposits and collagen cross-linking. Mild systolic murmurs (between S1 and S2) are expected findings in the older adult. Aortic and mitral valves are those most commonly affected. If the nurse auscultates a systolic murmur in an asymptomatic older adult, he or she should ask about it. Most older adults will reply that they have had it for a while. If this is not the case, the person is referred to a cardiologist. If the new finding is accompanied by any significant signs or symp-toms of distress, it is a medical emergency. Diastolic murmurs (heard between S2 and S1) are al-ways indicative of a serious problem in cardiac hemodynamics and these persons are followed closely by a cardiologist.

Answer to Question 2

ANS: A, B, C
Options A, B, and C are all roles of the nurse in the stable phase of chronic illness. Option d is a role of the nurse in the preventive phase of chronic illness. Option E is a role of the nurse in the acute phase of chronic illness.