The nurse hears a bruit when auscultating the right carotid artery of an elderly client. The nurse would choose which of the following actions next?

Question

1. Auscultate the heart for murmurs.
2. Obtain a surgical consult.
3. Document the findings as normal.
4. Assess for jugular vein distention.

Answer 1

1
Rationale 1: Bruits are abnormal signs of carotid stenosis and may signal an impending stroke. If a bruit is heard, auscultation of the aortic and pulmonic valves of the heart should be done to assess for murmurs that may be radiating into the neck. This is essential additional assessment data.
Rationale 2: There is no reason to obtain a surgical consult at this stage. The nurse should auscultate the aortic and pulmonic valves of the heart for the presence of murmurs. Murmurs may radiate into the client's neck.
Rationale 3: The findings are abnormal.
Rationale 4: The nurse should assess for jugular venous distention during the head-to-toe assessment. However, after hearing a bruit over the client's right carotid artery, the nurse must auscultate the heart for the presence of murmurs.