A patient with SLE has come to the clinic for a routine check-up. When auscultating the patient's apical heart rate, the nurse notes the presence of a distinct "scratching" sound. What is the nurse's most appropriate action?
A) Reposition the patient and auscultate posteriorly.
B) Document the presence of S3 and monitor the patient closely.
C) Inform the primary care provider that a friction rub may be present.
D) Inform the primary care provider that the patient may have pneumonia.
Ans: C
Feedback:
Patients with SLE are susceptible to developing a pericardial friction rub, possibly associated with myocarditis and accompanying pleural effusions; this warrants prompt medical follow-up. This finding is not characteristic of pneumonia and does not constitute S3. Posterior auscultation is unlikely to yield additional meaningful data.
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