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?
1. Informing the client of "the abnormality."
2. Stopping the assessment and referring the client to the healthcare provider immediately.
3. Bring in another examiner to assess the finding.
4. Documenting the finding and reassessing at the client's next visit.
Correct Answer: 3
The nurse needs to complete the assessment before deciding on the urgency of referral to the healthcare provider, and this includes having a colleague assess the nurse's unfamiliar finding. The finding should be investigated at this visit, first by asking another examiner to assess the concern. When the nurse identifies an unfamiliar finding, it is appropriate to consult with a colleague to assess the finding. Informing the client of "the abnormality" may cause the client undue anxiety, as the finding may be a normal variant.
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