While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. What is the nurse's next step?

Question

1. Inform the client of "the abnormality."
2. Stop the assessment and refer the client to the healthcare provider immediately.
3. Bring in another examiner to assess the finding.
4. Document the finding and reassess at the client's next visit.

Answer 1

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