During a cardiac assessment, the nurse notes a grade 3/6 systolic murmur at the left sternal border. What is the appropriate documentation for this finding?

Correct Answer: A

Rationale: Rationale for Correct Answer (A): 1. The term "systolic" indicates that the murmur occurs during systole. 2. The grade 3/6 signifies the loudness or intensity of the murmur. 3. "Heard best at the left sternal border" specifies the location where the murmur is most audible. 4. Therefore, documenting "Systolic murmur, grade 3/6, heard best at the left sternal border" accurately describes the finding. Incorrect Choices: B: Diastolic murmurs occur during diastole, not systole. C: A systolic click is a distinct sound different from a murmur. D: Diastolic clicks are also distinct sounds and do not indicate a murmur. Summary: Choice A is correct because it accurately describes the type, intensity, and location of the murmur. Choices B, C, and D are incorrect due to inaccuracies in the timing or nature of the sound

Correct Answer: A

Rationale: The correct answer is A: Chief complaint. The chief complaint is the main reason for the patient seeking medical attention. In this case, "I feel really tired" is a subjective symptom that is bothering the patient and prompting them to seek help. It is the primary concern that needs to be addressed first. B: Present illness focuses on the current symptoms and how they developed, not just a general feeling of tiredness. C: Personal and social history pertains to the patient's background and lifestyle, not their immediate health concerns. D: Review of systems involves a systematic inquiry about specific symptoms or issues, not a general statement like feeling tired.

Correct Answer: C

Rationale: The correct answer is C: Nausea. Nausea is a symptom related to the gastrointestinal system as it often indicates issues such as stomach problems or digestive disturbances. It can be caused by various gastrointestinal conditions like gastritis, gastroenteritis, or peptic ulcers. Cough (A) and chest pain (B) are more likely related to respiratory or cardiac issues, respectively. Polyuria (D) is a symptom of excessive urination, pointing towards potential kidney or endocrine system problems, not the gastrointestinal system.

Correct Answer: A

Rationale: The correct answer is A: Feeling anxious. In the review of systems, psychiatric symptoms are typically documented under the psychiatric system. Anxiety is a common psychiatric symptom that falls under this category. It is important to differentiate psychiatric symptoms from physical symptoms like ringing in the ears (choice B), skin rash (choice C), and joint stiffness (choice D) which are typically documented under other systems such as the neurological or dermatological systems. Symptoms like feeling anxious are subjective experiences related to mental health, making them more likely to be included in the psychiatric system.

Correct Answer: B

Rationale: The correct answer is B: 20/20. In the Snellen chart, the first number represents the distance at which the test is performed (usually 20 feet) and the second number represents the distance at which a person with normal vision can read the same line. A person with 20/20 vision can read at 20 feet what a person with normal vision can read at 20 feet. Therefore, a result of 20/20 indicates normal visual acuity. Choices A, C, and D all indicate vision impairment as they represent the ability to read at a distance closer than 20 feet compared to a person with normal vision.