NBCSN Nationally Certified School Nurse Practice Exam

Which of the following factors should be documented when assessing a heart murmur?

1. Height and weight

2. Rhythm, rate, and quality of sound

3. Family history of cardiac issues

4. Age and gender

The correct answer is: Rhythm, rate, and quality of sound

When assessing a heart murmur, documenting the rhythm, rate, and quality of sound is crucial as it provides essential information about the characteristics of the heart murmur itself. These factors allow healthcare professionals to determine whether the murmur is functional or pathological. The rhythm reveals whether the heartbeat is regular or irregular, which can indicate underlying cardiac conditions. The rate helps in assessing whether the heart is beating within normal limits and can suggest the presence of tachycardia or bradycardia. Quality of sound refers to distinct characteristics such as whether the murmur is systolic or diastolic, as well as its intensity and pitch, all of which are important in diagnosing potential heart issues. While height and weight, family history of cardiac issues, and age and gender can provide additional context for the patient's overall health and risk factors, they do not directly pertain to the specific characteristics of the heart murmur being assessed. Thus, documenting the rhythm, rate, and quality of sound is vital for a comprehensive assessment of the murmur.