A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?
A friction rub
A split second heart sound S₂
The third heart sound (S3)
The fourth heart sound (S4)
The Correct Answer is D
A. A friction rub: A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.
B. A split second heart sound S₂: A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.
C. The third heart sound (S3): S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.
D. The fourth heart sound (S4): S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A friction rub:A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.
B. A split second heart sound S₂:A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.
C. The third heart sound (S3):S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.
D. The fourth heart sound (S4):S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.
Correct Answer is B
Explanation
A. Respiratory alkalosis: Respiratory alkalosis is characterized by a decrease in carbonic acid (CO2) due to hyperventilation, leading to an increased pH. Shallow respirations would not typically cause respiratory alkalosis.
B. Respiratory acidosis: This is the correct answer. Shallow respirations result in inadequate elimination of CO2, leading to an excess of carbonic acid and the development of respiratory acidosis.
C. Metabolic acidosis: Metabolic acidosis is characterized by a decrease in bicarbonate (HCO3-), not carbonic acid (CO2). Shallow respirations would not directly contribute to metabolic acidosis.
D. Metabolic alkalosis: Metabolic alkalosis is characterized by an increase in bicarbonate (HCO3-). Shallow respirations would not typically cause metabolic alkalosis.
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