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 C
Explanation
A. Impaired tissue perfusion: While impaired tissue perfusion is a concern in clients with varicose veins, the presence of ulcerations indicates that skin integrity is already compromised. Addressing impaired skin integrity is a more immediate concern.
B. Alteration in activity tolerance: Alteration in activity tolerance may be a consequence of impaired tissue perfusion and impaired skin integrity, but the priority is to address the current skin breakdown and prevent further complications.
C. Impaired skin integrity: This is the correct answer. The presence of varicose veins, ulcerations, and lower extremity edema indicates compromised skin integrity. The nurse should prioritize interventions to promote wound healing, prevent infection, and address the underlying causes contributing to impaired skin integrity.
D. Alteration in body image: While body image concerns may arise in clients with varicose veins, the immediate priority is addressing the physical complications such as impaired skin integrity to prevent further deterioration.
Correct Answer is ["B","C","D"]
Explanation
A. Bradycardia: Emphysema itself is not directly associated with bradycardia. However, severe hypoxia or other complications may lead to changes in heart rate.
B. Barrel chest: Emphysema is characterized by the destruction of alveoli, leading to loss of elastic recoil in the lungs. This results in hyperinflation and an increase in the anteroposterior diameter of the chest, creating a barrel-shaped appearance.
C. Dyspnea: Emphysema causes difficulty in exhaling air due to the loss of elasticity in the lung tissue. This can lead to a feeling of breathlessness.
D. Deep respirations: Clients with emphysema often adopt a pattern of deep and labored breathing to compensate for the decreased efficiency of gas exchange.
E. Clubbing of the fingers: Clubbing of the fingers is more commonly associated with chronic hypoxia, but it is not a typical finding in emphysema. Clubbing can occur in certain lung diseases, but it is not a defining characteristic of emphysema.
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