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)

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. RBC (Red Blood Cells): ITP primarily affects platelet levels, not red blood cells. Therefore, red blood cell counts are not typically decreased in ITP.

B. Platelets: This is the correct answer. ITP is characterized by a low platelet count due to immune-mediated destruction of platelets. A decreased platelet count can lead to an increased risk of bleeding.

C. Granulocytes: While ITP primarily affects platelets, it does not have a direct impact on granulocyte counts. Granulocytes are a type of white blood cell.

D. WBC (White Blood Cells): ITP primarily affects platelets, not white blood cells. Therefore, white blood cell counts are not typically decreased in ITP.

A. Impaired tissue perfusion B. Alteration in activity tolerance C. Impaired skin integrity D. Alteration in body image

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.

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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?

Nursing Test Bank

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