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 A
Explanation
A. Cellular hypoxia: Hemoglobin carries oxygen to the body's tissues. A low hemoglobin level, as well as a low hematocrit, indicates a reduced oxygen-carrying capacity of the blood, putting the client at risk for cellular hypoxia. Symptoms may include fatigue, weakness, and shortness of breath.
B. Prolonged bleeding: Hemoglobin and hematocrit levels are not directly indicative of a risk of prolonged bleeding. Prolonged bleeding is more related to platelet function and clotting factors.
C. Impaired immunity: Hemoglobin and hematocrit levels are not directly indicative of impaired immunity. Immune function is more closely associated with white blood cell count and function.
D. Fluid retention: Hemoglobin and hematocrit levels are not directly associated with fluid retention. Fluid retention is more related to factors such as sodium balance and kidney function.
Correct Answer is D
Explanation
A. Serum amylase: Serum amylase is an enzyme associated with pancreatic function, and its elevation is not specific to myocardial infarction.
B. Unconjugated bilirubin: Elevation of unconjugated bilirubin is associated with liver function and hemolysis, not specifically with myocardial infarction.
C. Aspartate aminotransferase (AST): While AST may be elevated in conditions affecting the heart, it is not as specific or sensitive for myocardial infarction as troponin I.
D. Troponin I: This is the correct answer. Troponin I is a cardiac-specific biomarker released into the bloodstream when there is damage to cardiac muscle, such as during a myocardial infarction. Troponin I levels start to rise within 3-4 hours after the onset of myocardial infarction, making it a crucial marker for early detection.
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