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. Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by alternating periods of hyperventilation followed by apnea. This respiratory pattern is often observed in clients with conditions affecting the central nervous system, such as brain injury or stroke.
B. Apneustic respirations: Apneustic respirations are characterized by prolonged, gasping inhalations followed by extremely short, ineffective exhalations. This pattern is associated with damage to the pons, a part of the brainstem.
C. Stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a partially obstructed airway. It is not related to the described alternating pattern of hyperventilation and apnea.
D. Kussmaul respirations: Kussmaul respirations are deep, rapid respirations often seen in metabolic acidosis. They are not characterized by the alternating pattern described in the scenario.
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.
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