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 C
Explanation
A. Flexing her ankles: Ankle flexion exercises and periodic ankle flexion are encouraged to promote blood circulation and prevent venous stasis, which can contribute to the development of venous thromboembolism (VTE).
B. Elevating her feet: Elevating the feet can also help prevent venous stasis and promote blood circulation. It is a recommended action to reduce the risk of VTE.
C. Massaging her legs: This is the correct answer. Massage of the legs, particularly deep tissue massage, can dislodge blood clots and increase the risk of embolization, including the risk of venous thromboembolism.
D. Ambulating soon after surgery: Early ambulation is an important preventive measure for VTE. It helps stimulate blood flow and prevents venous stasis. Encouraging the client to ambulate as soon as possible after surgery is a recommended practice.
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