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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dependent edema: Dependent edema is more commonly associated with right-sided heart failure. In left-sided heart failure, fluid accumulates in the lungs, leading to pulmonary symptoms such as cough and frothy sputum.
B. Jugular distention: Jugular distention is often associated with right-sided heart failure due to impaired blood flow from the right atrium into the right ventricle. It is less likely to be prominent in left-sided heart failure.
C. Nocturnal polyuria: Nocturnal polyuria (increased urination at night) is a common symptom of heart failure, but it is not specific to left-sided heart failure. It can be seen in both left- and right-sided heart failure.
D. Frothy sputum: This is the correct answer. Left-sided heart failure can lead to pulmonary congestion, resulting in the accumulation of fluid in the lungs. Frothy, pink-tinged sputum is a characteristic finding in left-sided heart failure and is often associated with pulmonary edema.
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.
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