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 B
Explanation
Correct answer: B
A. "I will take my diuretic before sleep and drink fluids during the day": This statement is not correct. Diuretics are usually taken in the morning to avoid disrupting sleep with increased urination at night. Additionally, fluid intake is generally restricted in congestive heart failure to manage fluid balance.
B. "I plan to slow down if I am tired the day after exercising":This statement reflects an understanding of the need to manage activity levels and recognize the signs of overexertion, which is crucial for clients with congestive heart failure. Pacing activities and allowing for adequate rest can help prevent exacerbations of heart failure symptoms.
C. "I will read food labels and limit my sodium to 4 grams per day": This is incorrect. Limiting sodium intake is a key component of heart failure management. The recommended sodium intake for individuals with heart failure is often much lower than 4 grams per day, typically around 2 grams or less.
D. "I should use naproxen to manage discomfort": Using nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen can contribute to fluid retention and worsen heart failure symptoms. This statement is not indicative of effective teaching.
Correct Answer is C
Explanation
A. The pain persists with rest and organic nitrates: This statement is incorrect. Anginal pain typically improves with rest and can be relieved by the administration of organic nitrates.
B. The pain usually lasts longer than 20 min: This statement is incorrect. Anginal pain is often brief and lasts for a few minutes, typically less than 20 minutes.
C. Exertion and anxiety can trigger the pain: This is the correct answer. Anginal pain is often triggered by activities that increase the workload of the heart, such as exertion or emotional stress (anxiety). These triggers lead to an increased demand for oxygen by the heart muscle, which may exceed the compromised blood supply, resulting in angina.
D. The pain often radiates to the jaw or the back: This statement is correct. Anginal pain may radiate to the jaw, back, shoulder, arm, or neck. The radiation of pain is a characteristic feature of angina.
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