A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

Atrial gallop

Ventricular gallop

Closing of semilunar valves

Closing of the atrioventricular valves

Answer and Explanation

The Correct Answer is B

A. Atrial gallop: An atrial gallop is associated with the S4 heart sound, which occurs before the S1 sound due to the atrial contraction.

B. Ventricular gallop: An S3 heart sound is known as a ventricular gallop and is often a sign of heart failure or fluid overload. It occurs during early diastole when the ventricle fills rapidly.

C. Closing of semilunar valves: The closing of the semilunar valves (aortic and pulmonary) produces the S2 heart sound, not the S3 sound.

D. Closing of the atrioventricular valves: The closing of the atrioventricular valves (mitral and tricuspid) produces the S1 heart sound, not the S3 sound.

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Correct Answer is A

Explanation

A. A systolic murmur: A murmur heard between S1 and S2 occurs during systole, which is why it is classified as a systolic murmur. Systolic murmurs are often due to valve abnormalities like aortic stenosis or mitral regurgitation.

B. A third heart sound (S3): The S3 sound occurs after S2, not between S1 and S2. It is associated with rapid ventricular filling and may indicate heart failure.

C. A fourth heart sound (S4): The S4 sound occurs before S1, not between S1 and S2. It is associated with a stiff or hypertrophic ventricle.

D. An expected heart sound: A murmur is not considered an expected heart sound; it is typically abnormal and requires further investigation.

A. Wrap the blood pressure cuff snugly around the arm. B. Place the client's arm above the level of the heart. C. Center the cuff bladder over the brachial artery. D. Check the instrument gauge to ensure the reading starts at zero.

Correct Answer is B

Explanation

A. Wrap the blood pressure cuff snugly around the arm. Wrapping the cuff snugly ensures an accurate blood pressure reading. This statement does not indicate a need for further instruction.

B. Place the client's arm above the level of the heart. The arm should be at the level of the heart, not above. Placing the arm above the heart can result in falsely low blood pressure readings. This action indicates a need for further instruction.

C. Center the cuff bladder over the brachial artery. Proper placement of the cuff bladder over the brachial artery is necessary for an accurate reading. This statement does not indicate a need for further instruction.

D. Check the instrument gauge to ensure the reading starts at zero. Ensuring the gauge starts at zero before taking a reading is necessary to prevent errors. This statement does not indicate a need for further instruction.

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A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

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