A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?
Closure of pulmonic valve
Closure of the mitral valve
Ventricular gallop
Atrial gallop
The Correct Answer is C
Ventricular gallop is another name for the S3 sound, which is a low-pitched sound heard at the end of diastole, just after the S2 sound. It is caused by the rapid filling of the ventricles and the vibration of the ventricular walls.
Closure of the pulmonic valve is one of the components of the S2 sound, which is a high-pitched sound heard at the end of the systole, just before the S1 sound. It is caused by the closure of the semilunar valves (pulmonic and aortic).
Closure of the mitral valve is one of the components of the S1 sound, which is a high-pitched sound heard at the beginning of systole, just after the S2 sound. It is caused by the closure of the atrioventricular valves (mitral and tricuspid).
d. Atrial gallop is another name for the S4 sound, which is a low-pitched sound heard at the end of diastole, just before the S1 sound. It is caused by atrial contraction and increased resistance to ventricular filling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Planning to slow down if tired the day after exercising is a statement that indicates the client understands the importance of pacing activities and avoiding overexertion, which can worsen heart failure symptoms.
a. "I should use naproxen to manage discomfort." is not correct, as naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause fluid retention, increase blood pressure, and worsen heart failure. The client should avoid NSAIDs and use other analgesics, such as acetaminophen, unless contraindicated.
c. "I will read food labels and limit my sodium to 4 grams per day." is not appropriate, as 4 grams of sodium per day is too high for a client who has congestive heart failure. The client should limit sodium intake to 2 grams or less per day, as sodium can cause fluid retention and increase the workload of the heart.
d. "I will take my diuretic before sleep and drink fluids during the day." is not advisable, as taking a diuretic before sleep can cause nocturia and disrupt the sleep cycle, which can affect the quality of life and cardiac function. The
Correct Answer is A
Explanation
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
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