The nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

The third heart sound (S3)

A friction rub

The fourth heart sound (S4)

A split second heart sound S2

Answer and Explanation

The Correct Answer is A

A. The third heart sound (S3):

The third heart sound (S3) is an abnormal heart sound that occurs during early diastole, immediately after S2 (the second heart sound). It is caused by the rapid filling of the ventricles and is often associated with conditions like heart failure. In heart failure, the ventricles become stiff, causing vibrations that produce the S3 sound.

B. A friction rub:

A friction rub is a high-pitched, scratchy sound heard during both systole and diastole. It is caused by the rubbing together of inflamed pericardial layers (pericarditis) and is usually heard best at the left lower sternal border. Friction rubs can indicate pericardial inflammation and are often heard in conditions such as pericarditis or after a myocardial infarction.

C. The fourth heart sound (S4):

The fourth heart sound (S4) occurs late in diastole, just before S1, and is caused by atrial contraction. It is associated with increased resistance to ventricular filling, often due to conditions like hypertension or aortic stenosis. The S4 sound is heard as a low-pitched "atrial gallop."

D. A split second heart sound S2:

The second heart sound (S2) represents the closure of the aortic and pulmonic valves. Normally, S2 has two components: A2 (aortic valve closure) and P2 (pulmonic valve closure). A split S2 occurs when A2 and P2 do not close simultaneously. A physiological split S2 is common during inspiration and occurs due to delayed closure of the pulmonic valve. An abnormal or fixed split S2 can indicate underlying heart conditions such as atrial septal defect (ASD) or right bundle branch block (RBBB).

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Correct Answer is D

Explanation

A. A shiny, pearly white color tympanic membrane: This is a normal finding. A healthy tympanic membrane often appears shiny and pearly white.

B. The presence of cerumen: This is a normal finding. Cerumen, or earwax, is a natural substance that helps protect the ear canal.

C. The presence of a cone of light: This is a normal finding. The cone of light is a reflection of the otoscope light on the tympanic membrane and is a normal variation.

D. A yellow or amber color to the tympanic membrane: This is considered an abnormal finding. A yellow or amber coloration of the tympanic membrane can indicate the presence of fluid or infection behind the eardrum, which may be a sign of otitis media or other ear conditions.

A. Percussion of the posterior chest B. Inspection of the shape and configuration of the chest wall C. Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety nine" D. Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10

Correct Answer is D

Explanation

A. Percussion of the posterior chest: Percussion helps assess the underlying structures of the chest but does not directly confirm symmetric chest expansion.

B. Inspection of the shape and configuration of the chest wall: Inspection is a crucial part of assessing chest symmetry. Any deformities, asymmetry, or abnormalities in the shape and configuration of the chest wall can be visually identified.

C. Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety-nine": This technique, known as tactile fremitus, involves feeling for vibrations or tremors while the client repeats a phrase. While it can provide information about underlying lung conditions, it's not primarily used to confirm symmetric chest expansion.

D. Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10: This technique, known as chest expansion measurement, is used to assess symmetric chest expansion. Placing hands in this manner allows the nurse to feel for bilateral chest expansion during inspiration, ensuring that both sides of the chest expand symmetrically.

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The nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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