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).

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Listening for all possible sounds at a time at each specified area: This approach does not allow for specific localization of different heart sounds and murmurs, making it difficult to accurately assess the heart's condition.

B. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This option is close but lacks the systematic approach of method D. Listening at specific anatomical locations (aortic, tricuspid, pulmonic, mitral) is important, but the Z pattern allows for thorough coverage and precise localization of any abnormal sounds.

C. Listening to the sounds only at the site where the apical pulse is felt to be the strongest: This method does not cover all the important auscultation sites on the heart and may miss significant findings.

D. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex: This technique involves a systematic approach where the nurse listens at specific locations in a structured manner, ensuring comprehensive coverage of the heart sounds and murmurs.

A. Glandular tissue, which supports the breast by attaching to the chest wall. B. Fibrous, glandular, and adipose tissues C. Primarily muscle with very little fibrous tissue. D. Primarily milk ducts, known as lactiferous ducts.

Correct Answer is B

Explanation

A. Glandular tissue, which supports the breast by attaching to the chest wall: Glandular tissue is indeed a part of the breast structure, but it is not responsible for supporting the breast by attaching to the chest wall. It's the Cooper's ligaments, which are fibrous connective tissue, that provide structural support.

B. Fibrous, glandular, and adipose tissues: This statement is correct. The breast is composed of glandular tissue (responsible for milk production), fibrous tissue (including Cooper's ligaments for support), and adipose tissue (fat).

C. Primarily muscle with very little fibrous tissue: The breast contains very little muscle tissue. The main supportive structure is fibrous tissue, not muscle.

D. Primarily milk ducts, known as lactiferous ducts: Milk ducts are part of the glandular tissue and are responsible for carrying milk. However, the breast is not primarily made up of milk ducts; it consists of a combination of glandular, fibrous, and adipose tissues.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is preparing to auscultate for heart sounds on a client. Which of the following technique should be used by the nurse?

Correct Answer is D

Explanation

The nurse recognizes that the following statement is true regarding the internal structures of the breast: The breast is made up of:

Correct Answer is B

Explanation

The nurse is reviewing the sequence of the cardiac cycle. The nurse recognizes that the electrical stimulus of the cardiac cycle follows which sequence?

The nurse is auscultating the lungs of an adult client. The nurse hears low-pitched, soft breath sounds over the posterior lower lobes and inspiration that is longer than expiration. The nurse recognizes that these breath sounds are:

A client was recently diagnosed with a heart murmur and is asking the nurse for more information. The nurse will educate the client that a heart murmur:

The nurse is caring for an older adult client who has recently had a stroke. The nurse assesses that the right side of the client's face is drooping. The nurse might also expect which of the following assessment findings?

The nurse is listening to the heart sounds of a client. The nurse recognizes that the S2:

The nurse is auscultating the lungs of a sleeping client and hears short, popping, crackling breath sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:

The nurse is examining an adult client within normal weight limit. The nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action?

Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)