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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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"C"}

Explanation

The pacemaker of the heart is known as the sinoatrial (SA) node. The SA node is a specialized group of cells located in the right atrium of the heart. It generates electrical impulses that initiate each heartbeat and set the rhythm for the entire heart.

A. Xiphoid process. B. Suprasternal notch. C. Sternal angle. D. Costal angle.

Correct Answer is C

Explanation

A. Xiphoid process:

The xiphoid process is a small, cartilaginous extension at the inferior end of the sternum (breastbone). It does not play a role in the bifurcation of the trachea.

B. Suprasternal notch:

The suprasternal notch, also known as the fossa jugularis sternalis or jugular notch, is the visible dip in the superior part of the manubrium of the sternum between the clavicular notches. It is an important anatomical landmark for assessing the position of the trachea during emergency situations but is not the location of tracheal bifurcation.

C. Sternal angle (Angle of Louis):

The sternal angle, or Angle of Louis, is a palpable notch located at the articulation of the manubrium and the body of the sternum. It is where the second rib attaches and serves as a useful reference point for counting ribs and locating internal structures like the tracheal bifurcation.

D. Costal angle:

The costal angle is the acute angle formed by the junction of the costal margins at the xiphoid process. It is not related to the tracheal bifurcation.

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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?

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Naxlex Comprehensive Predictor Exams

A group of nursing students are studying the conduction system of the heart. The nursing students should recognize that the pacemaker of the heart is known as dropdown

Correct Answer is {"dropdown-group-1":"C"}

Explanation

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Correct Answer is C

Explanation

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