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 C

Explanation

A. Friction rub:

A friction rub is a grating or rubbing sound or sensation heard or felt during auscultation or palpation. It occurs when inflamed pleural or pericardial surfaces rub against each other during breathing or heartbeats, respectively.

B. Tactile fremitus:

Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks. It is assessed by placing hands on the patient's back while the patient speaks certain words. Increased tactile fremitus can occur in conditions with lung consolidation, such as pneumonia.

C. Crepitus:

Crepitus is a crackling or grating sensation felt under the skin or heard when the ends of a broken bone rub against each other. It can also occur when air leaks into subcutaneous tissue, leading to a crackling sensation upon palpation.

D. Adventitious sounds:

Adventitious sounds refer to abnormal lung sounds heard during auscultation. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. Adventitious sounds can indicate various respiratory conditions, such as pneumonia, bronchitis, or asthma.

A. The atria contract toward the end of diastole and push the remaining blood into the ventricles. B. The atria contract during systole and attempt to push against closed valves. C. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole. D. Contraction of the atria at the beginning of diastole can be felt as a palpitation.

Correct Answer is A

Explanation

A. The atria contract toward the end of diastole and push the remaining blood into the ventricles.

This choice is correct. During atrial systole (atrial contraction), the atria contract, pushing the remaining blood into the ventricles. This additional filling of the ventricles optimizes cardiac output.

B. The atria contract during systole and attempt to push against closed valves.

This statement is incorrect. The atria do not contract during systole; they contract during diastole (atrial systole) to fill the ventricles.

C. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole.

This statement is incorrect. Atrial kick refers to the atrial contraction, not the pressure exerted against the atria.

D. Contraction of the atria at the beginning of diastole can be felt as a palpitation.

This statement is not entirely accurate. A palpitation is a sensation of rapid or strong heartbeat, which might be felt during various cardiac events, not specifically during atrial contraction at the beginning of diastole.

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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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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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