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

Listening for all possible sounds at a time at each specified area.

Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas.

Listening to the sounds only at the site where the apical pulse is felt to be the strongest.

Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is A

Explanation

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).

A. Maxillary sinusitis B. Nasal polyps. C. Frontal sinusitis. D. Posterior epistaxis.

Correct Answer is A

Explanation

A. Maxillary sinusitis:

Explanation: The client's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and dull, throbbing pain in the cheeks and teeth on the right side, especially when palpated, are indicative of maxillary sinusitis. Maxillary sinusitis refers to the inflammation of the maxillary sinuses, which are located in the cheek area. The symptoms described align with a bacterial infection in this sinus.

B. Nasal polyps:

Explanation: Nasal polyps are soft, noncancerous growths on the lining of the nasal passages or sinuses. While they can cause nasal congestion and a runny nose, they do not typically present with the specific symptoms mentioned in the scenario, such as facial pain, fever, and purulent discharge.

C. Frontal sinusitis:

Explanation: Frontal sinusitis involves inflammation of the frontal sinuses located in the forehead area. Symptoms may include forehead pain, headache, and nasal discharge. However, the described symptoms in the scenario (dull, throbbing pain in the cheeks and teeth on the right side) are more characteristic of maxillary sinusitis.

D. Posterior epistaxis:

Explanation: Posterior epistaxis refers to a nosebleed that originates from the back of the nose, often due to bleeding from the sphenopalatine artery. While nosebleeds can cause blood drainage into the throat and result in a metallic taste, the other symptoms described in the scenario, such as facial pain, fever, and purulent discharge, are not indicative of posterior epistaxis.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is A

Explanation

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