While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?
A systolic murmur
A third heart sound (S3)
A fourth heart sound (S4)
An expected heart sound
The Correct Answer is A
A. A systolic murmur: A murmur heard between S1 and S2 occurs during systole, which is why it is classified as a systolic murmur. Systolic murmurs are often due to valve abnormalities like aortic stenosis or mitral regurgitation.
B. A third heart sound (S3): The S3 sound occurs after S2, not between S1 and S2. It is associated with rapid ventricular filling and may indicate heart failure.
C. A fourth heart sound (S4): The S4 sound occurs before S1, not between S1 and S2. It is associated with a stiff or hypertrophic ventricle.
D. An expected heart sound: A murmur is not considered an expected heart sound; it is typically abnormal and requires further investigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A systolic murmur: A murmur heard between S1 and S2 occurs during systole, which is why it is classified as a systolic murmur. Systolic murmurs are often due to valve abnormalities like aortic stenosis or mitral regurgitation.
B. A third heart sound (S3): The S3 sound occurs after S2, not between S1 and S2. It is associated with rapid ventricular filling and may indicate heart failure.
C. A fourth heart sound (S4): The S4 sound occurs before S1, not between S1 and S2. It is associated with a stiff or hypertrophic ventricle.
D. An expected heart sound: A murmur is not considered an expected heart sound; it is typically abnormal and requires further investigation.
Correct Answer is C
Explanation
A. Aim for a total cholesterol at 225 mg/dL. A total cholesterol level of 225 mg/dL is higher than the recommended target, which is typically less than 200 mg/dL. This is not an appropriate treatment goal.
B. Maintain blood pressure at less than 140/90 mm Hg. This is a reasonable goal for many clients with atherosclerosis. Keeping blood pressure below 140/90 mm Hg helps reduce the risk of further vascular damage.
C. Limit total fat intake to 50% of total daily calories. Limiting fat intake to 50% of total daily calories is excessive. The recommendation is usually around 25-35% of total daily calories from fat, with a focus on healthy fats.
D. Keep body mass index (BMI) above 30. A BMI above 30 is classified as obese, which is a risk factor for atherosclerosis. The goal is to reduce BMI to within a healthy range (18.5-24.9).
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