While auscultating a patient's heart sounds, a nurse detects a fourth heart sound (S4). The nurse understands that this finding possibly indicates:.
Pericarditis.
Arterial obstruction or aneurysm.
Forceful atrial contraction to overcome ventricular resistance.
An infectious valvular disorder.
The Correct Answer is C
Choice A rationale:
Pericarditis is an inflammation of the pericardium and would not directly cause an S4 heart sound.
Choice B rationale:
Arterial obstruction or aneurysm would cause changes in blood flow, but not specifically an S4 heart sound.
Choice C rationale:
An S4 heart sound is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle, often due to forceful atrial contraction to overcome ventricular resistance.
Choice D rationale:
An infectious valvular disorder could cause a variety of heart sounds, but not specifically an S42.
So, the correct answer is C, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A patient who had a myocardial infarction (MI) 4 days ago and is anxious about today’s planned discharge would need reassurance and education, but it’s not an immediate concern.
Choice B rationale:
A patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI) is at risk for hemorrhage from the arterial access site. Immediate assessment of blood pressure, pulses, and the access site is required.
Choice C rationale:
A patient with variant angina who is scheduled to receive nifedipine (Procardia) would need monitoring, but it’s not the most urgent.
Choice D rationale:
A patient with pericarditis complaining of sharp, stabbing chest pain would need evaluation, but the risk of complications is less immediate than for Choice B1.
So, the correct answer is B, after analyzing all choices.
Correct Answer is A
Explanation
Choice A rationale:
Elevated troponin is a sign of heart damage, which could be caused by a heart attack or other stresses on the heart. This is a critical finding that needs immediate attention.
Choice B rationale:
Q waves on an ECG can indicate a previous heart attack or myocardial infarction. However, they can also be a normal variant, meaning they are a harmless variation in the electrical activity of the heart.
Choice C rationale:
Bilateral crackles in the lungs can indicate mucus or fluid in the base of the lungs, often associated with conditions like pneumonia, heart failure, or bronchitis.
Choice D rationale:
Hyperglycemia, or high blood glucose, can be a sign of diabetes. If untreated, it can lead to serious complications like ketoacidosis.
So, the correct answer is Choice A, after analyzing all choices.
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