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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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

In a patient with severe dyspnea and a dry, hacking cough, auscultating the breath sounds would be the first action to assess for any abnormalities.

Choice B rationale:

Checking the capillary refill would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.

Choice C rationale:

Auscultating the abdomen would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.

Choice D rationale:

Asking about the patient’s allergies would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.

So, the correct answer is A, after analyzing all choices.

A. Heart rate increases from 66 to 98 beats/min. B. O2 saturation drops from 99% to 95%. C. Respiratory rate goes from 14 to 20 breaths/min. D. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. E. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

Correct Answer is A

Explanation

Choice A rationale:

An increase in heart rate from 66 to 98 beats/min indicates that the heart is working harder, which could be a sign of stress or exertion. This is a significant increase and could indicate that the patient needs to rest.

Choice B rationale:

While a drop in O2 saturation from 99% to 95% is noticeable, it is still within the normal range (95-100%). Therefore, it would not necessarily indicate a need for the patient to rest.

Choice C rationale:

A respiratory rate increase from 14 to 20 breaths/min is within the normal range (12-20 breaths/min) and would not necessarily indicate a need for the patient to rest.

Choice D rationale:

A blood pressure change from 118/60 to 126/68 mm Hg is within the normal range and would not necessarily indicate a need for the patient to rest.

So, the correct answer is Choice A, after analyzing all choices.

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While auscultating a patient's heart sounds, a nurse detects a fourth heart sound (S4). The nurse understands that this finding possibly indicates:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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