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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 B

Explanation

Choice A rationale:

Teaching the patient to take deep, slow breaths might not be effective in controlling the pain due to acute pericarditis.

Choice B rationale:

Placing the patient in Fowler’s position, leaning forward on the table, can help relieve the pain associated with acute pericarditis.

Choice C rationale:

Forcing fluids to 3000 mL/day to decrease inflammation is not a recommended action for managing pain due to acute pericarditis.

Choice D rationale:

Providing a fresh ice bag every hour for the patient to place on the chest is not a recommended action for managing pain due to acute pericarditis.

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

A. The pain has lasted longer than 30 minutes. B. The pain increases with deep breathing. C. The pain is relieved after the patient takes nitroglycerin. D. The pain is reproducible when the patient raises the arms.

Correct Answer is A

Explanation

Choice A rationale:

Chest pain that lasts for 20 minutes or more is characteristic of an acute myocardial infarction (AMI)123.

Choice B rationale:

Changes in pain that occur with deep breathing are more typical of musculoskeletal pain or pericarditis.

Choice C rationale:

Stable angina is usually relieved when the patient takes nitroglycerin.

Choice D rationale:

Pain that is reproducible when the patient raises the arms is more typical of musculoskeletal pain.

So, the correct answer is 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

A patient has pain due to acute pericarditis. Which action would the nurse take?.

Correct Answer is B

Explanation

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain may be from an acute myocardial infarction?.

Correct Answer is A

Explanation

The nurse is assessing a patient with myocarditis before giving a scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider?.

After receiving a change-of-shift report on four patients, which patient would the nurse assess first?.

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective?.

A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?.

After receiving a change-of-shift report about the following four patients on the cardiac care unit, which patient would the nurse assess first?.

Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective?.

The nurse is caring for a patient with mitral regurgitation. Where would the nurse listen to best hear a murmur typical of mitral regurgitation?.