A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

A friction rub

A split second heart sound S₂

The third heart sound (S3)

The fourth heart sound (S4)

Answer and Explanation

The Correct Answer is D

A. A friction rub: A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.

B. A split second heart sound S₂: A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.

C. The third heart sound (S3): S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.

D. The fourth heart sound (S4): S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.

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Correct Answer is D

Explanation

A. Wearing loose, non-constricting stockings: This instruction is not recommended for a client with DVT. Compression stockings, which are snug-fitting, may be prescribed to prevent DVT, but loose stockings would not provide the necessary compression.

B. Applying cool compresses to her legs: Cool compresses are not typically recommended for DVT. Warm compresses may be used to improve blood circulation, but cold compresses may not be suitable.

C. Taking an NSAID tablet daily: Nonsteroidal anti-inflammatory drugs (NSAIDs) are not typically recommended for individuals with DVT, especially when on anticoagulant therapy, as they may increase the risk of bleeding.

D. Flexing her knees and feet frequently: This is the correct answer. Encouraging the client to flex her knees and feet frequently helps promote blood circulation and reduces the risk of venous stasis, which can contribute to the formation of blood clots. It is a beneficial measure for clients with DVT.

A. Excessive thrombosis and bleeding B. Increased clotting factors C. Progressive increase in platelet production D. Immediate sodium and fluid retention

Correct Answer is A

Explanation

A. Excessive thrombosis and bleeding

Disseminated Intravascular Coagulation (DIC) is a complex and serious condition characterized by widespread activation of the coagulation cascade, leading to both excessive clot formation (thrombosis) and simultaneous consumption of clotting factors and platelets, resulting in bleeding. DIC can occur as a secondary complication to various conditions such as sepsis, trauma, or obstetric complications.

B. Increased clotting factors: In DIC, there is consumption and depletion of clotting factors, not an increase.

C. Progressive increase in platelet production: Platelet production does not increase in DIC; instead, there is consumption and decreased platelet count.

D. Immediate sodium and fluid retention: DIC is not associated with immediate sodium and fluid retention; instead, it is characterized by fluid loss due to bleeding.

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A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

Nursing Test Bank

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