A nurse is examining a client with diastolic dysfunction. Upon auscultation using the bell of the stethoscope the nurse hears a late diastolic heart sound at the 5th intercostal space, left midclavicular line. Based on these findings and the clients history, the nurse would recognize this extra heart sound is most likely what?
S1
S4
S3
S2
The Correct Answer is B
A. S1: S1 is the first heart sound, heard at the beginning of systole, and is not related to diastolic dysfunction.
B. S4: This is the correct answer. An S4 sound is heard late in diastole, often due to increased resistance to filling during diastole, which is typical in diastolic dysfunction.
C. S3: An S3 is a low-pitched sound heard early in diastole, typically associated with systolic dysfunction or heart failure with reduced ejection fraction.
D. S2: S2 is the second heart sound, heard during the end of systole and is not associated with diastolic dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Certain antihistamines can worsen urinary retention in BPH, so informing the allergist is a good practice.
B. Alcohol, including wine, can worsen the symptoms of BPH by increasing urinary retention and bladder discomfort. The client needs further teaching regarding the effects of alcohol on BPH symptoms.
C. It is advisable to avoid large volumes of fluids in the morning, as this can exacerbate BPH symptoms.
D. Caffeine can irritate the bladder and worsen BPH symptoms, so weaning off coffee is a helpful measure.
Correct Answer is B
Explanation
A. Administering oxygen is unnecessary at this time, as the client’s oxygen saturation is normal at 96%.
B. The client has had a myocardial infarction, which can lead to complications such as orthostatic hypotension or cardiovascular strain with sudden position changes. A bedside commode minimizes the need for the client to get out of bed and reduces the risk of these complications.
C. Suggesting the use of a bedpan may be an alternative but is less comfortable and may not adequately address the risk of strain from getting out of bed.
D. Allowing continued bathroom privileges may be unsafe, as it may increase the risk of a fall or cardiovascular strain.
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