A nurse is preparing to auscultate for heart sounds on a client. Which technique should be used by the nurse?

Listening for sounds from the apex to the heart to the base of the heart.

Listening to the sounds at the site where the apical pulse is heard to be the loudest.

Listening from the base of the heart across and down, then over to the apex.

Listening to the sounds at the aortic, tricuspid, pulmonic, arid mitral areas.

Answer and Explanation

The Correct Answer is D

A) Listening for sounds from the apex to the heart to the base of the heart: This technique is not the most effective for auscultation of heart sounds. While it may seem logical to start at the apex and move toward the base, heart sounds are best heard at specific anatomical locations where the valves are closest to the chest wall. Moving from apex to base does not follow the traditional systematic approach used to assess all heart sounds.

B) Listening to the sounds at the site where the apical pulse is heard to be the loudest: The apical pulse is typically located at the mitral area (left 5th intercostal space, midclavicular line), and while this is an important location for assessing heart sounds, it is not the recommended approach for auscultation. The nurse should listen to all the key valve areas to fully assess the heart's function and detect abnormalities such as murmurs or extra heart sounds.

C) Listening from the base of the heart across and down, then over to the apex: This approach is not systematic and may cause the nurse to miss important sounds in the other areas of the heart. The base of the heart is located at the top (around the second intercostal space), while the apex is at the bottom (left 5th intercostal space). A more structured method of auscultation is required to ensure all key areas are evaluated.

D) Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This is the correct technique for auscultating heart sounds. The nurse should listen over the aortic, pulmonic, tricuspid, and mitral valve areas in sequence to assess heart sounds thoroughly. Each of these areas is associated with a specific valve, and auscultation at these locations helps the nurse identify any abnormal heart sounds, such as murmurs, S3, or S4, as well as the timing of S1 and S2 heart sounds. This systematic approach ensures a comprehensive assessment of heart function.

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Correct Answer is B

Explanation

A) The third heart sound (S3): The third heart sound (S3) occurs early in diastole, immediately following S2. It is often associated with conditions that cause increased volume and pressure in the ventricles, such as heart failure or dilated cardiomyopathy. S3 is not heard late in diastole, so it does not match the described timing of the extra heart sound.

B) The fourth heart sound (S4): The fourth heart sound (S4) is heard late in diastole, just before S1. It is caused by the atria contracting forcefully to push blood into a non-compliant or stiff ventricle, often associated with conditions like left ventricular hypertrophy or ischemic heart disease. The timing of S4, occurring just before S1, makes it the correct identification of the described extra heart sound.

C) A split second heart sound S2: A split S2 occurs when the aortic and pulmonic valves do not close simultaneously, causing the second heart sound (S2) to be heard as two distinct components. This split can vary with respiration but does not occur late in diastole. Therefore, it does not align with the extra heart sound heard just before S1.

D) A friction rub: A friction rub is a sound associated with pericarditis, caused by the rubbing of inflamed pericardial layers. It has a distinct, grating quality and can be heard throughout the cardiac cycle. A friction rub is not a late diastolic sound, making it an incorrect identification for the extra heart sound described.

A. The presence of cerumen in the ear canal B. A shiny, pearly white color tympanic membrane C. A clear presence of a cone of light D. A yellow or amber color to the tympanic membrane

Correct Answer is D

Explanation

A) The presence of cerumen in the ear canal:
This is incorrect. The presence of cerumen (earwax) in the ear canal is not inherently abnormal. In fact, cerumen is a natural substance produced by the body to protect and clean the ear canal. While excessive buildup can lead to blockages or hearing impairment, some amount of cerumen is normal and does not indicate an abnormal finding.

B) A shiny, pearly white color tympanic membrane:
This is incorrect. A shiny, pearly white tympanic membrane is a normal finding. This color and appearance indicate a healthy, intact eardrum. The tympanic membrane should be translucent with a smooth surface and this typical pearly appearance in a healthy ear.

C) A clear presence of a cone of light:
This is incorrect. The cone of light is a normal finding during otoscopic examination. It is a reflection of the otoscope light off the tympanic membrane and should be visible in the anterior-inferior quadrant of the tympanic membrane. The presence of the cone of light suggests that the eardrum is intact and in a normal position.

D) A yellow or amber color to the tympanic membrane:
This is the correct answer. A yellow or amber color of the tympanic membrane suggests the presence of fluid behind the eardrum, which may indicate an ear infection or otitis media. This color change is considered abnormal and should prompt further investigation, as it can be a sign of inflammation, infection, or the accumulation of fluid in the middle ear.

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A nurse is preparing to auscultate for heart sounds on a client. Which technique should be used by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

Correct Answer is B

Explanation

A nurse examines a client's auditory canal and tympanic membrane with an otoscope. The nurse should recognize that which of the following is considered an abnormal finding?

Correct Answer is D

Explanation

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