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While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?

A.

A systolic murmur

B.

A third heart sound (S3)

C.

A fourth heart sound (S4)

D.

An expected heart sound

Answer and Explanation

The Correct Answer is A

A. A systolic murmur: A murmur heard between S1 and S2 occurs during systole, which is why it is classified as a systolic murmur. Systolic murmurs are often due to valve abnormalities like aortic stenosis or mitral regurgitation.

B. A third heart sound (S3): The S3 sound occurs after S2, not between S1 and S2. It is associated with rapid ventricular filling and may indicate heart failure.

C. A fourth heart sound (S4): The S4 sound occurs before S1, not between S1 and S2. It is associated with a stiff or hypertrophic ventricle.

D. An expected heart sound: A murmur is not considered an expected heart sound; it is typically abnormal and requires further investigation.


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Related Questions

Correct Answer is B

Explanation

A. 108/60 mm Hg: This is considered normal blood pressure and does not indicate hypertension.

B. 134/86 mm Hg: According to the current guidelines, stage 1 hypertension is defined as systolic 130-139 mm Hg or diastolic 80-89 mm Hg. This client's blood pressure falls into that category.

C. 164/104 mm Hg: This is classified as stage 2 hypertension, which is defined by systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg.

D. 128/68 mm Hg: This is considered elevated blood pressure, not stage 1 hypertension. Stage 1 begins at systolic BP of 130 mm Hg.

Correct Answer is A

Explanation

A. A systolic murmur: A murmur heard between S1 and S2 occurs during systole, which is why it is classified as a systolic murmur. Systolic murmurs are often due to valve abnormalities like aortic stenosis or mitral regurgitation.

B. A third heart sound (S3): The S3 sound occurs after S2, not between S1 and S2. It is associated with rapid ventricular filling and may indicate heart failure.

C. A fourth heart sound (S4): The S4 sound occurs before S1, not between S1 and S2. It is associated with a stiff or hypertrophic ventricle.

D. An expected heart sound: A murmur is not considered an expected heart sound; it is typically abnormal and requires further investigation.

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