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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While bilateral crackles at the lung bases indicate fluid accumulation, a common symptom of dilated cardiomyopathy, it’s not as immediately life-threatening as some other conditions.
Choice B rationale:
Acute aortic regurgitation can lead to a rapid and severe drop in blood pressure, which is a medical emergency. Therefore, this patient should be assessed first.
Choice C rationale:
While a murmur and splinter hemorrhages are symptoms of infective endocarditis, they are not as immediately life-threatening as acute aortic regurgitation.
Choice D rationale:
Sharp chest pain with a deep breath could be a symptom of rheumatic fever, but it’s not as immediately life-threatening as acute aortic regurgitation.
So, the correct answer is Choice B, after analyzing all choices.
Correct Answer is A
Explanation
Choice A rationale:
An irregular pulse could indicate that myocarditis is affecting the heart’s electrical system, leading to an irregular heartbeat or arrhythmia. This could potentially affect the action of digoxin, a medication used to treat heart conditions, and therefore should be communicated to the healthcare provider.
Choice B rationale:
Leukocytosis, or a high white blood cell count, can be a sign of infection or inflammation, including myocarditis. However, it is not as specific as an irregular pulse in indicating a potential issue with the administration of digoxin.
Choice C rationale:
Generalized myalgia, or muscle pain, can be a symptom of myocarditis. However, it is not as directly related to the action of digoxin as an irregular pulse.
Choice D rationale:
Fatigue can be a symptom of myocarditis. However, it is not as directly related to the action of digoxin as an irregular pulse.
So, the correct answer is A, after analyzing all choices.
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