When performing a cardiovascular assessment, what would the nurse understand about an S3 heart sound? Select all that apply
Can be caused by a poorly compliant (stiff) ventricle
Can occur with congestive heart failure
Heard just after S1
Always pathologic
Correct Answer : A,B,E
A. An S3 is often associated with a stiff or poorly compliant ventricle.
B. An S3 heart sound can be an indication of congestive heart failure in adults, as it reflects increased fluid volume and pressure in the ventricles.
C. S3 is heard just after S2, not S1.
D. The S3 heart sound is not always pathologic. It is often benign in children, adolescents, and young adults, where it may occur due to a rapid filling phase of the ventricles.
E. In adolescents and younger individuals, an S3 heart sound is usually considered a normal finding.
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Correct Answer is ["A","D"]
Explanation
A. Asking about shortness of breath is critical subjective data that indicates respiratory distress.
B. Palpating for masses is more of a physical assessment and does not yield subjective data.
C. Inspecting skin and nails is also part of the objective assessment rather than subjective data.
D. Inquiring about the color and quantity of sputum provides important subjective data related to respiratory function.
E. Auscultation is an objective assessment technique and does not pertain to subjective data.
Correct Answer is E
Explanation
A. Music can be a soothing nonpharmacologic method to reduce pain and may help with relaxation, even for confused patients, as it typically doesn’t require cognitive engagement.
B. Aromatherapy is generally safe and may offer calming effects for older adults without relying heavily on cognitive processing.
C. Heat application is a physical pain relief method, and as long as safety precautions are taken, it can be used effectively in confused patients.
D. Distraction can be a beneficial technique for pain relief and is often effective without requiring cognitive engagement.
E. Guided Imagery should be avoided in confused older adults, as it relies on the patient's ability to follow instructions and visualize mental images, which can be challenging and potentially frustrating for someone with cognitive impairment.