Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?
"I would palpate, inspect, percuss, and the auscultate.”
"I would percuss, palpate, auscultate, and then inspect.”
"I would auscultate, inspect, percuss, and then palpate."
"I would inspect, auscultate, palpate, and then percuss."
"I would inspect, palpate, percuss, then auscultate.”
The Correct Answer is E
A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.
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Correct Answer is ["A","B"]
Explanation
A. S4 is often considered a normal finding in older adults due to decreased ventricular compliance.
B. While it can be non-pathologic, it is more commonly associated with underlying conditions such as hypertension or heart failure.
C. The statement about being heard just after S2 is incorrect; S4 can be heard in various populations, particularly older adults.
D. An S4 sound is associated with a stiff or hypertrophied ventricle, not a dilated ventricle.
E. An S4 sound is not typically an expected finding in children; it is more common in older adults.
Correct Answer is ["A","B","E"]
Explanation
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.