单选题
While auscultating heart sounds of a client with heart failure, the
nurse hears an extra heart sound immediately after the second heart sound
(S
2). The nurse should document this as
- A. a first heart sound (S1).
- B. a third heart sound (S3).
- C. a fourth heart sound (S4).
- D. a murmur.
【正确答案】
B
【答案解析】An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventrieular filling. A murmur is heard when there's turbulent blood flow across the valves.