1. A nurse is

assessing the

heart sounds of

a client who has

developed chest

pain that

becomes worse

wth inspiration.

the nurse

auscultates a

high-pitched

scratching

sound during

both systole and

diastole with

diaphragm of the

stethoscope

positioned at the

left sternal

border. Which of

the following

heart sounds

should the nurse

document?

A. Audible click

B. Murmur

C.Third heart

sound

D. Pericardial

friction rub

2. A nurse is obtaining the blood

pressure in a

client's lower extremity. Which of

D. Pericardial friction rub

Pericardial friction rub

MY ANSWER

A pericardial friction rub has a high-pitched scratching,

grating, or squeaking leathery sound heard best with the

diaphragm of the stethoscope at the left sternal border.

A pericardial friction rub is a manifestation of pericardial

inflammation and can be heard with infective pericarditis

with myocardial infarction, following cardiac surgery or

trauma, and with some autoimmune problems, such as

rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration

or coughing and which may be relieved by sitting up and

leaning forward.

Audible click

An audible clicking sound occurs in clients who have prosthetic valve replacement surgery.

Murmur

A heart murmur has a swishing or a whistling sound.

Heart murmurs are caused by turbulent blood flow through

valves or ventricular outflow tracts. Low- and medium-frequency sounds are more easily heard with the bell of

the stethoscope applied lightly to the skin; high-frequency

sounds are more easily heard with a diaphragm. A murmur

can be a manifestation of valvular disease.

Third heart sound

A third heart sound is a low-pitched sound after the second

heart sound. An S3 is caused by rapid ventricular filling

during diastole. It is best heard at the mitral area, with the

client lying on the left side. An S3 is commonly heard in

children and young adults. In older adults and clients who

have heart disease, an S3 often indicates heart failure.