Author Question: The nurse is explaining to the student nurses the different heart sounds that are assessed during ... (Read 73 times)

mmm · **on:** Jun 25, 2018

The nurse is explaining to the student nurses the different heart sounds that are assessed during the cardiac assessment. Which statement made by a student indicates understanding of the expected normal heart sounds?

1. If I hear the S1 as lub and S2 as dub, then that is normal and means that the valves are working.
2. If I hear a 'lub-dub-ee' it means the client has a ventricular gallop.
3. If I hear 'dee-lub-dub' then the client may have an atrial gallop. This occurs near the very end of diastole just before S1 and creates the sound.
4. If I hear the 'dee-lub-dub' sound in an older adult, then I should know that is considered normal for the older client.

Question 2

The nurse is explaining to the client the need to do a more detailed assessment. This type of assessment involves obtaining which type of information?

1. Information regarding the client's overall assessment
2. Information of a specific medical condition
3. Information specific to the client's current condition
4. Information regarding past medical history

ecabral0 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1

When the AV valves close the S1 occurs and is the lub, and when the semilunar valve closes the S2 occurs as the dub; this indicates normal heart sounds. The other statements indicate abnormal heart sounds.

Answer to Question 2

Correct Answer: 3

Information specific to the client's current condition is a detailed assessment. Information regarding the client's overall assessment would be a head-to-toe assessment and is a basic assessment. Information of a specific medical condition is a focused assessment, which pertains to only one specific system. Information regarding past medical history is data that is gathered as part of a head-to-toe assessment.