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Zorluk: OrtaTechniques of Physical Assessment

An older adult client diagnosed with left-sided heart failure is undergoing a cardiovascular examination. The nurse is preparing to assess the client for an S3 ventricular gallop. Which action by the nurse demonstrates the correct physical assessment technique?

  1. Placing the bell of the stethoscope lightly against the skin over the fifth intercostal space at the midclavicular line.Cevap
  2. B
    Documenting the S3 gallop as an expected, normal physiological change of aging in older adults.
  3. C
    Palpating the precordium to locate the point of maximal impulse immediately before visually inspecting the chest.
  4. D
    Delegating the auscultation of the abnormal heart sound to the unlicensed assistive personnel.

Cevap

The correct technique is to place the bell of the stethoscope lightly against the skin over the fifth intercostal space at the midclavicular line (the mitral area).
The correct action applies the appropriate instrument (the bell) with the correct pressure (lightly) at the correct anatomical location (fifth intercostal space at the midclavicular line) for identifying a low-pitched S3 heart sound.

Adım Adım Çözüm

1
Identify the characteristics of the assessment finding (S3 gallop).
An S3 heart sound is a low-pitched extra heart sound that occurs during early ventricular diastole.
Knowing the pitch of the sound determines which part of the stethoscope is appropriate to use.
2
Select the correct stethoscope instrument and pressure.
The bell of the stethoscope is selected and must be applied lightly against the skin.
The bell is designed for low-pitched sounds. If pressed firmly, the patient's skin acts as a diaphragm, filtering out low-pitched sounds and amplifying high-pitched sounds.
3
Determine the correct anatomical landmark for auscultation.
The stethoscope should be placed over the mitral area (apex), located at the fifth intercostal space at the midclavicular line.
Left-sided S3 gallops are best auscultated over the apex of the heart where the left ventricle is closest to the chest wall.

Anahtar Kavram

Correct application of physical assessment tools and anatomical landmarks for cardiovascular auscultation.
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Konular

Techniques of Physical Assessment

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