Question

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

A. S3 gallop
B. Pericardial friction rub
C. Mitral valve prolapse
D. Aortic regurgitation

Answer 1

The nurse should document the sound as a pericardial friction rub, which is indicative of inflammation of the pericardial sac, distinguished from other heart sounds by its scratchy nature and occurrence throughout the cardiac cycle.

Step-by-step explanation:

The heart sound described by the student is a pericardial friction rub. This scratchy or high-pitched sound heard during auscultation indicates inflammation of the pericardial sac. Such inflammation can lead to a rubbing sensation as the heart beats, and this can worsen with inspiration as the heart moves against the inflamed pericardium.

Typically, this is different from the other heart sounds mentioned like an S3 gallop, which may indicate congestive heart failure, mitral valve prolapse which often has a clicking sound associated with it, or aortic regurgitation which may cause a blowing, decrescendo murmur heard in diastole.

The auscultation of a pericardial friction rub utilizing a stethoscope is crucial in diagnosing conditions such as pericarditis.