The nurse is caring for a patient with heart failure. What should the nurse expect when assessing this patient?
1. S1, S2, and flat neck veins
2. S3 and distended neck veins
3. S2 heard the loudest and followed by S1
4. S4 and flat neck veins
Correct Answer: 2
The abnormal S3 sound is reflective of the heart's attempts to fill an already distended ventricle, and the neck veins distend because of the increased venous pressure. Most patients have elements of both right- and left-sided heart failure. S1 and S2 are normal heart sounds; flat neck veins are considered a normal finding. The S1 and S2 sounds may be diminished in the heart failure patient and do not vary in intensity. S4 (gallop) may be present, but neck veins would be distended.
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