The nurse educator is reviewing Korotkoff's sounds with a group of student nurses. What is the best response by the student nurse about phase II Korotkoff's sounds?
A) Systolic pressure
B) Auscultatory gap
C) Diastolic pressure in children
D) Diastolic pressure in adults
B
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Phase I (following initial silence, the turbulence begins): Characterized by first appearance of faint, but clear tapping sounds that gradually increase in intensity. The first tapping sound is recorded as the systolic pressure (about 120–110). Phase II: Characterized by blowing, muffled, or swishing sounds (about 109–100). These sounds may temporarily disappear, especially if the client is hypertensive. This absence of sound is called the auscultatory gap and may be as great as 40 points. Failure to recognize this gap may result in error, overestimating the diastolic pressure. Phase III: Characterized by distinct, loud, sharp sounds as the blood flows relatively freely through the increasingly open artery (about 99–88). These sounds are softer than those in phase II. Phase IV: Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality (about 87–80). The onset of this phase is recorded as the diastolic pressure in children. Phase V: This is the last sound heard before a period of continuous silence (below 80). The point at which the last sound is heard is recorded as the diastolic pressure in adults.
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