The nurse assesses the client's heart sounds and auscultates a sharp clicking sound. Which does the nurse implement?
1. Asks client about valve replacement surgery
2. Instructs client to elevate the head of the bed
3. Requests tutoring for heart sound auscultation
4. Explains this is a normal finding in older adults
1
1. Sharp, clicking sounds from the heart result from valve replacement with a me-chanical valve, and the sound heard is the closing of a metal valve leaflet. Valve re-placement with pericardial or tissue valves can emit abnormal heart sounds but gen-erally do not click. Heart murmurs can produce clicking sounds, but the clicks from murmurs are not as sharp as the click from a mechanical heart valve.
2. Raising the head of the bed is not necessarily indicated because the client has a mechanical heart valve.
3. The nurse's assessment skills are of sufficient quality to auscultate the click.
4. The reader does not know whether the client is an older adult; however, a sharp clicking sound in any heart is abnormal.
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