The nurse caring for a patient with heart failure would expect which assessment findings?
1. S1, S2, and flat neck veins
2. S3 and distended neck veins
3. S2 loudest and followed by S1
4. S4 and flat neck veins
2
Rationale 1: S1 and S2 are normal heart sounds; flat neck veins are considered a normal finding.
Rationale 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.
Rationale 3: S1 always precedes S2.
Rationale 4: S4 (gallop) may be present, but neck veins would be distended.
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