# 護理師於心尖處聽診一名成年病人。請聽錄音。護理師應記錄哪一項發現？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=604457&lang=zh-tw  
> language: zh-TW  
> subject: Lifestyle Choices  
> category: HPM

## 題目

護理師於心尖處聽診一名成年病人。請聽錄音。護理師應記錄哪一項發現？

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🎧Cardiac auscultation recording

Use headphones if available. You may replay the recording.

1

S2 之後出現的 S3 奔馬音

✕

2

不規律的不規則心律

✕

3

規律的 S1 與 S2，無額外心音

✕

4

心包膜摩擦音

✕

## 解析

錄音呈現規律成對的 S1 與 S2 型態，無額外心音。預期的記錄應描述速率或節律以及 S1 與 S2 的存在，而非給予未經證實的診斷。

## 深入解析

快速解答
記錄規律的 S1 與 S2，無額外心音。
臨床推理
成對心音以規律間隔重複，未聽見明顯的第三心音或粗糙摩擦音。此發現直接記錄，不推論疾病。
音檔出處
James Heilman, MD · CC0-1.0
**參考資料**
- NCBI Bookshelf — Nursing Skills: Cardiovascular Assessment

- Audio source and license record

## 重要概念

- **S1** — 第一心音，與心室收縮開始時二尖瓣及三尖瓣關閉有關。
- **S2** — 第二心音，與心室收縮結束時主動脈瓣及肺動脈瓣關閉有關。

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