A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?
A friction rub
A split second heart sound S₂
The third heart sound (S3)
The fourth heart sound (S4)
The Correct Answer is D
A. A friction rub: A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.
B. A split second heart sound S₂: A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.
C. The third heart sound (S3): S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.
D. The fourth heart sound (S4): S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Red-colored urine: Rifampin, when taken orally or intravenously, can cause red discoloration of bodily fluids, including urine, sweat, saliva, and tears. This is a common and harmless side effect of the medication. Clients should be informed about this potential discoloration to avoid unnecessary concern.
B. Black-colored stools: Black-colored stools are not an expected side effect of rifampin.
C. Staining of teeth: While rifampin can cause staining of contact lenses, it is not associated with tooth discoloration.
D. Constipation: Constipation is not a common side effect of rifampin. Gastrointestinal side effects may include nausea, vomiting, and abdominal pain.
Correct Answer is ["B","D","E"]
Explanation
A. Montelukast: Montelukast is a leukotriene receptor antagonist commonly used in the management of asthma and allergic rhinitis. It is not part of the standard tuberculosis treatment regimen.
B. Rifampin: Rifampin is a key component of tuberculosis treatment and is effective against both active and latent tuberculosis.
C. Acyclovir is an antiviral medication primarily used for herpes simplex virus infections and is not part of the standard treatment for tuberculosis.
D. Isoniazid: Isoniazid is another essential drug in the treatment of tuberculosis, particularly for the prevention of latent tuberculosis progression to active disease.
E. Pyrazinamide: Pyrazinamide is part of the standard combination therapy for tuberculosis.
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