when auscultating an infants lungs the nurse detects diminished breath sounds what should the nurse interpret this as
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?

Correct answer: C

Rationale: Diminished breath sounds in an infant are an abnormal finding and warrant further investigation to rule out conditions like atelectasis or pneumonia.

2. Which clinical manifestations should the nurse expect in a child diagnosed with nephroblastoma?

Correct answer: D

Rationale: The correct answer is D: Hypertension. Nephroblastoma, also known as Wilms' tumor, often causes hypertension due to its impact on the kidney, which plays a role in regulating blood pressure. Atrial fibrillation (choice A) and endocarditis (choice B) are not typically associated with nephroblastoma. Hyperlipidemia (choice C) is also not a common clinical manifestation of nephroblastoma.

3. Which actions by the nurse demonstrate overinvolvement with patients and their families? (Select all that apply.)

Correct answer: C

Rationale: Overinvolvement includes personal actions like buying clothes, showing favoritism, and spending off-duty time with patients, which can blur professional boundaries.

4. Which reflex, present at birth, is elicited by stroking the sole of the infant's foot, resulting in the fanning of the toes?

Correct answer: A

Rationale: The Babinski reflex is the correct answer. This reflex is characterized by the fanning out of the toes when the sole of the foot is stroked. It is a normal reflex in infants and is typically present at birth, disappearing by around 12 months of age. The Moro reflex, which involves the infant's response to a sudden loss of support or a loud noise, is not related to the fanning of toes. Sucking and rooting reflexes are related to feeding behaviors and are not elicited by stroking the sole of the foot.

5. Which condition is characterized by a 'seal-like' barking cough in children?

Correct answer: A

Rationale: Croup is the correct answer. Croup is characterized by a 'seal-like' barking cough due to inflammation and narrowing of the upper airways, particularly the larynx and trachea. It is most common in young children and can cause significant respiratory distress, especially at night. Treatment often includes humidified air and corticosteroids. Asthma (choice B) typically presents with wheezing and shortness of breath, not a barking cough. Bronchitis (choice C) is characterized by productive cough with mucus, not a barking cough. Pneumonia (choice D) often presents with fever, productive cough, and chest pain, not a barking cough.

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