When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. The nurse's next action should be to:

Correct Answer: C

Rationale: The correct answer is C: Validate the data by asking a coworker to listen to the breath sounds. This is the best course of action as it involves seeking a second opinion to confirm the unclear sound heard, ensuring accuracy in assessment. Notifying the physician immediately (A) may be premature without validation. Documenting the sound (B) without confirmation can lead to inaccurate documentation. Assessing again in 20 minutes (D) may delay necessary intervention if the sound is significant. Asking a coworker to validate the data (C) allows for immediate clarification and ensures accurate assessment.

Correct Answer: C

Rationale: The correct answer is C: Sarcoidosis. Sarcoidosis is a respiratory disease characterized by granulomatous inflammation in the lung parenchyma, leading to a restrictive pattern of lung function. This results in decreased lung volume and impaired gas exchange. Myasthenia gravis (A) is a neuromuscular disorder, not a respiratory disease. Asthma (B) is characterized by reversible airway obstruction, not a restrictive pattern. Ankylosing spondylitis (D) primarily affects the spine and joints, not the lungs. Therefore, the correct choice is C based on the specific pathological and clinical features of sarcoidosis.

Correct Answer: B

Rationale: The correct answer is B: Consensual reaction. This phenomenon occurs when shining light into one eye causes both pupils to constrict due to the pupillary light reflex. The optic nerves from both eyes converge in the brain, leading to the consensual reaction in the non-illuminated eye. Direct reaction (A) refers to the pupil directly exposed to light. Near reaction (C) is associated with changes in pupil size in response to focusing on near objects. Accommodation (D) is the process of adjusting the lens shape for near vision and is not directly related to pupillary constriction.

Correct Answer: A

Rationale: The correct answer is A: It is a splenic rub. The rough grating noise heard on examination is characteristic of a splenic rub, which occurs when the peritoneum overlying the spleen rubs against the spleen itself. This is often associated with conditions like splenic infarction or abscess. In Cody's case, with his history of leukemia and an enlarged spleen, this finding is concerning and warrants further investigation. Summary of other choices: B: It is not a variant of bowel noise as bowel noises are typically more high-pitched and gurgling in nature. C: It is not borborygmi, which refers to the normal sounds produced by the movement of gas and fluid in the intestines. D: It is not a vascular noise as those are usually associated with blood flow abnormalities and are not typically heard in the left upper quadrant.

Correct Answer: D

Rationale: The correct answer is D because in children, the sound produced by percussing over the lungs can sometimes be louder, longer, and lower in pitch compared to adults due to their thinner chest walls. This finding is considered normal for a child of this age and should not raise concerns. Palpating for pain or tenderness (Choice A) is not necessary as the loud tones are not indicative of pathology. Asking the child to take shallow breaths (Choice B) would not change the percussion findings. Referring the child immediately (Choice C) is unwarranted as the findings are within the expected range for a 4-year-old.