A 13-year-old male presented with delirium, mumbling speech, tachycardia, dry flushed skin, dilated pupils, myoclonus, slightly elevated temperature, urinary retention, decreased bowel sounds, seizures, and dysrhythmia. The MOST likely cause is

Correct Answer: B

Rationale: The correct answer is B) amphetamine. This presentation aligns with amphetamine toxicity symptoms, which include delirium, tachycardia, mydriasis, hyperthermia, myoclonus, urinary retention, decreased bowel sounds, seizures, and dysrhythmias. Educational context: Amphetamines are stimulant drugs that can lead to severe toxicity, especially in adolescents due to their misuse for performance enhancement or recreational purposes. A) Antidepressant agents typically do not cause the constellation of symptoms described in the case. They may present with altered mental status and other specific signs. C) Barbiturates are central nervous system depressants and would not typically cause tachycardia, mydriasis, or myoclonus seen in this case. D) Benzodiazepines are central nervous system depressants that would not usually cause the symptoms described. They typically present with sedation, respiratory depression, and decreased level of consciousness. It is crucial for pediatric nurses to be able to recognize signs of drug toxicity in adolescents, as prompt identification and intervention are essential to prevent serious complications and provide appropriate care.

Correct Answer: B

Rationale: In this scenario, the most likely cause of the sudden drop in O2 saturation in a full-term baby with meconium aspiration syndrome is option B) endotracheal tube blockade. This is the correct answer because a blockage in the endotracheal tube would prevent the delivery of oxygen to the baby's lungs, leading to decreased oxygen saturation levels. Option A) O2 source supply is less likely to be the cause because if the machine was initially working fine and suddenly there is a drop in O2 saturation, it indicates a problem beyond the oxygen source supply. Option C) self-extubation is also less likely in this situation as it would typically result in sudden desaturation but not due to a drop in oxygen saturation as described in the scenario. Option D) low inspiratory pressure value is an important consideration in mechanical ventilation, but it is less likely to cause a sudden severe drop in O2 saturation compared to an endotracheal tube blockade. Educationally, it is crucial for pediatric nurses to be able to quickly identify and troubleshoot potential complications during ventilation in neonates, especially in critical conditions like meconium aspiration syndrome. Understanding the possible causes of sudden desaturation and knowing how to address them promptly can be life-saving for the infant. Regular training, simulation exercises, and staying updated on best practices in pediatric nursing are essential for nurses to provide safe and effective care to neonatal patients.

Correct Answer: D

Rationale: In the context of pediatric nursing, understanding risk factors for neonatal sepsis is crucial for providing effective care to newborns. The correct answer is D) low birth weight. Low birth weight infants are more vulnerable to infections due to their underdeveloped immune systems and are at a higher risk for neonatal sepsis. A) Maternal diabetes is not directly linked to neonatal sepsis. While diabetes can increase the risk of certain complications during pregnancy, it is not a primary risk factor for neonatal sepsis. B) Maternal hypertension, similarly to diabetes, does not directly contribute to neonatal sepsis. While it can lead to other maternal and fetal complications, it is not a specific risk factor for neonatal sepsis. C) Advanced maternal age is not a direct risk factor for neonatal sepsis. While older maternal age can be associated with certain pregnancy-related complications, it is not a primary factor in the development of neonatal sepsis. Educationally, it is important for nursing students to understand the specific risk factors for neonatal sepsis to provide targeted care and interventions for at-risk newborns. By knowing which factors contribute to neonatal sepsis, nurses can actively monitor and prevent infections in vulnerable neonates, ultimately improving patient outcomes.

Correct Answer: A

Rationale: In the first 2 months of life, a febrile, previously full-term infant is more likely to have sepsis caused by group B streptococci (Option A). This is because group B streptococci are a common cause of early-onset sepsis in neonates, often acquired during birth from the mother's genital tract. It is crucial to identify and treat this promptly to prevent serious complications like meningitis, pneumonia, and sepsis. Option B, pharyngitis caused by group A streptococci, is less likely in this age group as infants are less prone to throat infections compared to older children and adults. Option C, meningitis caused by Neisseria meningitidis, is also less common in the first 2 months of life and is more prevalent in older children and adolescents. Option D, urinary tract infection caused by Staphylococcus epidermidis, is rare in neonates and infants without underlying conditions predisposing them to UTIs. This question is important for pediatric nursing exam preparation as it highlights the unique susceptibilities of neonates to certain infections based on age and developmental factors. Understanding the common pathogens and clinical presentations in different age groups is crucial for providing effective and timely care to pediatric patients.

Correct Answer: C

Rationale: In the outpatient management of a minor burn involving less than 10% body surface area, the correct answer is C) begin prophylactic penicillin. The rationale behind this is that prophylactic antibiotics are not routinely recommended for minor burns as they do not significantly reduce infection rates and can contribute to antibiotic resistance. Option A) applying silver sulfadiazine (Silvadene) is a common practice for managing burns as it helps prevent infection and promotes healing. Option B) applying bacitracin is also a suitable topical antibiotic ointment for minor burns. Option D) leaving blisters intact is generally recommended as they act as a natural barrier against infection and aid in the healing process. However, if the blister is large, causing discomfort, or at risk of rupturing, it may need to be drained under sterile conditions. In an educational context, it is crucial for healthcare providers to stay updated on evidence-based practices in managing burns to ensure the best outcomes for patients. Understanding the rationale behind each option helps in making informed clinical decisions and providing optimal care to pediatric patients with minor burns.