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: In this scenario, the correct answer is B) amphetamine. The presentation of delirium, tachycardia, myoclonus, dilated pupils, seizures, and dysrhythmia is indicative of amphetamine toxicity. Amphetamines are central nervous system stimulants that can cause a spectrum of symptoms ranging from agitation to seizures and cardiac dysrhythmias. Antidepressant agents (option A) typically do not present with the constellation of symptoms described. Barbiturates (option C) usually cause respiratory depression and hypotension, rather than the tachycardia and myoclonus seen in this case. Benzodiazepines (option D) are more likely to cause sedation, respiratory depression, and hypotension rather than the symptoms described. In an educational context, understanding the signs and symptoms of common pediatric poisonings is crucial for nurses working with children. Recognizing the specific toxidrome associated with different substances helps in providing prompt and appropriate care. It is also essential for nurses to educate families about safe medication storage and the risks associated with various substances to prevent accidental ingestions in children.

Correct Answer: B

Rationale: In this scenario, the most likely cause of the sudden drop in O2 saturation when ventilating a full-term baby with meconium aspiration syndrome is option B) endotracheal tube blockade. Endotracheal tube blockade can occur due to the accumulation of meconium or mucus in the tube, leading to inadequate ventilation and oxygenation. Option A) O2 source supply is unlikely to be the cause as the baby was fine on the machine previously. Option C) self-extubation is less likely in a full-term baby with meconium aspiration syndrome as they are typically not able to self-extubate. Option D) low inspiratory pressure value could lead to inadequate ventilation but is less likely to cause a sudden severe drop in O2 saturation. Educationally, it is crucial for pediatric nurses to understand the common complications and challenges in ventilating newborns, especially those with meconium aspiration syndrome. Recognizing and promptly addressing issues like endotracheal tube blockage can be life-saving for these vulnerable patients. Nurses must be skilled in troubleshooting and responding quickly to changes in a baby's condition during ventilation to ensure optimal outcomes.

Correct Answer: D

Rationale: Neonatal sepsis is a serious infection in newborns that can be life-threatening. The correct answer is D) low birth weight. Low birth weight infants have underdeveloped immune systems, making them more susceptible to infections like sepsis. Option A) maternal diabetes is not a direct risk factor for neonatal sepsis. While infants of diabetic mothers may be at risk for other complications, sepsis is more closely associated with factors like low birth weight. Option B) maternal hypertension is also not a direct risk factor for neonatal sepsis. Hypertension in the mother can lead to other complications during pregnancy, but it is not a primary risk factor for sepsis in the newborn. Option C) advanced maternal age is not a direct risk factor for neonatal sepsis either. While older mothers may face certain pregnancy-related risks, sepsis in the newborn is more commonly linked to factors like prematurity or low birth weight. In an educational context, understanding the risk factors for neonatal sepsis is crucial for healthcare providers working in pediatrics. By recognizing and addressing these risk factors, healthcare professionals can take proactive measures to prevent, diagnose, and treat neonatal sepsis effectively, ultimately improving outcomes for newborns.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Sepsis caused by group B streptococci. In the first 2 months of life, infants are at a higher risk of serious bacterial infections due to their immature immune systems. Group B streptococci are a common cause of sepsis in neonates, especially within the first month of life. These bacteria can be transmitted from the mother during childbirth, leading to infection in the newborn. Option B) Pharyngitis caused by group A streptococci is less likely in a febrile infant, as pharyngitis is more common in older children and adults. Option C) Meningitis caused by Neisseria meningitidis is also less common in infants under 2 months compared to older children. Option D) Urinary tract infection caused by Staphylococcus epidermidis is rare in neonates and more commonly seen in older children or adults. Educational Context: Understanding the age-specific risks and common pathogens in pediatric patients is crucial for nurses working in pediatric settings. Recognizing the unique challenges in diagnosing and treating infections in neonates can help healthcare providers provide timely and appropriate care to this vulnerable population. By knowing the typical pathogens associated with different age groups, nurses can quickly assess and intervene in cases of febrile illness in infants.

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. This is because prophylactic antibiotics are not routinely recommended for minor burns as they do not prevent infection and can contribute to antibiotic resistance. Option A) apply silver sulfadiazine (Silvadene) is a common topical agent used for burn wound care to prevent infection and aid in healing. Option B) apply bacitracin is another topical antibiotic ointment that can be used for minor burns to prevent infection. Option D) leave blisters intact is also a recommended practice for minor burns as it helps protect the underlying skin from further damage and reduces the risk of infection. In an educational context, it is important for healthcare providers to be aware of evidence-based practices in the management of burns to provide optimal care to pediatric patients. Understanding the rationale behind each intervention helps in making informed decisions and promoting best outcomes for patients. It is crucial to prioritize non-pharmacological interventions and appropriate wound care in the management of minor burns to promote healing and prevent complications.