The nurse is caring for a child with suspected ingestion of some type of poison. What action should the nurse take next after initiating cardiopulmonary resuscitation (CPR)?

Correct Answer: D

Rationale: The correct action for the nurse to take next after initiating CPR for a child suspected of ingesting poison is to call poison control (Option D). This is the most crucial step as poison control experts are specifically trained to provide immediate and accurate guidance on managing poison exposures. In cases of poisoning, time is of the essence, and getting expert advice promptly can save the child's life. Option A, emptying the mouth of pills, plants, or other material, is incorrect because it can potentially lead to further harm if done incorrectly. It is crucial to avoid inducing vomiting in cases of poisoning without proper guidance. Option B, questioning the victim and witness, is not the priority at this moment. The immediate focus should be on ensuring the child's safety and obtaining expert advice. Option C, placing the child in a side-lying position, is a general first aid measure for an unconscious child but is not the next step to take after initiating CPR for a suspected poisoning. In an educational context, it is vital for nurses to be well-versed in the correct steps to take in emergencies such as poisoning. Understanding the importance of seeking expert advice from poison control centers can help nurses provide efficient and effective care to pediatric patients in critical situations.

Correct Answer: D

Rationale: In the case of a child with acetylsalicylic acid (aspirin) poisoning being admitted to the emergency department, the early clinical manifestation that the nurse would expect to assess is hyperventilation. This is because aspirin poisoning can lead to respiratory alkalosis, causing the child to hyperventilate as a compensatory mechanism to try to normalize the blood pH. Option A) Hematemesis, vomiting blood, is not typically an early clinical manifestation of aspirin poisoning. It may occur later in severe cases due to gastrointestinal bleeding. Option B) Hematochezia, the passage of fresh blood through the rectum, is also not an early sign of aspirin poisoning. It may occur in advanced stages if there is gastrointestinal bleeding. Option C) Hyperglycemia is not a typical early clinical manifestation of aspirin poisoning. Aspirin poisoning is more likely to cause metabolic acidosis rather than hyperglycemia. Educational Context: Understanding the clinical manifestations of aspirin poisoning is crucial for nurses caring for children. Early identification of symptoms like hyperventilation can prompt swift interventions and prevent further complications. Aspirin poisoning can be serious, so prompt recognition and management are essential for improving patient outcomes.

Correct Answer: C

Rationale: Activated charcoal is commonly used in cases of poisoning to prevent absorption of toxins in the gastrointestinal tract by binding to them. In the scenario of acetaminophen poisoning in a preschool child, potential complications from activated charcoal administration include diarrhea, vomiting, and risk of aspiration. Option A: Diarrhea is a common side effect of activated charcoal due to its cathartic effect. It helps eliminate toxins from the body rapidly. Option B: Vomiting can occur as activated charcoal may induce nausea and vomiting, which could lead to aspiration of stomach contents. Option D: Intestinal obstruction is a rare but serious complication, especially in patients with a compromised gastrointestinal tract or if a large amount of charcoal is given. It can cause blockages in the intestines. The correct answer is C because all the options are potential complications of activated charcoal administration. It is crucial for nurses to monitor for these side effects to prevent further harm to the child. Understanding these complications is vital for pediatric nurses to provide safe and effective care in cases of poisoning.

Correct Answer: A

Rationale: In the context of pediatric nursing, understanding the classification of hydrocarbon poisons is crucial for providing safe and effective care to children. The correct answer, "All below," is the most comprehensive choice as gasoline, turpentine, and lighter fluid are all considered hydrocarbon poisons. Gasoline is a common household product that can be accidentally ingested by children, leading to serious health risks such as aspiration pneumonia. Turpentine, often found in paints and varnishes, can cause respiratory distress and central nervous system depression if ingested. Lighter fluid, used for igniting fires, can result in chemical burns and respiratory complications if swallowed. By selecting option A, students demonstrate their understanding of the diverse substances that fall under the category of hydrocarbon poisons. The incorrect options, B, C, and D, are single examples of hydrocarbon poisons and do not encompass the full range of substances that pose a risk to children if ingested or inhaled. Educationally, this question reinforces the importance of recognizing common household toxins and highlights the need for vigilance in preventing pediatric poisonings. Nurses must be equipped with knowledge about different types of poisons to provide prompt and appropriate interventions in cases of exposure, emphasizing the significance of poison prevention education for families and caregivers.

Correct Answer: A

Rationale: The most appropriate nursing action in this scenario is to refer the 13-year-old boy for immediate medical evaluation (Option A). Sudden and severe scrotal pain in the absence of trauma could indicate a serious condition such as testicular torsion, which is a medical emergency requiring prompt intervention to prevent testicular damage or loss. Administering analgesics or applying ice (Options B and C) without a proper diagnosis could delay necessary medical treatment and potentially worsen the boy's condition. Additionally, reassuring the adolescent that occasional pain is common with puberty (Option D) is inappropriate in this case as it fails to address the urgency of the situation. From an educational perspective, this question highlights the importance of recognizing signs and symptoms that require immediate medical attention in pediatric patients. Nurses need to be vigilant in assessing complaints of sudden and severe pain, especially in sensitive areas like the scrotum, to ensure timely intervention and prevent complications. Prompt referral for evaluation in such cases is crucial for ensuring the well-being of the child.