Well Child Care and Preventive Pediatric Health Care Guidelines, Exams of Pediatrics

Download Well Child Care and Preventive Pediatric Health Care Guidelines and more Exams Pediatrics in PDF only on Docsity! Burns Pediatric Final Exam Study Guide Questions with Verified Answers. 1. The primary care pediatric nurse practitioner understands that a major child health outcome associated With worldwide climate change is: A. cost of living. B. education. C. nutrition. D. pollution. - Correct answer ANS: C There is growing evidence that climate change is having a dramatic effect on food crops that leads to food Distribution issues and food insecurity among families. 2. The primary care pediatric nurse practitioner understands that, to achieve the greatest world- wide Reduction in child mortality from pneumonia and diarrhea, which intervention is most effective? a. Antibiotics b. Optimal nutrition c. Vaccinations d. Water purification - Correct answer ANS: C Rotavirus is the most common cause of diarrhea globally and Strep pneumonia is the leading cause of Pneumonia, and together these are the leading infectious causes of childhood morbidity and mortality Globally. Both are vaccine-preventable diseases. Antibiotics to treat pneumonia, optimal nutrition, and Clean water all help to reduce morbidity and mortality, but vaccination prevents the diseases from Occurring. 3. When providing well child care for an infant in the first year of life, the primary care pediatric nurse Practitioner is adhering to the most recent American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care guidelines by: A. focusing less on development and more on illness prevention and nutrition. B. following guidelines established by the Bright Futures publication. C. scheduling well-baby visits to coincide with key developmental milestones. D. seeing the infant at ages 2, 4, 6, and 12 months when immunizations are due. - Correct answer ANS: C In the most recent AAP Recommendations for Preventive Pediatric Health Care, there is a greater P a g e 1 | 208 Emphasis on behavioral and developmental issues and a recommendation that well child care be based on Child and family development rather than the periodicity of immunization schedules. This will require a Revision of the current recommendations in Bright Futures. 4. Which is true about the health status of children in the United States? a. Globalism has relatively little impact on child health measures in the U.S. b. Obesity rates among 2- to 5-year-olds have shown a recent significant decrease. c. The rate of household poverty is lower than in other economically developed nations. d. Young children who attend preschool or day care have higher food insecurity. - Correct answer ANS: B Obesity rates are a major concern for child health in the U.S. but recently have stabilized in the rate of Increase and have declined among 2- to 5-year-olds between 2004 and 2013. Globalism has an increasing Effect on child health in the U.S. The rate of household poverty in the U.S. is higher than in other Economically developed nations. Young children who attend preschool or day care have lower food Insecurity. 5. Which region globally has the highest infant mortality rate? a. Indonesia B. Southern Asia c. Sub-Saharan Africa d. Syria - Correct answer ANS: C Although Sub-Saharan Africa and Southern Asia together account for 81% of the infant mortality rate Globally, Sub-Saharan Africa has the highest infant mortality rate in the world. 1. The parent of a toddler is concerned that the child may have autism. The primary care pediatric nurse Practitioner completes a Modified Checklist for Autism in Toddlers (M-CHAT) tool, which indicates Several areas of concern. What will the nurse practitioner do? a. Administer a Childhood Autism Rating Scale (CARS) in the clinic. b. Consult a specialist to determine appropriate early intervention strategies. c. Refer the child to a behavioral specialist for further evaluation. d. Tell the parent that this result indicates that the child has autism. - Correct answer ANS: C The M-CHAT is a screening tool and is useful for detecting behaviors that may indicate autism. This Instrument has been found to have acceptable sensitivity, specificity, and significant positive predictive P a g e 2 | 208 7. The primary care pediatric nurse practitioner sees a 3-year-old child who chronically withholds stools, In spite of the parents' attempts to stop the behavior, requiring frequent treatments with laxative Medications. Which diagnosis will the nurse practitioner use to facilitate third-party reimbursement? a. Altered elimination pattern b. Elimination disorder c. Encopresis d. Parenting alteration - Correct answer ANS: C Encopresis is a medical diagnosis, classified in the ICD-10-CM, and is recognized for reimbursement Purposes. "Altered elimination pattern" and "Parenting alteration" are NANDA International diagnoses And are not recognized for reimbursement. "Elimination disorder" is a developmental diagnosis. 8. A child is in the clinic for evaluation of an asthma action plan. The primary care pediatric nurse Practitioner notes that the child's last visit was for a pre-kindergarten physical and observes that the Child is extremely anxious. What will the nurse practitioner do initially? a. Ask the child's parent why the child is so anxious. b. Perform a physical assessment to rule out shortness of breath. c. Reassure the child that there is nothing to be afraid of. d. Review the purpose of this visit and any anticipated procedures. - Correct answer ANS: D The PNP should remember that young children are learning "scripts" for health care visits and may be Stressed when recalling previous visits, especially if those involved immunizations. The PNP should Explain the purpose and any anticipated procedures for this visit to help put the child at ease. 9. When meeting with a new family, the primary care pediatric nurse practitioner develops a database That identifies family members and others living in the household, relationships with others outside the Household, and significant behavioral and emotional problems. Which tool will the nurse practitioner Use to record this information? a. CRAFFT b. Eco map c. Genogram d. Pedigree - Correct answer ANS: C The genogram is an approach to developing a family database to provide a graphic representation of P a g e 5 | 208 Family structure, roles, and problems of recurring significance in a family. The CRAFFT tool is used to Assess substance abuse in adolescents. The coma is used to identify relationships in the family and Community that are supportive or harmful. The pedigree is used to identify potential genetic disorders. 10. The primary care pediatric nurse practitioner evaluates a school-age child whose body mass index (BMI) is greater than the 97th percentile. The nurse practitioner is concerned about possible metabolic Syndrome and orders laboratory tests to evaluate this. Which diagnosis will the nurse practitioner Document for this visit? a. Metabolic syndrome b. Nutritional alteration: more than required c. Obesity d. Rule out type 2 diabetes mellitus - Correct answer ANS: C A problem should never be included on the problem list that is not supported by subjective and objective Data found and recorded in the database. This child has a BMI that suggests obesity, so this may be used As a diagnosis. Metabolic syndrome is a diagnosis that is determined by laboratory data, which has not Been evaluated yet. Nutritional alteration is a NANDA diagnosis and not acceptable for reimbursement. "Rule out" should not be used as a diagnosis, but may be considered part of a plan. 11. The primary care pediatric nurse practitioner performs a developmental assessment on a 3- year-old Child and notes normal cognitive, fine-motor, and gross-motor abilities. The child responds Appropriately to verbal commands during the assessment but refuses to speak when asked questions. The parent tells the nurse practitioner that the child talks at home and that most other adults can Understand what the child says. The nurse practitioner will: A. ask the parent to consider a possible speech delay and report any concerns. B. continue to evaluate the child's speech at subsequent visits. C. refer the child for a speech and hearing evaluation. D. tell the parent to spend more time in interactive conversations with the child. - Correct answer ANS: B Development should be monitored over time and within the context of the child's overall well- being, Rather than at an isolated testing session. The child has normal development in observed measures and P a g e 6 | 208 Appears to hear and understand well. By parental report, the child is able to speak. The PNP should Continue to evaluate speech over time, since this refusal to speak may be associated with shyness or Intimidation in the clinic. It is not necessary to tell the parent that the child has a possible speech delay. Unless an actual speech delay is observed, a referral is not indicated, nor is it necessary to implement a Home therapy. 12. The primary care pediatric nurse practitioner is performing a well-child assessment on an adolescent And is concerned about possible alcohol and tobacco use. Which assessment tool will the nurse Practitioner use? a. CRAFFT b. HEEADSSS c. PHQ-2 d. RAAPS - Correct answer ANS: A The CRAFFT tool is a six-question tool used to screen for adolescent substance abuse. The HEEADSSS Is used as a psychosocial screening tool. The PHQ-2 is a rapid screen for depression. The RAAPS is used To assess risk behaviors that contribute to most morbidity, mortality, and social problems in teens. 13. The primary care pediatric nurse practitioner is assessing a toddler whose weight and body mass index (BMI) are below the 3rd percentile for age. The nurse practitioner learns that the child does not have Regular mealtimes and is allowed to carry a bottle of juice around at all times. The nurse practitioner Plans to work with this family to develop improved meal patterns. Which diagnosis will the nurse Practitioner use for this problem? a. Failure to thrive b. Home care resources inadequate c. Nutrition alteration - less than required d. Parenting alteration - Correct answer ANS: D Because the PNP is planning to intervene by helping the parents to provide appropriate food habits, the Correct diagnosis should be "Parenting alteration." "Failure to thrive" is a medical diagnosis and requires A medical and social evaluation to rule out organic causes or detect neglect. "Home care resources P a g e 7 | 208 An essentialist view of culture, which dominates the health care literature, portrays an ethnic minority Group as having a static set of traits and oversimplifies cultural information, applying traits to all members Of the group. Assuming that all people from Central America are Catholic is an example of this Oversimplification. Collectivism refers to a member of an ethnic group who perceives himself or herself To be intrinsically part of that group. A constructive view recognizes culture as complex and dynamic and Sees people as individuals who may belong to multiple cultures simultaneously. Individualism recognizes The individual, and not the group, as the basic unit of survival. 5. The primary care pediatric nurse practitioner cares for children from a Native American family and Learns that they used many herbs to treat and prevent illness. Which approach will the pediatric nurse Practitioner use to promote optimum health in the children? a. Ask about the types of practices used and when they are applied. b. Provide a list of harmful herbs and ask the family to avoid those. c. Suggest that the family avoid using these remedies in their children. d. Tell the parents to use the herbs in conjunction with modern medications. - Correct answer ANS: A The challenge, when working with families from different cultural backgrounds, who use alternative or Complementary medicines, is to find ways to achieve a mutual understanding of the differences and to Negotiate an acceptable plan of care. The first step is to begin a discussion about these practices. Providing a list of harmful herbs, suggesting that the family avoid certain herbs, and suggesting that the Herbs are only an adjunct to "modern medicine" will sound disparaging and will convey a sense of Mistrust. 6. A primary care pediatric nurse practitioner working in a community health center wishes to develop a Program to assist impoverished children and families to have access to healthy foods. Which strategy Will the pediatric nurse practitioner employ to ensure the success of such a program? a. Asking community members to assist in researching and implementing a program b. Designing a community garden approach that involves children and their parents c. Gaining support from the corporate community to provide needed resources P a g e 10 | 208 d. Providing evidence-based information about the importance of a healthy diet - Correct answer ANS: A Community collaboration can be fostered through community-based participatory research (CBPR), Which is transformative research that bridges the gap between science and practice by actively engaging Communities with formally trained researchers. In this type of research, community members formally Participate in all aspects of the process, making the findings more relevant to the community it affects the Most. Designing a community garden approach without first knowing whether the community needs or Wants it does not ensure success. Gaining support from the corporate community without input from the Affected community does not guarantee success. Giving evidence-based information does not involve the Community members in research and does not increase success. 7. The primary care pediatric nurse practitioner works with families from a variety of cultures and Socioeconomic classes. Which is an example of cultural humility in practice? a. Giving health care advice that takes cultural differences into account b. Identification of other cultures that may be superior to one's own culture c. Receptivity to learning about the perspectives of other cultures d. Respecting other cultures while maintaining the views of one's own - Correct answer ANS: C Cultural humility is defined as the lifelong commitment to developing mutually beneficial, No paternalistic partnerships and is based on a model of passive volition, receptivity, and being open to Learning from others. Practitioners who have cultural humility are always seeking to learn about other Cultures. Cultural humility involves asking questions, rather than giving answers. Cultural humility does Not mean identifying one's own culture as inferior. Practitioners who are culturally competent are open to The influence of other cultures. 8. A Somalia immigrant mother is concerned that her 8-year-old child is underweight. The primary care Pediatric nurse practitioner notes that the child's weight is at the 25th percentile. After realizing that The mother is comparing her child to a group of American-born children who are overweight, the Pediatric nurse practitioner is able to convince the mother that this is a normal weight. Which domain Of cultural competence does this represent? P a g e 11 | 208 a. Global b. Interpersonal c. Intrapersonal d. Organizational - Correct answer ANS: B The interpersonal domain of cultural competence refers to how cultural competence is manifested Between and among individuals and includes all relationships within the health care setting. The PNP Becomes aware of cultural norms in body weight and uses this knowledge to discuss healthy weights with The parent. The global domain recognizes a movement toward integration and interconnection of the World population in economic, political, technological, and sociocultural terms. The intrapersonal domain Refers to an understanding of the self to understand one's own cultural background. The organizational Domain is knowledge of institutional culture and how it affects health care. 9. The primary care pediatric nurse practitioner prescribes a twice daily inhaled corticosteroid for a 12- Year-old child. At a well-child visit, the child reports not using the medication on a regular basis. Which response by the pediatric nurse practitioner demonstrates an understanding of client- centered? Care? a. Asking the child to describe usual daily routines and schedules b. Referring the family to a social worker to help with medication compliance c. Reviewing the asthma action plan with the parent and the child d. Teaching the child how the medication will help to control asthma symptoms - Correct answer ANS: A In a client-centered relationship, there is reciprocal communication and understanding. The PNP should Be able to understand the client's perspective and unique situation. The first step is to evaluate possible Reasons for no adherence and not to make referrals or re-educate until potential barriers have been Identified and negotiation with the client has occurred. 10. The parents of a special needs child tell the primary care pediatric nurse practitioner that they are Planning a 3-month visit to their home country in Africa. The pediatric nurse practitioner assists the Family to obtain a sufficient supply of medications and formula and to make sure that the child's Equipment can be transported and used during the trip and at the destination. This is an example of P a g e 12 | 208 Strengths. Explaining that developmental delays develop over time is true but does not reassure the parent Or help the parent cope with feelings. Referrals are not indicated unless delays are present and may take Time. 5. Which recommendation will a primary care pediatric nurse practitioner make when parents ask about? Ways to discipline their 3-year-old child who draws on the walls with crayons? a. Give the child washable markers so the drawings can be removed easily. b. Provide a roll of paper for drawing and teach the child to use this. c. Put the child in "timeout" each time the child draws on the walls. d. Take the crayons away from the child to prevent the behavior. - Correct answer ANS: B Discipline involves training or education that molds appropriate behavior and is used to teach the child What is permitted and encouraged. Providing an appropriate outlet for drawing helps to teach the child Where to use the crayons. Using washable markers allows the parents to clean the walls but does not teach The child appropriate behaviors. Timeout and taking away the crayons are forms of punishment, or a loss Of privileges, that are administered as a form of retribution. 6. The primary care pediatric nurse practitioner enters an exam room and finds a 2-month-old infant in a Car seat on the exam table. The infant's mother is playing a game on her smart phone. The nurse Practitioner interprets this behavior as: A. a sign that the mother has postpartum depression. B. extremely concerning for potential parental neglect. C. of moderate concern for parenting problems. D. within the normal range of behavior in early parenthood. - Correct answer ANS: C A parent who seems disinterested in a child raises moderate concerns for parenting problems. It does not Necessarily signal postpartum depression. It is not a mark for extreme concern. It is not within the Expected range of behaviors. 7. During a well-child assessment of an 18-month-old child, the primary care pediatric nurse practitioner Observes the child becoming irritable and uncooperative. The parent tells the child to stop fussing. What will the nurse practitioner do? a. Allow the parent to put the child in a "timeout." P a g e 15 | 208 b. Ask the parent about usual discipline practices. c. Offer the child a book or a toy to look at. d. Stop the exam since the child has reached a "meltdown." - Correct answer ANS: C The child has exhibited early signs of misbehavior. At this stage, distraction and active engagement may Be used to stop more problems from occurring. It is not necessary to use a timeout because the child Hasn’t reached the point where cooperation is impossible. The PNP should model appropriate Interventions by offering the child a distraction and may ask the parent about discipline practices later in The visit. The child is not at a "meltdown" state. 8. The primary care pediatric nurse practitioner performs a physical examination on a 9-month- old infant And notes two central incisors on the lower gums. The parent states that the infant nurses, takes solid Foods three times daily, and occasionally takes water from a cup. What will the pediatric nurse? Practitioner counsel the parent to promote optimum dental health? a. To begin brushing the infant's teeth with toothpaste b. To consider weaning the infant from breastfeeding c. To discontinue giving fluoride supplements d. To make an appointment for an initial dental examination - Correct answer ANS: D The American Academy of Pediatric Dentistry recommends a first dental examination at the time of Eruption of the first tooth and no later than 12 months old. Parents should be counseled to clean the Infant’s teeth but with water only. Weaning from breastfeeding is not indicated, although mothers should Not let the infant nurse while sleeping to prevent milk from bathing the teeth. Fluoride supplements Should not be discontinued. 9. The primary care pediatric nurse practitioner has a cohort of patients who have special health care Needs. Which is an important role of the nurse practitioner when caring for these children? a. Care coordination and collaboration b. Developing protocols for parents to follow c. Monitoring individual education plans (IEPs) d. Providing lists of resources for families - Correct answer ANS: A Care coordination is one of the key elements for children with special health care needs. PNPs are Especially suited for this role and have the unique skills to function as care coordinators. Care for these P a g e 16 | 208 Children should involve shared decision making and individualized care and not "cookbook" approaches. The PNP may advocate for children's health care needs for the IEP but does not monitor these. The PNP Should not just give parents lists of phone numbers but should assist them to make appointments. 10. A single mother of an infant worries that living in a household with only one parent will cause her Child to be maladjusted. To help address the mother's concerns, the primary care pediatric nurse Practitioner will suggest: A. developing consistent daily routines for the child. B. exposing her child to extended family members when possible. C. not working outside the home during the first few years. D. taking her child to regular play date activities with other children. - Correct answer ANS: A Providers can teach parents that providing predictable, consistent, and loving care helps an infant to learn Trust and help influence positive brain development. Involving extended family members and going to Play dates are good ways to socialize children but are not essential to learning trust. It may not be possible For her to be a stay-at-home mother. 1. The primary care pediatric nurse practitioner performs a well-baby examination on a 7-day- old infant Who is nursing well, according to the mother? The nurse practitioner notes that the infant weighed 3250 grams at birth and 2990 grams when discharged on the second day of life. The infant weighs 3080 grams at this visit. Which action is correct? a. Follow up at the 2-month checkup. b. Refer to a lactation consultant. c. Schedule a weight check in 1 week. d. Suggest supplementing with formula. - Correct answer ANS: C This infant lost about 8% of its birth weight, which is normal and, since discharge home, has gained at Least 15 grams per day, which is also normal. The PNP should schedule a weight check in a week to make Sure the infant regains its birth weight, since most should regain this in 10 to 14 days and since this loss of Birth weight is at the high end of normal. It is not necessary to refer to a lactation consultant or Supplement with formula, since the infant is gaining weight adequately. P a g e 17 | 208 Practitioner that her infant seems fussy and wants to nurse more often. What will the nurse? Practitioner tell her? a. She may not be making as much breast milk as before. b. She should keep a log of the frequency and duration of each feeding. c. The infant may be going through an expected growth spurt. d. The infant should stay on the previously established nursing schedule. - Correct answer ANS: C Infants may have a growth spurt at 6 to 8 weeks, and mothers who are breastfeeding may be concerned That they are not making enough milk when they notice that the infant is fussy and wanting to nurse more Often. The PNP should reassure the mother that this is expected. It is not necessary, since the infant is Gaining weight appropriately, for the mother to keep a log. The mother should follow the infant's cues for Feeding since the extra suckling will increase the milk supply to meet the growing infant's needs. 8. The primary care pediatric nurse practitioner is performing a well-child examination on a 9- month-old Infant whose hearing is normal but who responds to verbal cues with only single syllable Vocalizations. What will the nurse practitioner recommend to the parents to improve speech and Language skills in this infant? a. Provide educational videos that focus on language. b. Read simple board books to the infant at bedtime. c. Sing to the child and play lullabies in the baby's room. d. Turn the television to Sesame Street during the day. - Correct answer ANS: B The best way to improve language skills is to read to children. As long as the reading includes positive Interactions with the baby and the reader, the baby is learning language. Educational videos, music, and Television are all passive media and do not involve this interaction. 9. The parent of a 5-month-old is worried because the infant becomes fussy but doesn't always seem Interested in nursing. What will the nurse practitioner tell this parent? a. The infant may be expressing a desire to play or to rest. b. The parent should give ibuprofen for teething pain before nursing. c. This is an indication that the infant is ready for solid foods. d. This may indicate gastrointestinal discomfort such as constipation. - Correct answer ANS: A At this age, infants may cry when they are tired or need social interaction and not just when they are P a g e 20 | 208 Hungry. The PNP should teach parents about this change in social development so they can be responsive To their infant's needs. Solid foods are not added until age 6 months. Teething usually does not begin until At least 6 months. GI discomfort usually occurs after eating. 10. The primary care pediatric nurse practitioner is examining a 12-month-old infant who was 6 weeks Premature and observes that the infant uses a raking motion to pick up small objects. The PEDS Questionnaire completed by the parent did not show significant developmental delays. What will the Nurse practitioner do first? a. Perform an in-depth developmental assessment. b. Reassure the parent that this is normal for a premature infant. c. Refer the infant to a developmental specialist. d. Suggest activities to improve fine motor skills. - Correct answer ANS: A When developmental screening indicates an infant is not progressing at the expected rate, additional Testing to determine the degree of delay is necessary. A referral may be needed if a delay is determined. This is not normal for this degree of prematurity Infants should develop a pincer grasp by 9 to 10 months Of age. - Correct answer 1. 1. The parent of a 4-year-old points to a picture and says, "That's your sister." The Child responds by saying, "No! It's my baby!" This is an example of which type of thinking in Preschool-age children? a. a. Animism b. b. Artificialize c. c. Egocentrism d. d. Realism - Correct answer ANS: D Children at this age are developing their ability to establish causality. Nominal realism occurs When children think that one type of thing can only be called by one name. All dogs are dogs And not various breeds. Animism refers to the belief that objects possess person-like qualities. Artificialize occurs when children think things are caused by a controlling force. Egocentrism is When children see things only as they relate to themselves. 1. 2. The primary care pediatric nurse practitioner performs a developmental Assessment on a 32-month-old child. The child's parent reports that about 70% of the child's Speech is intelligible. The pediatric nurse practitioner observes that the child has difficulty Pronouncing "t," "d," "k," and "g" sounds. Which action is correct? a. a. Evaluate the child's cognitive abilities. P a g e 21 | 208 b. b. Obtain a hearing evaluation. c. c. Reassure the parent that this is normal. d. d. Refer the child to a speech therapist. - Correct answer ANS: C Intelligibility of speech reaches about 66% between the ages of 24 and 36 months. Tongue- Contact sounds are more intelligible by age 5 years. This child exhibits normal speech for age. It Is not necessary to perform a cognitive assessment based on these findings. Referrals for Hearing and speech evaluations are not indicated, since these findings are within normal limits. 1. 3. The primary care pediatric nurse practitioner is offering anticipatory guidance to The parents of a 12-month-old child. The parents are bilingual in Spanish and English and Have many Spanish-speaking relatives nearby. They are resisting exposing the child to Spanish out of concern that the child will not learn English well. What will the pediatric nurse? Practitioner tell the parents? a. a. Children who learn two languages simultaneously often confuse them in Conversation. b. b. Children with multi-language proficiency do not understand that others cannot Do this. c. c. Learning two languages at an early age prevents children from developing a Dominant language. D. d. Most bilingual children are able to shift from one language to another when Appropriate. - Correct answer ANS: D Most children who are bilingual are able to sort out the languages in conversation but may "code Switch" at times for clarity as they speak. They seem to understand that not everyone has this Ability. Most children who are bilingual develop a dominant language. 1. 4. The parents of a 3-year-old child are concerned that the child has begun refusing Usual foods and wants to eat mashed potatoes and chicken strips at every meal and snack. The child's rate of weight has slowed, but the child remains at the same percentile for weight On a growth chart. What will the primary care pediatric nurse practitioner tell the parents to? Do? a. a. Allow the child to choose foods for meals to improve caloric intake. b. b. Place a variety of nutritious foods on the child's plate at each meal. c. c. Prepare mashed potatoes and chicken strips for the child at mealtimes. d. d. Suggest cutting out snacks to improve the child's appetite at mealtimes. - Correct answer ANS: B Young children should have three meals and two nutritious snacks each day. The parents' Responsibility is to provide nutritious foods and allow children to choose how much they will eat. Children who are allowed to choose foods will likely make selections that are not healthy. Parents should be discouraged from preparing separate meals for their children. Snacks are Necessary to maintain adequate intake and energy. P a g e 22 | 208 Symbolic language increases interactive play. Children need both structured and free play, but Structured play will not increase interaction during this normally parallel period. 1. The primary care pediatric nurse practitioner is preparing to conduct a well-child assessment of an 8- Year-old child. How will the nurse practitioner begin the exam? a. Ask the child about school, friends, home activities, and sports b. Discuss the purpose of the visit and explain the procedures that will be performed c. Offer age-appropriate information about usual developmental tasks d. Provide information about healthy nutrition and physical activities - Correct answer ANS: A To build rapport with the child and parent, the PNP will begin by asking direct questions to the child, Encouraging the child to share information about daily routines. The other answers list aspects of the well Child visit that can be introduced after the initial conversation. 2. The primary care pediatric nurse practitioner is examining a 6-year-old child who attends first grade. The child reports "hating" school. The parent states that the child pretends to be sick frequently in Order to stay home from school. To further assess this situation, the nurse practitioner will first ask the Child: A. about school performance and grades. B. why school is so distressing. C. to name one or two friends. D. whether bullying is taking place. - Correct answer ANS: C The earliest school-age psychosocial milestone occurs when children learn to separate easily from family, Allowing them to go to school. Mastery of these skills enables them to develop and maintain peer Friendships. Social interaction skills are necessary in order to develop mastery over school activities. Asking the child to describe why school is distressing may not elicit information, since the child may not Be able to articulate this. Bullying is not the only reason for disliking school, but, if it is, will emerge During a discussion about friends and schoolmates. 3. A school-age child has begun refusing all cooked vegetables. What will the primary care pediatric? Nurse practitioner recommend to the parent? a. Allow the child to make food choices since this is usually a phase b. Ensure that the child has three nutritious meals and two nutritious snacks each day P a g e 25 | 208 c. Prepare vegetables separately for the child to encourage adequate intake d. Teach the child how important it is to eat healthy fruits and vegetables - Correct answer ANS: B Children have food jags that are generally self-limited. The parent's responsibility is to provide three Nutritious meals and two nutritious snacks each day so that all available choices are acceptable. Allowing Food choices may result in an overabundance of non-nutritious foods selected. It is not necessary to Prepare separate dishes for a child who is going through a temporary phase. Teaching the child about Nutrition is important but will not likely have much impact during this phase. 4. The parent of a 6-year-old child expresses concern that the child may have ADHD. Which screening Tool will the primary care pediatric nurse practitioner use to evaluate this possibility? a. Behavioral and Emotional Screening System for Children (BESS-2) b. Behavioral Assessment for Children - 2nd ed. (BASC-2) c. Conner's 3 Parent and Teacher Rating Scale D. Pediatric Symptom Checklist (PSC) - Correct answer ANS: C The Conner's Parent and Teacher Rating Scale is used to assess ADHD symptoms in children aged 6 to 18 years. The BESS-2 is used to evaluate social emotional and mental health in children. The BASC-2 is Used to further assess children who have positive findings on the BESS-2. The PSC is used to assess Cognitive, emotional, and behavioral problems in children. 5. The primary care pediatric nurse practitioner performs a physical examination on a 12-year- old child And notes poor hygiene and inappropriate clothes for the weather. The child's mother appears clean And well dressed. The child reports getting 6 to 7 hours of sleep each night because of texting with Friends late each evening. What action by the nurse practitioner will help promote healthy practices? a. Discuss setting clear expectations about self-care with the mother b. Give the child information about sleep and self-care c. Reassure the mother that this "non-compliance" is temporary d. Tell the mother that experimenting with self-care behaviors is normal - Correct answer ANS: A Parents of school-age children should be advised to set clear limits for their children for cleanliness, P a g e 26 | 208 Healthy exercise, hours of sleep, and other health promotion behaviors to encourage the development of Responsibility for these things. Giving the child information can be done along with setting expectations, But, at this age, the parent should still be supervising. While "non-compliance" is a part of this process, And is a means of asserting independence, parents need to discuss this with children to resolve the issue. 6. The parents of a 12-year-old child are concerned that some of the child's older classmates may be a Bad influence on their child, who, they say, has been raised to believe in right and wrong. What will? The primary care pediatric nurse practitioner tell the parent? a. Allowing the child to make poor choices and accept consequences is important for learning values b. Children at this age have a high regard for authority and social norms, so this is not likely to Happen c. Moral values instilled in the early school-age period will persist throughout childhood d. The pressures from outside influences may supersede parental teachings and should be confronted - Correct answer ANS: D Although early school-age children learn values from their parents, these may be challenged as children Learn that others have different values. Parents must confront and negotiate these issues daily with their Children. While children may make poor choices and subsequently learn from the consequences, it is best For parents to actively discuss these issues with their children. Children do have a high regard for Authority and social norms but may easily transfer this authority to other, less reliable people, such as Peers. Moral values may not persist if other sources of authority become prominent. 7. The parent of a 10-year-old boy tells the primary care pediatric nurse practitioner that the child Doesn’t appear to have any interest in girls and spends most of his time with a couple of other boys. The parent is worried about the child's sexual identity. The nurse practitioner will tell the parent A. children at this age who prefer interactions with same-gender peers usually have a homosexual Orientation. B. children experiment with sexuality at this age as a means of deciding later sexual orientation. C. this attachment to other same-gender children is how the child learns to interact with others. P a g e 27 | 208 12. The parent of a 5-year-old child who has just begun kindergarten expresses concern that the child will Have difficulty adjusting to the birth of a sibling. What will the primary care pediatric nurse Practitioner recommend? a. Allowing the child opportunities to discuss feelings about the baby B. Giving the child specific baby care tasks to promote sibling bonding c. Having snack time with the child each day to discuss the school day d. Providing reassurance that the sibling will not replace the child - Correct answer ANS: C Family routines provide support to children and help them self-regulate, especially during times of Change, and serve as a buffer during times of change and transition. This child has two major changes, so Setting aside regular time to spend with the child will help stabilize these changes. The other options may Be useful as well, but routines and special activities are most important. 1. The primary care pediatric nurse practitioner is examining a 15-year-old female who reports having Her first period at age 13. She states that she has had five periods in the last year, with the last one 2 Months prior. She participates in basketball at school. Which action is correct? A. Perform biometric screening to determine lean body mass. b. Prescribe oral contraceptives pills to regulate her periods. c. Reassure her that this is perfectly normal at her age. d. Refer her to an endocrinologist for hormonal evaluation. - Correct answer ANS: A Although it can take 18 to 24 months for adolescents to establish regulatory cycles, periods can also be Affected by athletic activity that decreases body fat. The PNP should assess the percentage of lean body Mass, which should be 75% or less to maintain regular ovulatory cycles. OCPs are useful for regulating Periods if this persists and other causes are ruled out. It is not necessary to refer her to an endocrinologist Unless problems persist in spite of standard management. 2. The parent of a 14-year-old child tells the primary care pediatric nurse practitioner that the child skips Classes frequently in spite of various disciplinary measures, such as grounding and extra homework And is earning Cs and Ds in most classes. What will the nurse practitioner recommend? a. Counseling for emotional problems b. Development of an Individual Education Plan c. Evaluation for possible learning disorders P a g e 30 | 208 d. Referral for a behavioral disorder - Correct answer ANS: C Frequent school absenteeism, class skipping, and other types of school avoidance may indicate a problem With cognitive ability and should be assessed. When cognitive disorders are ruled out, other issues, such As behavioral and emotional problems may be considered. IEPs are used for children who have identified Special physiological or cognitive needs and may be useful if a cognitive disorder is identified. 3. The primary care pediatric nurse practitioner is performing a well-child exam on a 12-year-old female Who has achieved early sexual maturation? The mother reports that she spends more time with her Older sister's friends instead of her own classmates. What will the nurse practitioner tell this parent? a. Early-maturing girls need to identify with older adolescents to feel a sense of belonging. b. Girls who join an older group of peers may become sexually active at an earlier age. c. Spending time with older adolescents indicates a healthy adjustment to her maturing body. d. The association with older adolescents will help her daughter to gain social maturity. - Correct answer ANS: B While it is true that early maturing females may join an older group of peers to feel that they fit in, the Ones who do put themselves at risk for risky behaviors, including sexual activity. Although many teens Feel awkward when they mature at different rates than their peers, joining a group of older peers Demonstrates a poor adjustment and does not promote social maturity. 4. The primary care pediatric nurse practitioner is performing a well-child assessment on a 13- year-old Female whose mother asks when her daughter's periods may start? Which information will the nurse Practitioner use to help estimate the onset of periods? a. The age of the mother's menarche b. The patient's age at thelarche c. When adrenarche occurred d. Whether linear growth has stopped - Correct answer ANS: B Thelarche, or the development of breast budding, generally precedes menarche by 2.5 years, so this Should be determined when attempting to predict this milestone. The age of the mother at menarche is not A reliable indicator. Adrenarche is related to adrenal and not gonadal development and is less valid than P a g e 31 | 208 Other secondary sex characteristics in assessing sexual maturation. Rapid linear growth usually begins After thelarche and peaks about a year later but is not used to predict menarche. 5. The mother of a 15-year-old adolescent female tells the primary care pediatric nurse practitioner that Her daughter has extreme mood swings prior to her periods, which the adolescent vehemently denies. When asked if she notices anything different just before her periods, the adolescent points to her Mother and says, "She gets really hard to live with." This demonstrates which characteristic of Adolescent thinking? a. Apparent hypocrisy b. Imaginary audience c. Overthinking d. Personal fable - Correct answer ANS: A Apparent hypocrisy is the notion that rules apply differently to adolescents than to others. The adolescent Who chalks up the conflict with her mother related to her premenstrual mood swings does not see her own Role in the conflict. Imaginary audience is the perception that everyone is thinking about them. Personal Fable is the idea that they are special. Overthinking involves making things more complicated than they Need to be. 6. During a well-child assessment of a 13-year-old male, the primary care pediatric nurse practitioner Notes small testicles and pubic and axillary hair. To further evaluate these findings, the nurse Practitioner will ask the patient about A. alcohol and tobacco use. B. changes in voice. C. increase in height and weight. D. participation in sports. - Correct answer ANS: D The initial sign of puberty in males is testicular enlargement. If this does not precede other changes, the PNP should consider whether the boy is taking exogenous anabolic steroids, common among those who Wish to improve athletic ability. These findings are not concerning for alcohol or tobacco use. Voice Changes and rapid growth may occur with pubic hair development, but the primary concern is anabolic Steroid use. P a g e 32 | 208 And hanging out with friends at the local shopping mall. When she confronts her child, he responds by Saying that he hates her. What will the nurse practitioner tell this mother? a. Adolescence is marked by an inability to comprehend complex situations. b. Adolescence is typically marked by tempestuous and transient episodes. c. Adolescents normally have extreme, disruptive conflicts with parents. d. Adolescents often need counseling to help them cope with life events. - Correct answer ANS: D Adolescent brains respond differently to toxic stress, so counseling is indicated to help them manage Serious events, such as family abuse and divorce. Early adolescents have concrete thinking, but the formal Operational thinking occurs later. "Storm and stress" are not the norm in adolescence nor are disruptive Periods of conflict. 12. The parent of a 16-year-old tells the primary care pediatric nurse practitioner that the teen was Recently caught smoking an electronic cigarette (e-cigarette). What will the nurse practitioner tell this? Parent? a. E-cigarette use may be a risk factor for later substance abuse. b. Experimentation with e-cigarettes does not lead to future tobacco use. c. Most teens who experiment with tobacco usually do not become addicted. d. This form of nicotine ingestion is safer than regular cigarettes. - Correct answer ANS: A Although many adolescents consider e-cigarettes to be a safe form of tobacco use, increasing evidence Indicates that their use may be a significant risk factor for later marijuana and substance abuse. The risk Of dependence and addiction is the same for e-cigarettes and other cigarettes, since both use nicotine. Only 41% of teens try tobacco 80% of older adolescents do not smoke. - Correct answer 1. The primary care pediatric nurse practitioner sees a 17-year-old client who quit smoking almost a year Prior but who reports having renewed cravings when around friends who smoke. Using knowledge of The maintenance stage of change, the primary care pediatric nurse practitioner will A. go over with the adolescent about the health risks associated with smoking. B. recommend avoiding friends who smoke and making new friends. C. remind the adolescent about the struggles associated with quitting smoking. P a g e 35 | 208 D. suggest that the teen consider taking up a sport or other physical activity. - Correct answer ANS: D During the maintenance stage, the PNP should help the client with plans to prevent relapse, including Establishing new behaviors as long-term changes. Adding a sport can help the client enjoy the benefits of Not smoking, while substituting one activity for another. The adolescent already knows about the health Risks and the difficulties of quitting. Suggesting giving up friends may be seen as another hardship and is Not part of the maintenance stage. 2. The pediatric nurse practitioner provides primary care for a special needs infant whose parent takes an Active role in the infant's care. The parent has a high school diploma and asks many questions about Her infant's treatments. Which approach will the nurse practitioner take to ensure health literacy for? This parent? a. Ask the parent to read back all information given. b. Encourage the parent to ask questions when confused. c. Provide written materials presented at an 8th grade level. d. Reinforce written information with verbal instructions. - Correct answer ANS: A The PNP should take a precautionary approach and assume that all clients will have health literacy Limitations. Assessment of health literacy can be done by asking clients to "read back" the information the Provider gives. While encouraging questions is important, parents may not want to admit that they are Confused and may not ask questions. Written materials should be given at a 5th grade level. Parents who Do not understand medical terms will not understand written or verbal information. 3. The primary care pediatric nurse practitioner is counseling an obese adolescent whose parents both Have type 2 diabetes mellitus. Which health behavior prediction model is useful when the nurse Practitioner discusses lifestyle changes with this client? a. Behavioral change model b. Health belief model c. Health promotion model d. Trans theoretical model - Correct answer ANS: B The health belief model explains behavior used to prevent disease rather than to promote health. Clients P a g e 36 | 208 Need to believe that they are vulnerable to the disease, will have negative consequences if they are Affected, and that taking action will reduce the risk. The adolescent who believes that there is a risk of Diabetes may be willing to undertake lifestyle changes if taught that these can reduce the risk. The Behavioral change model is useful for changing behaviors to promote health. The health promotion model Has a focus on health promotion and not disease promotion. The Trans theoretical model identifies the Stages of change. 4. The primary care pediatric nurse practitioner is assessing the health literacy of the parent of a toddler. Which tool will the nurse practitioner use to estimate reading level? a. Flesch-Kincaid Readability Test b. Gunning Fog Index c. Number of children's books in the home d. SMOG - Correct answer ANS: D The best tool to estimate reading level is the SMOG. The Gunning Fog Index and the Flesch- Kincaid Readability Test are used as well but are not considered the best indices. The number of children's books In the home can be asked as a screen but is not a reliable estimate of true literacy. 5. The primary care pediatric nurse practitioner examines an infant whose weight is below the 3rd Percentile and whose mother does not comply with the feeding regimen. When attempting to enlist the Help of the infant's grandmother, the grandmother says, "My daughter was like this when she was a Baby and she turned out all right." Which approach will the nurse practitioner take to improve the Outcome for this infant? a. Ask the grandmother about her daughter's health during childhood. b. Explain that the condition is potentially serious if not treated. c. Give the grandmother and mother information about normal growth. d. Refer the family to a social worker to investigate possible neglect. - Correct answer ANS: A This family has an altered perception of health and health behaviors based on their own experience with The condition. The grandmother considers this infant's weight similar to her own daughter's and assumes That things will resolve. The PNP should evaluate the mother's health to see if any problems occurred. P a g e 37 | 208 Advised against this. The nurse practitioner recognizes this as a possible alteration in which functional Health pattern? a. Cognitive-perceptual b. Health perception c. Role-relationship d. Values-beliefs - Correct answer ANS: B The health perception-health management pattern describes client perceptions of personal health and Health behaviors and includes the belief that there is a relationship between health status and health Practices. The cognitive-perceptual pattern describes sensory-perceptual and cognition patterns. The role- Relationship pattern describes patterns of roles and responsibilities of the client and other family members. The values-beliefs pattern identifies the beliefs that influence daily living, decision making, and meaning Of life. 11. The parent of a newborn has quit smoking cigarettes within the past month and reports feeling fidgety. Using a "reframing" technique, how will the primary care pediatric nurse practitioner respond? a. Explore ways that the parent can use this extra energy to do things for the baby. b. Remind the parent that this is a normal, temporary part of nicotine withdrawal. c. Suggest that the parent take up exercise to enjoy the benefits of not smoking. d. Tell the parent that, over time, these symptoms of withdrawal will subside. - Correct answer ANS: A Reframing is a counseling strategy that uses the context of an experience to give it a new meaning, Creating a frame of reference that focuses on a desired outcome instead of the current problem. The Withdrawal symptoms associated with tobacco cessation are uncomfortable, but the PNP can suggest Channeling this nervous energy into positive action for the baby. Telling the parent that the symptoms of Withdrawal are temporary or normal does not reframe the perception. Suggesting exercise may be Beneficial, but does not reframe the situation. 12. The primary care pediatric nurse practitioner is counseling a school-age child about asthma Management strategies. The child states that it is "too much trouble" to remember to use an inhaled P a g e 40 | 208 Corticosteroid medication twice daily and reports feeling fine, in spite of exhibiting expiratory Wheezes. Which action uses the health belief and self-efficacy model to teach this child about asthma? Management? a. Asking the child to try to use the inhaler at least once daily b. Discussing whether the child wants to participate in athletics c. Obtaining pre- and post-treatment spirometer testing D. Providing written information about inhaled corticosteroids - Correct answer ANS: C In the health belief model, clients need to believe that taking some action will reduce the risk of Symptoms and that the benefits of the action will outweigh the costs or effort. Demonstrating pre- and Post-treatment spirometer measures can help the child see that symptoms are reversible. Asking the child To make one change may be part of the Trans theoretical model, in which small behavior changes may Precede commitment to the actual plan. Discussing athletics may be useful when using the health Promotion model to encourage the client to participate in behaviors that will promote healthy activities, Such as sports. Providing written information is not part of any of the health behavior models. 1. 1. The primary care pediatric nurse practitioner is examining a newborn who is Breastfeeding and notes the presence of an ankyloglossia. What will the nurse practitioner? Do next? a. a. Ask the mother if the infant has any feeding difficulties. b. b. Refer the infant for a possible frenulectomy. c. c. Schedule an appointment with a lactation consultant. d. d. Suggest that the mother feed breast milk by bottle. - Correct answer ANS: A Infants with ankyloglossia may have difficulty feeding if the tongue does not extend well. The PNP should first assess feeding difficulties and then may refer for a lactation consultant or Consider a frenulectomy. 1. 2. The mother of a 2-month-old infant tells the primary care pediatric nurse Practitioner that she is afraid her breast milk is "drying up" because her baby never seems Satisfied and wants to nurse all the time. Which action is correct? a. a. Recommend pumping her breasts after feedings. b. b. Refer the mother to a lactation consultant. c. c. Suggest supplementation with formula. d. d. Weigh the infant to assess for a growth spurt. - Correct answer ANS: D Infants have growth spurts about every 3 to 4 weeks that increase their breast milk needs. Until The mother's milk supply catches up, the infant will act hungry and want to nurse more Frequently. The PNP should evaluate for this growth spurt and then instruct the mother to feed Her baby more often to increase her milk supply. Since the infant is hungry, the infant should Nurse. It is not necessary to refer for a lactation consultation or to supplement with formula. P a g e 41 | 208 1. 3. The primary care pediatric nurse practitioner is performing an assessment on a 1- Week-old newborn with a slightly elevated bilirubin who is breastfeeding well and who has Gained 30 grams in the past 24 hours. The infant is stooling and voiding well. The nurse Practitioner suspects breast milk jaundice. Which action is correct? a. a. Order home phototherapy and closely monitor bilirubin levels. b. b. Reassure the mother that the bilirubin level will drop in a few days. c. c. Recheck the serum bilirubin and infant's weight in 24 hours. d. d. Recommend that the mother pump her breast milk for a couple of days. - Correct answer ANS: C Infants with breast milk jaundice who are gaining weight and thriving should continue to Breastfeed and be monitored for the development of pathologic jaundice. It is not necessary to Order phototherapy or discontinue breastfeeding unless pathologic jaundice is present. The Bilirubin may remain elevated up to 3 months. 1. 4. The mother of a newborn asks the primary care pediatric nurse practitioner about The benefits of breastfeeding. What will the nurse practitioner tell her? a. a. Breastfeeding for 9 months or longer will reduce the incidence of food Allergies. b. b. Breast milk is an excellent source of vitamin D, iron, and other essential Nutrients for the baby. c. c. nursing her baby exclusively for at least 4 months will help her infant to resist Infections. D. d. There is a decreased risk of atopic dermatitis in babies who nurse for 12 Months or longer. - Correct answer ANS: C There is evidence that infants who exclusively breastfeed for at least 4 months have less risk for Infection than infant’s breastfed for less time. However, infants who breastfeed exclusively for 9 Months or for longer than 12 months may have increased risks for food hypersensitivities and Atopic dermatitis. Breast milk is a poor source of vitamin D and iron. 1. 5. The primary care pediatric nurse practitioner sees a 3-day-old nursing infant Whose newborn metabolic screen is positive for galactosemia? The nurse practitioner refers The newborn to a specialist for immediate evaluation and will tell the mother a. a. to continue to breastfeed her infant. b. b. to give the infant a cow's milk formula. c. c. to supplement breast milk with formula. d. d. to stop breastfeeding immediately. - Correct answer ANS: D Infants with galactosemia cannot consume GA lactose, which is in both cow's milk and breast Milk. Since there is a potential for a life-threatening response, the mother should be instructed to Stop nursing immediately. 1. 6. The mother of a nursing infant expresses concern about whether high-cholesterol Foods will increase her infant's risk of hyperlipidemia. What will the primary care pediatric? Nurse practitioner tell her? P a g e 42 | 208 Frozen breast milk may be stored up to 3 months in a well-regulated freezer. It is not necessary to use only pumped breast milk once this begins. Refrigerated breast milk may be stored up to 8 days. Once frozen breast milk is thawed it should be used within 24 hours. 3. The primary care pediatric nurse practitioner is evaluating a 4-year-old female child for enuresis. The parents reports that the child has never been dry at night and has recently begun having daytime incontinence, usually when at preschool. The nurse practitioner learns that the child does not appear to have an abnormal urine stream. What will the nurse practitioner do next? a. Examine the urethral meatus and labia and obtain a dipstick clean catch urinalysis. b. Reassure the parent that the child probably gets distracted and puts off voiding until it is urgent. c. Refer the child to a pediatric urologist for evaluation of possible vesicoureteral reflux. d. Suggest a bladder retraining program and use of a nighttime bedwetting alarm. - Correct answer ANS: A Urinary tract infection and labial adhesions are both in the differential diagnosis of dysfunctional voiding and can easily be ruled out or confirmed in the clinic setting with an exam and a UA. Although distractibility can contribute to daytime incontinence, it is important to rule out other causes. The child does not exhibit signs such as abnormal urine streams or recurrent UTI that warrant referral to a pediatric urologist. Until the causes are known, it is premature to recommend treatment. 4. The primary care pediatric nurse practitioner is managing a 6-year-old child who has chronic constipation and encopresis. The nurse practitioner has ruled out neurogenic etiology. The parents report that the child was difficult to toilet train as a toddler. What is key to managing this child's condition? a. Encouraging use of maintenance medications for at least 2 months after resolution of constipation b. Referral to a mental health consultant to manage problems in the parent-child dyad c. Spending time with the parents to uncover their feelings about their child's condition d. Teaching the parents that the symptom of stool retention is often voluntary for the child - Correct answer ANS: A The emphasis of management of encopresis in the absence of pathology is to establish a regular bowel routine after bowel evacuation. Parents should be taught to use the maintenance laxative for at least 2 months after resolution of the constipation. Referral to a mental health consultant should be reserved for P a g e 45 | 208 situations where the child and family may have underlying issues contributing to an ongoing problem. It is not necessary to spend time attributing cause or blame unless the problem continues to be chronic following initial management strategies that include maintenance medications. Parents should be taught what the dynamics of encopresis, including retention, are and that they are involuntary. 5. The primary care pediatric nurse practitioner is performing a well child exam on a 12-month- old infant. The parent tells the nurse practitioner that the infant has predictable bowel and bladder habits and asks about toilet training. What will the nurse practitioner tell this parent? a. It is too early to begin introducing the child to the toilet, and the parent should wait until the child is at least 2 years old. b. Placing the child on a "potty" chair helps the child associate elimination cues with the toilet. c. Predictability of elimination patterns indicates readiness for toilet training, and the parent can begin this process. d. The parent should wait until other signs of toilet training readiness occur before introducing the child to the toilet. - Correct answer ANS: B Once elimination patterns are predictable, the parent may place the child on a potty chair to help the child associate elimination with the toilet, as long as the parent understands that this is not actual potty training. It is not too early to begin this association exercise. Predictability of elimination patterns does not indicate cognitive readiness for toilet training. 6. The primary care pediatric nurse practitioner is performing a well child exam on a 24-month- old child. The parent tells the nurse practitioner that the child is being toilet trained and expresses frustration that on some days the child uses the toilet every time and on other days not at all. What will the nurse practitioner do? a. Advise the parent to make the child get clean clothes after an accident. b. Ask the parent about the child's toilet habits and understanding of toilet training. c. Recommend using an awards system to encourage toilet use. d. Suggest that the parent place the child on the toilet at predictable intervals. - Correct answer ANS: B Children often will not toilet train easily if the process is started too early. The PNP should assess toilet P a g e 46 | 208 training readiness to see if the child is ready. If the child is not ready, toilet training can be very stressful to both the child and the parent(s), so the PNP should not make recommendations that add to this stress. 7. The parent of a 5-year-old child tells the primary care pediatric nurse practitioner that the child has been using the toilet to urinate for since age 3 but continues to defecate in "pull-ups." The nurse practitioner learns that the child has predictable bowel movements and a physical examination is normal. What will the nurse practitioner recommend? a. Providing a reward system to offer incentives when the child uses the toilet b. Put the child back in diapers and resume toilet training in a few months. c. Putting the child on the toilet for 5 to 10 minutes at the usual time of defecation d. Use of polyethylene glycol until the child is able to use the toilet regularly - Correct answer ANS: C Since this child has predictable bowel patterns, the parent can put the child on the toilet for 5 to 10 minutes at these times to encourage toilet use. Rewards may be used at some point, but it is not recommended since the child is learning to do what is to be expected. Younger children may be put back in diapers and retrained in a few months. The child is not constipated and does not need medication. 8. The primary care pediatric nurse practitioner evaluates a 4-year-old girl whose parent reports frequent urination in the evenings on weekdays, incontinence after voiding. The parent reports that the child has soft formed stools 5 or 6 times weekly. Which assessment will the nurse practitioner make initially? a. Examination for labial adhesions b. Palpation for abdominal masses c. Screening for potential child abuse d. Urine culture and sensitivity - Correct answer ANS: A The child exhibits incontinence after voiding, or vaginal voiding, which may indicate labial adhesions. Examination for this may be completed easily during the physical assessment. Since the parent reports normal stools, it is less likely that chronic constipation is causing dysfunctional voiding. Screening for child abuse may be necessary if physiologic causes are ruled out. If a UTI is suspected, the first test will be a urinalysis, not a culture. P a g e 47 | 208 The child has been toilet trained and has recently developed chronic constipation. The first step is to evaluate recent illnesses or dietary changes that could cause constipation and painful stools that resulted in stool withholding. The other options represent more underlying physiologic or psychological pathology and should be explored if simple physiologic causes are not present. 1. 1. The primary care pediatric nurse practitioner is evaluating a school-age child who, after removal of a pituitary tumor, has altered hypothalamic control over hunger and satiety. The child is morbidly obese and expresses feeling depressed because of the obesity. What will the nurse practitioner recommend? a. a. Developing a system to reward compliance with a dietary regimen b. b. Restricting all access to food in the house and at school c. c. Suggesting an after-school exercise program to help with weight loss d. d. Using a food diary to track all calories and food intake - Correct answer ANS: B Children with brain dysfunction affecting hypothalamic control may need rigid restrictions of access to all foods in refrigerators, cupboards, and even garbage cans parents may need to install locks to prevent access. Because the child has no ability to control hunger, developing a reward system is likely to fail. An exercise program and a food diary may be beneficial, but the primary concern is to restrict access to foods. - Correct answer 1. 2. The primary care pediatric nurse practitioner is providing anticipatory guidance to the mother of a breastfed 6-month-old infant who asks about "baby-led weaning." What will the nurse practitioner tell her about this practice? a. a. "Foods given for this purpose do not meet all the child's nutritional needs." b. b. "Giving infants control of the feeding process will help prevent obesity." c. c. "Infants are given soft, mashable table foods when able to self-feed." d. d. "Infants must be able to grasp and feed themselves from a spoon to do this." - Correct answer ANS: C Baby-led weaning is a concept where infants feed themselves, soft, mashable table foods that they grasp rather than being spoon-fed, allowing the infant more control. Foods given either by spoon or finger-fed will meet the child's nutritional needs. More research is needed to determine if this method affords protection from obesity by improving self-regulation. Infants must be able to sit without support and to reach and grasp for objects. 1. 3. The parent of a 12-month-old infant asks the primary care pediatric nurse practitioner why 2% cow's milk is recommended instead of whole milk. What will the nurse practitioner tell this parent? a. a. Whole milk is usually not fortified with vitamin D. b. b. 2% milk is higher in essential proteins and minerals. c. c. Young children don't need the extra calories found in whole milk. P a g e 50 | 208 d. d. Younger children need a limited amount of fats. - Correct answer ANS: D The AAP recommends transitioning to unflavored 2% or fat-free cow's milk in the second year of life. Whole milk contains vitamin D and contains similar amounts of proteins and minerals. Children can get calories from other sources the reason for giving 2% milk is to minimize fat intake. - Correct answer 1. 4. The parent of a school-age child reports that the child is on a gluten-free diet. When questioned about the reason for this diet, the parent states that the child has fewer stomach aches since beginning the diet but has never been diagnosed with celiac disease. The parent reports using gluten-free grain products for all family members. The nurse practitioner will tell this parent that gluten-free diets a. a. are generally low in sugar and fat. b. b. are healthy and help prevent obesity. c. c. may be deficient in essential nutrients. d. d. provide adequate protein to meet daily needs. - Correct answer ANS: C Gluten-free grain products are often highly processed and not enriched with iron or folate. Many are very low in protein, enough so that they are used for patients with metabolic conditions such as PKU who need severe protein restrictions. They often have sugar and fat added to them to improve taste and do not help prevent obesity. 1. 5. The mother of a 6-year-old child tells the primary care pediatric nurse practitioner that the child only wants to eat French fries and hamburgers and refuses most vegetables. What will the nurse practitioner recommend? a. a. Giving the child a multivitamin since this is a phase b. b. Having the child eat vegetables before getting the hamburger c. c. Providing a variety of healthy foods at each meal d. d. Putting extra lettuce and tomatoes on hamburgers - Correct answer ANS: C Parents are responsible for the foods their children eat, and it is their responsibility to provide healthful foods. Children should be exposed to a variety of healthy foods but not forced to eat any of them. However, parents should not bribe children with the reward of getting the unhealthy food that they want. With a well-balanced diet, not eating a vegetable prepared at one meal, for example, will not compromise the child's health, so a multivitamin is not necessary if the overall diet is healthy. Allowing hamburgers and adding desired foods again puts the child in control. 1. 6. The primary care pediatric nurse practitioner provides anticipatory guidance for a 6-month-old infant who is breastfed who takes 400 IU of vitamin D daily. The parent reports that the infant has begun taking cereals, fruits, and vegetables in addition to nursing. What will the nurse practitioner recommend to promote healthy nutrition? a. a. Begin supplementing with iron. b. b. Continue to nurse as long as desired. c. c. Discontinue the vitamin D supplement. d. d. Stop breastfeeding at 1 year of age. - Correct answer ANS: B P a g e 51 | 208 Infants who are breastfed should exclusively nurse until age 6 months and then may continue breastfeeding, supplemented with appropriate foods for 1 year or longer as long as desired by both infant and mother. It is not necessary to supplement with iron unless there is a documented iron deficiency. Vitamin D supplements should continue for all breastfed infants until 1 year old. 1. 7. The parent of a toddler tells the primary care pediatric nurse practitioner that the family has adopted a plant-based diet and the child is receiving rice and almond milk instead of cow's milk. The nurse practitioner will counsel the parents about a. a. calcium deficiency. b. b. excess caloric intake. c. c. excess fat intake. d. d. protein deficiency. - Correct answer ANS: D Plant-based milks are low in protein and young children who consume them are at risk for protein deficiency. They are not low in calcium, high in calories, or high in fat. 1. 8. The parents of a toddler tell the primary care pediatric nurse practitioner that they get frustrated trying to get the child to eat any vegetables other than squash and carrots. What will the nurse practitioner recommend? a. a. Continue to offer a variety of foods without forcing the child to eat them. b. b. Offer snacks to make up for calories the child misses by not eating the vegetables. c. c. Prepare dishes the child likes to ensure that a vegetable is eaten at each meal. d. d. Require the child to take 1 to 2 bites of each food at each meal. - Correct answer ANS: A Children reject new foods (food neophobia) for a variety of reasons and it sometimes takes as many as 15 to 20 exposures to a food before they become accustomed to it and enjoy eating it. Parents should offer the foods and remove them without comment if they are rejected in order to avoid food battles. If the child refuses foods, parents should not give snacks to make up for lost calories the child will be hungrier at the next meal if no snack is given and may be more likely to try something new. It is not concerning if the child misses a vegetable at a meal or two. Requiring the child to take a certain number of bites only sets up a food battle. - Correct answer 1. 9. The primary care pediatric nurse practitioner is performing a well child examination on a 15-year-old girl who consumes a vegan diet. Based on this assessment, which nutrients may this adolescent need to supplement? a. a. Calcium, vitamin C, and vitamin A b. b. Iron, folic acid, and B12 c. c. Magnesium, vitamin E, and zinc d. d. Vitamin D, vitamin C, and phosphorus - Correct answer ANS: B Menstruating females are at risk for iron deficiency. Women of childbearing age should take folic acid supplements. Children who eat a vegan diet will need B12 supplements. The other options represent nutrients that do not have implications specific to menstruating females or vegans. P a g e 52 | 208 swimming ability. What will the nurse practitioner recommend? a. Avoiding strength training programs until after puberty to minimize the risk for injury b. Enrolling their daughter in a program that uses fixed weight machines or resistance bands c. Having their daughter participate in weight training 4 or 5 times each week for maximum effect d. Making sure that their daughter begins with the greatest weight tolerable using lower repetitions - Correct answer ANS: B Fixed weights or resistance bands are recommended for pre-pubertal youth to help prevent injury. Strength training prior to menarche helps to strengthen long bones and is considered beneficial. Weight training should be 2 to 3 times weekly with a day in between sessions. Initially, youth should begin with a low number of sets and low intensity. 4. The parent of a 14-year-old child asks the primary care pediatric nurse practitioner how to help the child prevent injuries when basketball tryouts begin later in the school year. Which recommendation will be of most benefit? a. Preseason conditioning b. Proper footwear c. Protective knee braces d. Stretching before practices - Correct answer ANS: A Conditioning in the preseason is one of the most important things children can do to build muscle strength, to prevent sports injuries, and to learn how to make twisting, jumping, and landing movements safely. Proper footwear is also recommended but is not the most important. Protective knee braces may be worn but do not prevent injury. Stretching should be done after warming up to maintain flexibility. 5. The parent of a high school basketball player tells the primary care pediatric nurse practitioner that the adolescent becomes short of breath only when exercising. What will the nurse practitioner recommend? a. Permanent discontinuation of all strenuous and aerobic activities b. Enrollment in a conditioning program to improve performance c. Evaluation for underlying cardiac causes of this symptom d. Treatment for exercise-induced asthma with a bronchodilator - Correct answer ANS: C While shortness of breath may indicate several more benign causes, athletes who exhibit this symptom P a g e 55 | 208 should be evaluated for underlying cardiac causes to prevent sudden cardiac death. Once this is ruled out, other causes may be considered, such as EIA or poor conditioning. 6. A 15-year-old female basketball player who has secondary amenorrhea is evaluated by the primary care pediatric nurse practitioner who notes a BMI in the 3rd percentile. What will the nurse practitioner counsel this patient? a. That amenorrhea in female athletes is not concerning b. That she should begin a program of plyometrics and strength trainin c. To consider a different sport, such as volleyball d. To work with a dietician to improve healthy weight gain - Correct answer ANS: D Female athletes who have amenorrhea have an increased risk of stress fractures. The adolescent should work to attain a healthy weight, which should allow normal periods to return and reduce this risk. Even though amenorrhea in female athletes is common, it is concerning. Plyometrics and volleyball can increase the risk of stress fractures since both involve jumping and thus not be suggested. 7. The parent of a child who has asthma asks the primary care pediatric nurse practitioner about whether the child may engage in strenuous exercise. What will the nurse practitioner tell the parent? a. Children with asthma should be excluded from vigorous exercise and most strenuous sports. b. Children with asthma show improved aerobic and anaerobic fitness with moderate to vigorous/physical activity. c. Physical activity has been shown to improve overall pulmonary function in children with asthma. d. Vigorous exercise helps improve symptoms in children with poorly controlled asthma. - Correct answer ANS: B Children with mild or well-controlled asthma may participate in moderate to vigorous sports and show benefits to aerobic and anaerobic fitness, which helps lung function and overall health outcomes. It is not necessary to exclude children with asthma from sports as long as symptoms are well controlled. Overall pulmonary function does not substantially improve with exercise. Children with poor control should not engage in sports until symptoms are under control. 8. The primary care pediatric nurse practitioner diagnoses a high school basketball player with mononucleosis. The adolescent asks when she may resume play. What will the nurse practitioner tell her? P a g e 56 | 208 a. After 3 weeks, she may begin lifting weights but not full sports. b. After 4 weeks, she may return to full play and practice. c. At 4 weeks, she must have an exam to determine fitness for play. d. She may engage in moderate exertion and practice after 3 weeks. - Correct answer ANS: C Full return to play should be determined on a case-by-case basis and is generally considered safe at 4 weeks after symptom onset, assuming physical stamina has returned, all symptoms have resolved, and the sport does not increase intraabdominal pressure during play. Athletes should avoid any form of exertion, including all sports during the first 3 weeks at a minimum and should avoid anything with a risk of chest or abdominal contact or anything that involves increased intra-abdominal pressure. Splenic rupture can occur spontaneously (rare), but the risk of rupture increases when participating in a contact or collision sport or a sport in which there is an increase in intraabdominal pressure. The nurse practitioner should recommend an exam at 4 weeks to determine fitness for play. 9. The primary care pediatric nurse practitioner is counseling a parent about bicycle helmet use. The parent reports having a helmet used a year previously by an older child and wonders about using it for a younger child since they are so expensive. What will the nurse practitioner tell the parent? a. "As long as the helmet does not have cracks, you may use it." b. "If the helmet is free from marks, you may use it." c. "You may continue to use a helmet up to 10 years." d. "You should always purchase a new helmet for each child." - Correct answer ANS: B While parents should be taught not to purchase a secondhand helmet, using a fairly new, undamaged helmet from an older child is acceptable. Any helmet that has marks should be discarded, even if not cracked. Helmets should be replaced every 5 years or sooner, depending on the manufacturer's recommendations. It is not necessary to purchase a new helmet for each child, especially if money is an issue. 10. The primary care pediatric nurse practitioner is performing a well child examination on a high school age adolescent who plays football who has hypercalciuria. Which dietary supplement will the nurse practitioner question the adolescent about? a. Protein supplements P a g e 57 | 208 Given this set of symptoms, which performance-enhancing substance will the nurse practitioner be most concerned about and ask about? a. Creatine b. Dehydroepiandrosterone (DHEA) c. Ephedra d. Growth hormone - Correct answer ANS: B DHEA is a prohormone that is converted to either testosterone or estrone and will cause adverse changes similar to anabolic steroids, such as increased weight, gynecomastia, and acne. Creatine is taken because athletes believe it enhances endurance. Side effects include weight gain but not androgenic effects such as gynecomastia or acne. Ephedra is similar to amphetamine, with most side effects related to the heart, such as tachycardia and arrhythmias. Growth hormone will cause increased weight and has side effects associated with diabetes, cardiomyopathy, hepatitis, and renal failure. 16. The parent of a 12-year-old child who has sickle cell trait (SCT) asks the primary care pediatric nurse practitioner whether the child may play football. What will the nurse practitioner tell this parent? a. Children with SCT should not play any contact sports. b. Children with SCT may not play for NCAA schools in college. c. Children with SCT should follow heat acclimatization guidelines. d. Children with SCT should not participate in organized sports. - Correct answer ANS: C Children with SCT may play in sports as long as preventative measures, including heat acclimatization, are taken to prevent sickling crises. They may play contact sports and may play for NCAA teams as long as their sickle cell trait status is known. 17. A 10-year-old is hit in the head with a baseball during practice and is diagnosed with concussion, even though no loss of consciousness occurred. The primary care pediatric nurse practitioner is evaluating the child 2 weeks after the injury and learns that the child is still experiencing some sleepiness every day. The neurological exam is normal. The child and the parent are adamant that the child be allowed to return to play baseball. What will the nurse practitioner recommend? a. Continuation of cognitive rest only b. Continuation of physical and cognitive rest c. Continuation of physical rest only P a g e 60 | 208 d. Returning to play - Correct answer ANS: B Both physical and cognitive rest is indicated after diagnosis of concussion in youth, particularly if symptoms continue following injury. Cognitive recovery may lag behind physical recovery and is a key factor in return-to-play decisions. Only after all symptoms resolve may athletes progress through steps to gradually return to play. 18. A 12-year-old child who plays soccer is diagnosed with vocal cord dysfunction. What will the primary care nurse practitioner say when the child's parents ask about continued sports participation? a. The child may continue to participate in soccer. b. The child should limit activity to non-aerobic sports. c. This condition is a contraindication for all sports. d. This condition predisposes the child to sudden cardiac death. - Correct answer ANS: A Vocal cord dysfunction causes shortness of breath and must be managed but does not prevent children from participation in sports. It does not indicate underlying cardiac problems and does not mean children should avoid any sport that may increase heart or respiratory rates. 19. The primary care pediatric nurse practitioner is offering anticipatory guidance to the parents of a 6- year-old child who has Down syndrome. What will the nurse practitioner tell the parents about physical activity and sports in school? a. Children with Down syndrome get frustrated easily when engaging in sports. b. Children with Down syndrome should not participate in strenuous aerobic activity. c. Their child should have a cervical spine evaluation before participation in sports. d. Their child should only participate in sports sanctioned by the Special Olympics. - Correct answer ANS: C Because up to 40% of children with Down syndrome have a hypermobility or instability between C1-C2 and up to 61% have occipito-atlantal hypermobility, they should undergo radiological evaluation of the cervical spine to be cleared for strenuous sports. Many children and adolescents with intellectual and developmental disabilities (including those with Down, fragile X, Turner, or Klinefelter syndromes or autism) are capable of performing exercise or strenuous activities. Special needs children should be encouraged to participate in sports to increase physical abilities and increase self-confidence. Children with Down syndrome may benefit from strenuous aerobic activity and may participate in any sports once P a g e 61 | 208 cervical spine stability is evaluated, not just those sanctioned by the Special Olympics. 1. The parent of a 3-year-old child tells the primary care pediatric nurse practitioner that after falling asleep in the living room and being awakened to go to bed one evening, the child appeared confused and disoriented for a period of time. What will the nurse practitioner counsel this parent? a. That if this occurs again, to question the child about nightmares b. That this is a sign of sleep walking and could be dangerous c. That this is a type of sleep terror which will resolve over time d. That this is probably a benign, temporary type of a sleep disorder - Correct answer ANS: D This child most likely exhibits confusional arousal, which occurs when a child is awakened from a deep sleep during the first part of the night. It is most likely benign and temporary, usually diminishing by age 5 years. It is not a sign of nightmares or night terrors. It may be the start of sleep walking but is less likely. 2. The primary care pediatric nurse practitioner is counseling the parents of a toddler about sleep. The parents report that the toddler has recently begun resisting sleep and is often more irritable during the day. What will the nurse practitioner recommend? a. Co-sleeping with the child to help alleviate possible nighttime fears b. Referral to a sleep disorders clinic for evaluation of sleep-disordered breathing c. Reintroducing a second, morning nap time to compensate for lost sleep d. Understanding that sleep resistance is a common developmental problem - Correct answer ANS: D Toddlers may develop sleep resistance as a normal part of their behaviors associated with increased autonomy or may have nighttime fears or night terrors. Parents should understand that this is common and transient. Co-sleeping may be practiced in some cultures but is not recommended. It is not necessary to refer to a sleep disorders clinic unless there are specific symptoms, such as snoring or restless sleep or sleepiness in spite of adequate sleep. 3. During a well child examination, the primary care pediatric nurse practitioner learns that a 5- year-old child has had several episodes of walking out of the bedroom after falling asleep, looking dazed, with P a g e 62 | 208 Newborns sleep a total of 15 to 18 hours per day. 8. The parent of a school-age child who is overweight tells the primary care pediatric nurse practitioner that the child seems to crave high-calorie, high-carbohydrate foods, even when full. The nurse practitioner learns that the child is often irritable and sleepy at school in spite of sleeping 9 or 10 hours each night. What will the nurse practitioner recommend? a. Assessment of leptin and ghrelin hormone levels b. Consultation with a dietician to develop an appropriate diet c. Referral to a sleep disorder clinic for a sleep study d. Taking one or two naps each day to increase the amount of sleep - Correct answer ANS: C Obstructive sleep apnea has been suggested to be a contributing factor to the pathogenesis of obesity by inducing leptin resistance and increasing ghrelin levels, two hormones that regulate satiety. The child shows symptoms of these abnormalities by craving high-calorie comfort foods. The child should be evaluated for this underlying cause. Assessment of these hormone levels is not routinely done. Consultation with a dietician may be necessary at some point but does not get at the underlying problem. Increasing sleep time with naps has not been shown to counteract the obesity effect. 9. The parent of a school-age child tells the primary care pediatric nurse practitioner that the child is restless most nights and complains often that bugs are in the bed. After consultation with a sleep disorder specialist and subsequent evaluation of a ferritin level of 30, the nurse practitioner may expect to treat this child with a. clonazepam. b. ferrous sulfate. c. gabapentin. d. sertraline. - Correct answer ANS: B A ferritin level of less than 50 is associated with periodic limb movements. The treatment for this is ferrous sulfate 3 mg/kg per day. Clonazepam and gabapentin may be ordered if ferritin levels are normal and other organic causes of PLM have been ruled out. Sertraline may make PLM worse. 10. An adolescent exhibits mild depressive symptoms and tells the primary care pediatric nurse practitioner that he is most concerned about difficulty falling and staying asleep. The adolescent does not want to take medication to treat the depressive symptoms. What will the nurse practitioner recommend? a. A program of sleep hygiene and gradual sleep extension P a g e 65 | 208 b. A sedative-narcotic will help both sleep and depression c. Cognitive therapy can help the adolescent to sleep better d. Using an antidepressant will improve sleep patterns - Correct answer ANS: A Depression is linked to sleep problems and both predict and are predicted by a diagnostic cluster that includes ODD, GAD, and depression. One study found that gradual sleep extension combined with sleep extension advice had a beneficial effect on depressive symptoms of adolescents with chronic sleep reduction. Sedatives will not affect depression. Cognitive therapy is useful for insomnia related to anxiety. Antidepressants do not necessarily treat insomnia. 11. The primary care pediatric nurse practitioner is performing a well child examination on a 4- year-old child. The parent reports that the child snores frequently, often awakens during the night, and seems cranky during the day. What will the nurse practitioner tell this parent? a. Most sleep disorders are benign and will be outgrown. b. Sleep disorders are symptomatic of underlying behavior problems. c. Sleep disorders at this age can have long-term impacts on learning. d. The child will need longer daytime naps to compensate for lost sleep. - Correct answer ANS: C Behavioral sleep disorders and sleep-disordered breathing before age 5 can result in increased special education needs in children by 8 years of age. Sleep disorders are not usually benign or outgrown. Sleep disorders can result in behavioral difficulties but are not symptomatic of behavioral problems. Sleep- disordered breathing disrupts all sleep napping will not produce adequate quality sleep. - Correct answer 12. The parent of a 3-year-old child tells the primary care pediatric nurse practitioner that the child has never been able to fall asleep without a parent in the room. The child has a new sibling and the parent is concerned that the toddler's cries will awaken the infant. What will the nurse practitioner counsel the parent? a. Leaving the room as the child is falling asleep and returning at intervals to check on the child b. Offering a reward for each night the child falls asleep without the parent in the room c. Putting the child to bed at the same time every night and ignoring all sleep interfering behaviors P a g e 66 | 208 d. Taking away a favorite activity or video for each night the child fusses about the parent not being in the room - Correct answer ANS: A Leaving the room as the child becomes drowsy and checking on the child at intervals is called graduated extinction and allows parents to ensure safety while helping the child to initiate and maintain sleep independently. The other measures may result in the toddler becoming upset and crying, which would awaken the baby. Rewards and punishments are not necessarily successful. 1. The primary care pediatric nurse practitioner is performing a well child exam on an 8-year-old girl and notes the presence of breast buds. What will the nurse practitioner include when initiating anticipatory guidance for this patient? a. A discussion about the risks of pregnancy and sexually transmitted diseases b. Information about sexual maturity and menstrual periods c. Material about the human papillomavirus vaccine d. Sexual orientation and the nature of sexual relationships - Correct answer ANS: B Since this child is 8 years old, it is early to discuss sexual behavior and reproduction given the level of the child's cognition and understanding. However, with these early changes in telearche marking the onset of puberty, it is wise to discuss menstruation in an age-appropriate manner before it occurs so that the child can be prepared. Since this child is showing signs of early puberty, this information can be included in anticipatory guidance. 2. The mother of a 3-month-old male infant tells the primary care pediatric nurse practitioner that she occasionally notices he has a penile erection just after nursing. What will the nurse practitioner tell the mother? a. Infants should be prevented from masturbating. b. The infant is conscious of the pleasure associated with nursing. c. This is a form of infantile priapism. d. This is a normal, reflexive behavior at this age. - Correct answer ANS: D Newborn infants are reflexive beings, and sexual reflexes, which are present prenatally, are easily stimulated. A penile erection may occur while nursing. Infants explore with their hands and may touch their own genitalia for pleasure and for the purpose of soothing, and this is normal. A penile erection at P a g e 67 | 208 The child's parent reports that the child has recently begun masturbating. What will the nurse practitioner counsel this parent? a. To allow the behavior whenever it occurs, since it is normal b. To discuss sexuality with the child c. To explore whether the child is being abused d. To teach the child about privacy and hand hygiene ANS: D Masturbation is normal at this age and children do this because it is pleasurable. Parents should be taught to discuss privacy and hygiene with the child and to encourage the child to limit the activity to a private place. At this age, the behavior is not associated with sexual fantasies, so a discussion of sexuality is not warranted. Masturbation at this age is common and is not usually an indication of abuse. 8. The parent of an 8-year-old child tells the primary care pediatric nurse practitioner that the child has begun to ask questions about why a schoolmate has "2 daddies" and wonders how to talk to the child about this. What will the nurse practitioner recommend? a. Beginning a discussion about different types of sexual relationships and same-sex partners b. Discussing the issue with the child in terms of the parent's religious values and norms c. Explaining that not all families are the same and what is most important is that they love and care for their children d. Telling the child that some adult relationships are complicated and will be understood when the child is older - Correct answer ANS: C School age is a good time for parents to reinforce the notion that there is diversity in families within which parents and adults love and care for their children. It is not necessary to be explicit but to establish a good history of communication and to explain complex issues to children at a level of the child's understanding. In this way, the child will know that parents are accessible and open to discussion of complex and/or puzzling issues. 9. During a well child examination, a 15-year-old female tells the primary care pediatric nurse practitioner that some of her friends have begun having sex. She has a boyfriend but denies engaging in sex with him. What will the nurse practitioner do initially? a. Ask her for her definitions of "sex." P a g e 70 | 208 b. Discuss the risks of sexually transmitted diseases. c. Find out if she is considering sexual relations. d. Give her information about contraception. - Correct answer ANS: A Many adolescents do not equate oral or anal intercourse with sex, so it is important to find out how this patient defines sex. The other options also may be considered depending on the situation, however, clarity about the words used in the discussion are most important initially for the nurse practitioner to focus the subsequent conversation appropriately. 1. 1. The mother of a 15-year-old female expresses concerns that her daughter may be sexually active because she's had a steady boyfriend for over a year. The primary care pediatric nurse practitioner learns that the family is Catholic and that the mother had an abortion when she was 16 years old. What will the nurse practitioner do initially? a. a. Explore the mother's feelings about her own past experience. b. b. Offer to prescribe contraception to prevent pregnancy. c. c. Recommend that the mother discuss this with her daughter. d. d. Suggest that the mother talk to a priest about her daughter. - Correct answer ANS: A An initial step when assisting families to manage ethical and behavioral issues is to assist parents and children in values clarification. Before offering other suggestions, the PNP should help the mother to clarify her own feelings. The other options may be necessary after values are clarified. 1. 2. The primary care pediatric nurse practitioner sees a 6-year-old child after a hospitalization for injuries sustained in a motor vehicle accident (MVA) in which the child's grandfather was killed. The parent states that it is difficult to get the child to stop talking about the accident and is worried that the child will have permanent emotional scars. What will the nurse practitioner suggest? a. a. Assure the child that he is safe and this won't happen again. b. b. Encourage the child to express and examine feelings. c. c. Reassure the child that his grandfather is in heaven. d. d. Redirect these conversations to happier topics. - Correct answer ANS: B Management goals when health crises occur should focus on helping children and families make sense of the events and to better understand what is happening to help regain control. Helping the child to express and examine feelings will help him to put what happened in perspective. Assuring the child that accidents won't happen again is false and can lead to even more distress in the future. Telling the child that the grandparent is in heaven doesn't address all his fears about the accident. Redirecting the conversation to happier topics minimizes the child's concerns. 1. 3. The primary care pediatric nurse is performing a well child examination on an adolescent who was adopted as a toddler. The parent reports that the child had been removed from an abusive home at age 3 years. What will the nurse practitioner evaluate in P a g e 71 | 208 light of possible long-term effects of this early situation? a. a. Cognitive and psychosocial development b. b. Mental health and suicide risk c. c. Moral development and conscience formation d. d. Spirituality, faith, and religious affiliation - Correct answer ANS: B Findings of early research suggest that epigenetic changes may mediate the effect of prenatal and infant environment on mental health and disease in older children and adults. Adult suicide victims who were abused as children show decreased levels of a genetic marker of a stress reduction gene, suggesting that child abuse may have an epigenetic effect leading to prolonged stress and mental disorders. 1. 4. During a well child examination of a school-age child from a family who recently immigrated from Africa, the primary care pediatric nurse practitioner learns that the child has been involved in many arguments at school. The parents are concerned that their child will never fit in with classmates. How will the nurse practitioner address this situation? a. a. Assess the conditions in the country of origin prior to immigration. b. b. Recommend counseling to determine underlying causes of this behavior. c. c. Stress that this may be a normal response to feeling different at school. d. d. Suggest that the child may be responding to being bullied by others. - Correct answer ANS: A Many children who exhibit signs of spiritual distress can express this by being angry or withdrawn. Trauma or violence to the self or to others can contribute to spiritual distress. The PNP should evaluate conditions in the country of origin since it is likely that the family may have escaped war or persecution prior to immigration. Once underlying conditions are known, the PNP can recommend options or try to explain the behavior to parents. 1. 5. While the primary care pediatric nurse practitioner is discussing anticipatory guidance with the mother of a 12 month old, the child repeatedly pulls objects out of the mother's purse. Each time, the mother slaps the child's hands as she takes the objects away. What will the nurse practitioner recommend to help the mother manage this child's misbehavior in a developmentally appropriate manner? a. a. Keep her purse up high and out of the child's reach. b. b. Place acceptable objects in her purse for the child to find. c. c. Say "No!" instead of slapping the child's hands. d. d. Use timeout each time the child gets into the purse. - Correct answer ANS: A Parents should provide a developmentally appropriate environment to minimize children's misbehavior. Children at this age who are naturally curious will explore the environment and will seek out objects within their reach. It is easier to put the purse up high than to have to repeatedly say "No." Putting acceptable objects in her purse only reinforces the undesired behavior. 1. The primary care pediatric nurse practitioner is performing an examination on a 2-year-old child who P a g e 72 | 208 6. The primary care pediatric nurse practitioner is examining a young child who was brought in by a grandmother for evaluation of a partial-thickness burn on one arm. The PNP suspects that this is an intentional injury, but the grandmother states that the parents are "just careless" and that the child is now living with her. What will the PNP do? a. Flag this as a concerning incident in the child's record. b. Reassure the grandmother that she is doing the right thing. c. Refer the child's parents to a parenting resource center. d. Report a suspicion of abuse to child protective services. - Correct answer ANS: D All states have mandatory reporting laws that require health care professionals to report suspected or known abuse to appropriate agencies and provide both civil and criminal immunity to mandated reporters. The other options may be necessary once the case is investigated, but the priority is to report the suspicion of abuse. 7. The primary care pediatric nurse practitioner is assessing a special needs school-age child whose family has just moved to the area. What is a priority concern at this initial visit? a. Asking the parents to describe the child's illness, treatments, and unique needs b. Connecting the family to local support groups, school programs, and resources c. Gathering information about financial concerns related to the child's condition d. Providing expert information about the child's condition and its management - Correct answer ANS: A Parents of children with special needs often become medical experts in their child's diagnosis, management, and idiosyncratic responses and expect to be treated seriously and respectfully in order to develop a trusting alliance with their health care providers. This family has experience caring for their child, and it is important to find out what that experience is and what works well for this child. The other options may be necessary after this collaborative relationship is established and when both parents and providers agree that these interventions are useful. 8. The primary care pediatric nurse practitioner suspects that the parent of a child who is doing poorly in school is being abused by a partner. What is a priority response by the nurse practitioner? a. Notifying the child's school counselor about this problem P a g e 75 | 208 b. Referring the child and family to a social worker c. Reporting this according to any mandated reporting laws d. Suggesting that the parent avoid the abusive situation - Correct answer ANS: C In most states, health care providers are mandated to report a child's exposure to Intimate partner violence since it is considered a form of emotional child abuse. The PNP should follow any state laws that mandate this as a priority. Once child protective services is involved, the PNP may assist with notification of school personnel, referrals to social workers, and suggestions to parents. 9. The primary care pediatric nurse practitioner learns that a school-age child continues to hope that his parents will remarry 1 year after they have divorced. What will the nurse practitioner tell this child's parents? a. "If one of you remarries, he is more likely to understand that this is permanent." b. "This is a normal response and is an expression of hope that things will be OK." c. "You will need to help him accept the reality of the permanence of the divorce." d. "Your child is most likely blaming himself for your separation and divorce." - Correct answer ANS: C Accepting the permanence of the divorce is one of the psychological tasks children of divorce must master in order to master normal developmental tasks. Parents need to focus on helping the child achieve these tasks. A remarriage does not necessarily help the child to achieve this task. It is a sign that the child cannot accept the reality of the situation, not of hope, and does not indicate self-blame. 10. The primary care pediatric nurse practitioner is evaluating a 12-year-old girl who reports penile penetration of her vagina by her mother's boyfriend the day before yesterday. The PNP reports this to the local child abuse hotline. What is the PNP's next action? a. Attaining a history of the abuse from the child b. Obtaining urethral specimens for STI testing c. Performing a colposcopic examination to evaluate for trauma d. Referring the child to the ED for forensic specimen collection - Correct answer ANS: D If sexual abuse has occurred within 72 hours, it is required that appropriate forensic specimens be collected. Getting a history from the child is part of the child abuse evaluation and will be done by the child abuse team, as well as obtaining urethral specimens for STI. Colposcopic exams should be done by P a g e 76 | 208 an expert in sexual abuse if trauma is suspected but is not performed by the PCPNP. 11. The primary care pediatric nurse practitioner is performing a well baby examination on a newborn whose mother is 17 years old. The mother states that she is living with her parents and plans to finish high school. The maternal grandmother will care for the infant while she is in school. What will the nurse practitioner discuss with this mother at this visit? a. Early child intervention programs b. Her needs for socialization with peers c. Immunizations and well child visits d. Referral to a community health nurse - Correct answer ANS: B Adolescent mothers face problems inherent when this major role is assumed before they are developmentally ready themselves. Their developmental needs may sometimes be in conflict with their children. Although this mother has support from her family, the PNP should assess her desires to socialize with her peers to evaluate her developmental needs. Early child intervention may be necessary when the child is preschool age and immunizations and well child visits should be discussed, but these do not take precedence over the need to evaluate a potential role conflict. Referrals to community health may be necessary if problems arise. 12. The primary care pediatric nurse practitioner is examining a young child who has cerebral palsy. Which part of the family history raises concerns about potential child maltreatment? a. Child attends day care b. Limited financial resources c. Mother works outside the home d. No membership in a church - Correct answer ANS: B Limited financial resources can put a strain on caring for a child with special needs whose medical needs are expensive. The fact that the mother works outside the home and the child attends day care may actually provide some respite from the strain of caring for a special needs child. Families may have strong spiritual values whether they attend church or not. 13. The mother of two school-age children tells the primary care pediatric nurse practitioner that she and P a g e 77 | 208 with body image problems become overly concerned with appearance and compare themselves to others. This child is losing weight and working out too often to try to change his body. Children with personal identity issues internalize negative perceptions of others and manifest feelings of inferiority. Children with role performance problems feel incompetent and are hesitant to try new things or become perfectionists to overcompensate. Children with poor self-esteem seek attention, importance, and security. 3. The primary care pediatric nurse practitioner is evaluating a 16-year-old adolescent male who is on the high school wrestling team and whose weight fluctuates as much as 7 or 8 pounds before matches. The child is eager to talk about the various trophies he has won. When he expresses confidence that he will get a wrestling scholarship for college, his father remarks that his grades will never be good enough for college, causing him to blame his teachers. The nurse practitioner may identify potential problems with a. body image. b. personal identity. c. role performance. d. self-esteem. - Correct answer ANS: D Children with poor self-esteem seek attention, importance, and security and may become self- absorbed with external markers of self-worth, such as performance in a sport. Another mark of insecurity is defensiveness, which this child exhibits by blaming his teachers for his poor grades. Children with body image problems become overly concerned with appearance and compare themselves to others. This child is losing and gaining weight to be better at wrestling, not to look different. Children with personal identity issues internalize negative perceptions of others and manifest feelings of inferiority. Children with role performance problems feel incompetent and are hesitant to try new things or become perfectionists to overcompensate. 4. A school-age child enjoys playing basketball but doesn't make the intramural team. Which response by the child is characteristic of the concept of a growth mindset? a. "I didn't play well on the day of the tryouts." P a g e 80 | 208 b. "I'll just have to find another sport I'm good at." c. "I'll need to work more on my outside shot." d. "I'm probably too short to be really good at this sport." - Correct answer ANS: C Children who have a growth mindset have been taught to believe that hard work is key to success and that effort and practice contribute to growth. By not being discouraged and identifying something to work on, the child is exhibiting a growth mindset. Saying that he didn't play well is making excuses, while stating he needs to find something else he's good at or blaming his failure on a physical characteristic indicates a belief that success is dependent on fixed traits. 5. The primary care pediatric nurse practitioner is performing a well child examination on a fussy toddler who has red hair. The child's parent tells the toddler to stop being fussy and says, "red hair gives him such a temper." Which common error that erodes self-esteem is this? a. Dwelling on negatives b. Expecting too much c. Negating the child's feelings d. Stereotyping and typecasting - Correct answer ANS: D The parent is typecasting the child by associating having a temper with the trait of red hair, which can limit his sense of possibilities. Dwelling on negatives describes making critical remarks instead of positive remarks. A parent who expects too much creates pressures for behaviors that are beyond the reach of the child and makes the child feel inadequate. Negating feelings is a rejection of the child's emotions. 6. The primary care pediatric nurse practitioner sees a 10-year-old child whose parent describes as a "class clown." The child denies having problems at school, but acknowledges poor grades by saying, "I'm not very smart, I guess." When counseling the parent about helping this child deal with this self- perception issue, the nurse practitioner will recommend which strategy? a. Empower the child to make decisions and assume more responsibilities. b. Help the child identify skills and activities that he is good at. c. Spend time each evening helping the child with homework to improve grades. d. Work with the teacher to set appropriate limits on school behavior. - Correct answer ANS: B P a g e 81 | 208 This child exhibits problems with personal identity and copes by clowning around to avoid dealing with problems of inferiority about school performance. The parent should work with the child to find areas of strength and help the child become accomplished in those things to improve self-esteem. 7. The parent of a school-age child is concerned that the child is going to be short like both parents and worries that he will have difficulty in school if he can't participate in a variety of sports. What will the primary care pediatric nurse practitioner do to counsel this parent? a. Encourage the child to engage in regular physical activity. b. Overlook his or her own feelings about this physical characteristic. c. Point out the accomplishments of other short people. d. Steer the child into other activities at school. - Correct answer ANS: A Children should be encouraged to participate in all activities and to explore their own abilities and limitations without attributing "good" or "bad" to any of these experiences to improve self- esteem. Parents should be encouraged to explore their own feelings about their child's appearance to avoid subliminal messages of low self-worth. Pointing out the characteristic puts an unnecessary focus on the trait. Steering the child to specific activities is limiting. 1. During a well child assessment of a preschool-age child, the parent voices concerns that, because the child has behavior problems at school, the child may have a mental health disorder. Which initial approach will provide the best information? a. Ask the parent whether other caregivers have voiced similar concerns. b. Interview the child separately from the parent to encourage sharing of feelings. c. Take time to actively listen to the parent's and child's perceptions of the problem. d. Use a validated screening tool to ensure that all aspects of behaviors are evaluated. - Correct answer ANS: C Providers can get a clearer picture of the situation by taking the time to sit down and actively listen to both the parent's and child's concerns about the issue. It is important to remember that many parents have been trying to cope with the problem for some time, so asking for validation from others may be viewed as belittling. School-age children and adolescents should be interviewed separately to encourage sharing of information. Validated screening tools may be used later, but allowing parents to voice concerns P a g e 82 | 208 weeks of a depressive episode. A diagnostic rating scale may help in diagnosing the depression, but assessing suicide risk is a priority. Antidepressant medications may be useful but are best initiated by a mental health specialist. The initial response in adolescents should be to determine suicide risk to decide whether to admit to inpatient therapy or refer to a mental health specialist. 7. A child has a difficult temperament. What will the primary care pediatric nurse practitioner tell the parent about managing this child's behavior? a. A difficult temperament is its own risk factor for maladjustment disorders. b. Children with difficult temperaments need strict adherence to rules. c. Having a difficult temperament limits intelligence and emotional maturity d. It is important for the parent to learn to manage criticism and power struggles. - Correct answer ANS: D Children with difficult temperaments tend to engender parental criticism and irritability, power struggles, and restrictive parenting, and this dynamic leads to difficulties with psychosocial adjustment. Parents of children with difficult temperaments must be aware of behavioral manifestations as temperament expressions in order to reframe their own responses to these behaviors. A difficult temperament alone is not a risk factor for maladjustment. Restrictive parenting only increases power struggles and maladaptive behaviors. Temperament is unrelated to IQ but does affect academic outcomes because of behavior issues in school. 8. A toddler has begun hitting and biting other children at a day care center and is exhibiting temper tantrums and bad language at home. The parent reports that these behaviors began shortly after a sibling was born. What will the primary care pediatric nurse practitioner do? a. Advise the parent that the child is exhibiting early symptoms of ADHD. b. Engage the parent in positive parenting strategies to facilitate appropriate child coping. c. Recommend evaluating the child for conduct or oppositional defiant disorder. d. Suggest putting the child in another day care center to ameliorate the problems. - Correct answer ANS: B Children with social aggression may exhibit the behaviors described above. When social aggression is a response to acute stress, such as the birth of a sibling, the problem usually resolves if parents use positive P a g e 85 | 208 parenting strategies and facilitate developmentally appropriate child coping efforts. These are not symptoms of ADHD. Conduct disorder (CD) symptoms usually manifest in the preschool age. Oppositional defiant disorder (ODD) is characterized by disobedience rather than aggressiveness. Moving the child to another day care or school does not solve the problem. 9. The parent of a school-age child reports that the child doesn't like being alone in rooms because of a fear of aliens hiding in closets. What will the primary care pediatric nurse practitioner tell the parent? a. "Fear of imaginary creatures does not usually occur at this age." b. "I may need to refer your child to a pediatric mental health specialist." c. "Your child is expressing normal fears for a school-age child." d. "Your child may be watching too much violence on television." - Correct answer ANS: A Preschoolers tend to fear imaginary creatures but not school-age children. The PNP does not have enough information about the severity of the fear or its effects on behavior to refer the child to a mental health specialist. The PNP should evaluate the situation before attributing the fear to a cause such as television. 10. The parents of a 4-year-old boy are concerned because he has begun twisting and pulling out his hair, especially when he is tired or stressed. What will the primary care pediatric nurse practitioner recommend as part of an initial approach to treat this behavior? a. Consultation with a pediatric behavioral specialist b. Cutting his hair so that it is too short to pull c. Long-term anti-streptococcal prophylaxis d. Medication with risperidol or clonidine - Correct answer ANS: B Children with mild to moderate tic disorders can be managed with cognitive-behavioral therapy part of this includes strategies to help distinguish the undesired behavior, such as cutting the hair so it cannot be pulled out. If this is not effective, consultation with a behavioral specialist and medications, prescribed following assessment by a qualified mental health specialist, may be needed. - Correct answer 11. An adolescent is diagnosed with major depression, and the mental health specialist has prescribed fluoxetine. What other treatment is important to protect against suicide risk? a. Addition of risperidone therapy P a g e 86 | 208 b. Cognitive-behavioral therapy c. Family therapy d. Hospitalization - Correct answer ANS: B Cognitive-behavioral therapy appears to have a protective effect against suicide and the best treatment responses come from combinations of cognitive-behavioral therapy and SSRIs. Risperidone and other antipsychotics are used if psychosis is present to control those symptoms. Family therapy is useful but does not add protection from suicide. Hospitalization is not the first-line treatment and is used for severe exacerbations or suicide attempts. 12. A middle-school-age child is skipping school frequently and getting poor grades since the child's father was killed while deployed in the military. How will the primary care pediatric nurse practitioner manage this situation? a. Prescribe short-term antidepressants for this situational depression. b. Refer the child to a mental health specialist for evaluation and treatment. c. Schedule extended appointments for counseling and mental health interventio. d. Suggest that the child have close follow-up by a school counselor. - Correct answer ANS: B Children who are experiencing enduring problems, such as the loss of a parent, should be treated either in consultation with or by referral to a pediatric mental health specialist. Antidepressants and other pharmacotherapeutic agents should never be used without a thorough mental health evaluation. The PNP is not qualified to manage this in a primary care setting without consultation or referral, nor is a school counselor, although both may be part of the team of professionals who help to manage this child. 13. The parent of a school-age child reports that the child becomes frustrated when unable to perform tasks well and often has temper tantrums and difficulty sleeping. Which disorder may be considered in this child? a. Generalized anxiety disorder (GAD) b. Obsessive-compulsive disorder (OCD) c. Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) d. Separation anxiety disorder (SAD) - Correct answer ANS: A GAD is characterized by over-concern about competence, significant self-consciousness, irritability and P a g e 87 | 208 d. Refer the child to a child psychiatrist for evaluation of bipolar disorder. - Correct answer ANS: D Children who have ADHD symptoms and depression should be evaluated by a child psychiatrist for bipolar disorder. Medications are not appropriate until the disorder is correctly diagnosed. Stimulant medications are not effective in treating bipolar disorder. Antidepressants may potentiate manic responses. Providers should carefully evaluate and refer any child treated for ADHD who does not respond to therapy or who experiences a sudden worsening of agitation while using ADHD medications. 19. The parent of a preschool-age child reports that the child often appears anxious and nervous and that this is associated occasionally with a rapid heart rate and tremors. What is the best type of referral that the primary care pediatric nurse practitioner could recommend? a. Cognitive-behavioral therapy b. Family therapy c. Medication therapy d. Play therapy - Correct answer ANS: D Toddlers and preschoolers who are experiencing anxiety often respond to play therapy. School- age children and adolescents benefit from cognitive-behavioral therapy. Family therapy may be a secondary choice. Medications are not indicated as first-line treatment for anxiety. 1. The single mother of a 4-year-old who attends day care tells the primary care pediatric nurse practitioner that she had difficulty giving her child a twice-daily amoxicillin for 10 days to treat otitis media during a previous episode several months earlier because she works two jobs and is too busy. The child has an ear infection in the clinic today. What will the nurse practitioner do? a. Administer an intramuscular antibiotic. b. Order twice-daily amoxicillin for 5 days. c. Prescribe azithromycin once daily for 5 days. d. Reinforce the need to adhere to the plan of care. - Correct answer ANS: C To improve adherence, the PNP should shorten the length of treatment, if possible and, if possible, reduce the number of times per day that a medication is given. This mother indicated that she had difficulty giving two doses per day, so a once daily for 5 days medication is ideal. It is not necessary to give an IM P a g e 90 | 208 injection unless the child refuses to take the medication. Reinforcing the need to adhere to the plan is important but does not address the underlying difficulty associated with scheduling. 2. The primary care pediatric nurse practitioner is considering use of a relatively new drug for a 15- month-old child. The drug is metabolized by the liver, so the nurse practitioner will consult a pharmacologist to discuss giving the drug: a. less often or at a lower dose. b. more often or at a higher dose. c. via a parenteral route. d. via the oral route. - Correct answer ANS: A Infants metabolize drugs more slowly than older children due to decreased levels of oxidases and conjugating enzymes produced in the immature liver, so they may need drugs given less often or at lower doses to avoid toxicity. The route does not necessarily play a role in this case. 3. The parent of a school-age child who has asthma tells the primary care pediatric nurse practitioner that the child often comes home from school with severe wheezing after gym class and needs to use his metered-dose inhaler right away. What will the nurse practitioner do? a. Recommend that the child go to the school nurse when symptoms start. b. Review the child's asthma action plan and possibly increase his steroid dose. c. Suggest asking the school to excuse the child from gym class. d. Write the prescription for two metered-dose inhalers with spacers. - Correct answer ANS: D When children have to take a medication at school or day care, the PNP should dispense two units of the medication so that one can remain at school and one at home to avoid missed doses. The school nurse will not be able to order a medication that the child does not have available. The child is missing his rescue medication and just needs access to his inhaler. It is not necessary to excuse the child from gym class if his symptoms can be controlled. 4. A pharmaceutical company has developed a new drug that was tested only on adults. The FDA has declared this drug to have potential benefits for ill children. According to the Pediatric Research Equity Act (PREA), what may the pharmaceutical company be required to do? a. Conduct pediatric drug studies to determine whether the drug is safe and effective in children. b. Provide labeling stating that the safety and efficacy of the drug is not established for children. c. Receive a patent extension for conducting pediatric studies to determine use in children. P a g e 91 | 208 d. Survey existing data about the drug to determine potential use in the pediatric population. - Correct answer ANS: A The PREA gives the FDA more leverage over the types of new drugs developed for children and can require pharmaceutical companies to conduct pediatric drug trials if the FDA declares a drug as possibly useful to ill children or one that might be used by a substantial number of children. The Food and Drug Administration Modernization Act (FDAMA) allowed labeling that "safety and effectiveness in pediatric patients have not been established" on drugs with insufficient evidence to support pediatric indications. The Best Pharmaceuticals of Children Act (BPCA) grants a patent extension when a drug company voluntarily studies a known or new drug in children. The FDAMA also requires pharmaceutical companies to survey existing data and determine potential drug use and indications in pediatric populations. 5. The primary care pediatric nurse practitioner is considering using a drug for an "off-label" use in a child. The nurse practitioner has used the drug in a similar situation previously, has consulted a pharmacology resource and the FDA website, and has determined that there are no significant contraindications and warnings for this child. What else must the nurse practitioner do when prescribing this drug? a. Discuss recommendations with the parents and document their consent. b. Document anecdotal reports of previous use of the drug by other providers. c. Follow up daily with the parents to determine safe administration of the drug. d. Report this use to the FDA Medwatch website for tracking purposes. - Correct answer ANS: A Many prescriptions are written for "off-label" uses for children because the drug doesn't have enough substantial evidence for FDA approval. The PNP should make sure to discuss the drug and this use with the family and document the decision-making process and their consent for this use. It is not enough to base a decision solely on what someone else has done. Unless the drug is experimental or has many serious adverse effects, close daily monitoring is not necessary. The PNP is not required to report off- label drug use to the FDA. 6. The primary care pediatric nurse practitioner prescribes a new medication for a child who develops a previously unknown adverse reaction. To report this, the nurse practitioner will : P a g e 92 | 208 a. HAV vaccine b. Immunoglobulin G c. Interferon-alfa d. Supportive care - Correct answer ANS: D The child has symptoms consistent with hepatitis A virus. HAV vaccine and IgG may be given within 2 weeks of exposure otherwise supportive care is indicated. Interferon-alfa is used for hepatitis B virus. - Correct answer 4. A 10-month-old infant has an erythematous, fluctuant, non-draining abscess on the right buttock after 10 days of treatment with amoxicillin for impetigo. What is the next step in managing this infant's care? a. Consultation with a pediatric infectious disease specialist b. Culture of any superficial open surface wounds c. Empiric treatment with clindamycin d. Incision and drainage of the abscess with culture - Correct answer ANS: D Non-draining, fluctuant abscesses should be incised, drained, and cultured to determine the causative organism. Consultation with an infectious disease specialist is necessary for seriously ill children, those who are immunocompromised, or those who have an increased risk for myocarditis. Superficial wounds should not be cultured because of the chance of sample contamination. Empiric treatment may be considered for severe infection, but many mild abscesses may not need antibiotic therapy after I&D. 5. An unimmunized school-age child whose mother is in her first trimester of pregnancy is diagnosed with rubella after a local outbreak. What will the primary care pediatric nurse practitioner recommend? a. Assessment of maternal rubella titers b. Intravenous immunoglobulin for the child c. MMR vaccine for the mother and child d. Possible termination of the pregnancy - Correct answer ANS: A Reinfection or revaccination with rubella for pregnant women rarely results in congenital rubella syndrome, and these are not a reason for pregnancy termination. Maternal rubella antibody titers should be assessed. MMR vaccine is not given during pregnancy. IVIG is not indicated P a g e 95 | 208 rubella rarely has serious sequelae in children. - Correct answer 6. A 2-month-old infant has a staccato cough and fever. Which aspect of the history is most important in determining the diagnosis? a. Day care attendance b. Immunization history c. Medication history d. Past medical history - Correct answer ANS: B A staccato cough may be present with pertussis, which is a vaccine-preventable disease. Careful assessment of immunization history is important when this is suspected. Day care attendance is an important aspect of determining exposure and may be considered, but it is not the most important part of the history in this case. Medication and past medical history are probably not relevant in this case since it is less likely that a 2-month-old infant has been taking medications or has a chronic or recurrent illness. 7. The parent of a 2-month-old infant is reluctant to have the baby vaccinated. What is an initial step in responding to these concerns? a. Inform the parent that all vaccines may be given without thimerosol. b. Providing Vaccine Information Statements for the parent to review. c. Question the parent's reasons for concern about immunizations. d. Remind the parent that the infant is exposed to thousands of germs each day. - Correct answer ANS: C PNPs should question and listen carefully to parents' concerns about vaccines. Once concerns are identified and understood, the PNP can address the issues. The presence of thimerosol in vaccines is just one concern and should be addressed if that is identified. Providing a Vaccine Information Statement (VIS) should be done as part of the discussion to provide information to the parent. Unless the parent expresses concerns that vaccines will overwhelm the child's immune system, it is not necessary to bring up this possibility . 8. Which lab value is most concerning in an infant with fever and a suspected bacterial infection? a. C-reactive protein of 11.5 mg/L P a g e 96 | 208 b. Lymphocyte count of 8.7 c. Platelet count of 475 d. White blood cell count of 14 - Correct answer ANS: A CRP levels are non-specific acute phase indicators of inflammation with low diagnostic value except in predicting the likelihood of sepsis in infants, especially when the level is greater than 10 mg/L. Elevated lymphocyte, platelet, or WBC counts help with the differential diagnosis, but these values are not especially concerning. 9. An adolescent has a TB skin test prior to working as a volunteer in a hospital. The adolescent is healthy and has not travelled to or from a TB-endemic area or had close contact with anyone who has TB. The Mantoux skin test shows 10 mm of induration after 48 hours. What will the primary care pediatric nurse practitioner do? a. Ask the adolescent about exposure to homeless persons. b. Order a chest radiograph to rule out active TB. c. Reassure the adolescent that this is a negative screen. d. Refer the adolescent to an infectious disease specialist. - Correct answer ANS: C In children 4 years and older without risk factors, induration must be at least 15 mm or greater to be considered to be a positive screen. It is not necessary to question the adolescent about possible exposures. Chest radiographs are ordered to evaluate for active TB in persons with a positive screen. Referral to an infectious disease specialist is done if active TB is present. 10. A parent is concerned about vaccine adverse reactions. Based on an Institute of Medicine report, what will the primary care pediatric nurse practitioner tell the parent? a. Administering multiple vaccines may trigger the development of type 1 diabetes. b. The MMR may be linked to febrile seizures in immunocompromised children. c. There is some risk of CNS disorders associated with the hepatitis B vaccine. d. Vaccines containing thimerosol are linked to pervasive developmental disorders. - Correct answer ANS: B The IOM report found that febrile seizures and measles inclusion body encephalitis can occur in immunocompromised children. The IOM found no substantiated evidence that multiple vaccines trigger type 1 diabetes, hepatitis B vaccine is associated with increased risk of CNS disorders, or thimerosol- containing vaccines are linked to pervasive developmental disorders. P a g e 97 | 208