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 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 P a g e 1 | 155 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 Value. If these behaviors are detected, the PNP should refer the child to a specialist for further assessment, Using more diagnostic tools. The CARS may be used but requires specialty training and proper Credentials. Until the diagnosis is determined, strategies for intervention are not discussed. The M-CHAT Is a screening tool and is not diagnostic. 2. The mother of a newborn tells the primary care pediatric nurse practitioner that she is worried that her Child will develop allergies and asthma. Which tool will the nurse practitioner use to evaluate this? Risk? A. Three-generation pedigree b. Review of systems c. Genogram d. Eco map - Correct answer ANS: A The three-generation pedigree is used to map out risks for genetic diseases in families, as well as Conditions with modifiable risk factors. The review of systems is used to evaluate the history of the Child’s body systems. The genogram is an approach to developing a family database to provide a graphic Representation of family structure, roles, and problems of recurring significance in a family. The coma Is used to identify relationships in the family and community that are supportive or harmful. 3. The primary care pediatric nurse practitioner is performing a well-child check-up on a 20- month-old Child. The child was 4 weeks premature and, according to a parent-completed developmental P a g e 2 | 155 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 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 P a g e 5 | 155 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 Inadequate" would be used if the PNP suspects that the family lacks adequate funds to purchase food. "Nutrition alteration" is a NANDA diagnosis and would be used if the PNP planned to consult with a Dietician or give nutritional information. 14. The primary care pediatric nurse practitioner is obtaining a medical history about a child. To integrate Both nursing and medical aspects of primary care, which will be included in the medical history? a. Complementary medications, alternative health practices, and chief complaint b. Developmental delays, nutritional status, and linear growth patterns c. Medication currently taking, allergy information, and family medical history d. Speech and language development, beliefs about health, and previous illnesses - Correct answer ANS: D An assessment model that integrates the nursing and medical aspects of primary care uses three domains: Developmental problems (speech and language development), functional health problems (beliefs about Health), and diseases (chief complaint). The other examples all use domains associated with the traditional Medical model and do not contain nursing aspects associated with functional health problems. 1. The primary care pediatric nurse practitioner learns that an African-American family lives in a Neighborhood with a high crime rate and suggests that they try moving to another neighborhood for The safety of their children. This is an example of A. cultural sensitivity. B. group bias. C. individual privilege. D. racial awareness. - Correct answer ANS: C Privilege can be individual- or group-based and refers to the often unconscious lack of understanding of What other groups must deal with. The PNP is not aware that the family may lack the resources to move, May be fearful of moving to a "white" neighborhood, or may even feel safe around people that they know. Cultural sensitivity is an awareness of and respect for other cultures. Group bias is a prejudice, based on Cultural, racial, or ethnic differences, toward a group of people. Racial awareness would describe an Awareness of cultural differences based on race. 2. The primary care pediatric nurse practitioner is examining a child whose parents recently emigrated From a war-torn country in the Middle East. Which is a priority assessment when performing the P a g e 6 | 155 Patient history? a. Asking about physical, psychological, and emotional trauma b. Determining the parents' English language competency and literacy level c. Learning about cultural preferences and complementary medicine practices d. Reviewing the child's previous health and illness records - Correct answer ANS: A Recent history that includes trauma, loss, and refugee camp experience may exacerbate difficulties Adjusting to life in the U.S. and can lead to acute and chronic physical and mental health concerns. All of The other parts of the history will be necessary, but this should be a priority, since the family has escaped a War-torn country. 3. The primary care pediatric nurse practitioner in a community health center meets a family who has Recently immigrated to the United States who speak only Akron. They arrive in the clinic with a Church sponsor, who translates for them. The pediatric nurse practitioner notices that the sponsor Answers for the family without giving them time to speak. The pediatric nurse practitioner will: A. ask the sponsor to allow the family to respond. B. develop the plan of care and ask the sponsor to make sure it is followed. C. request that the sponsor translate written instructions for the family. D. use the telephone interpreter service to communicate with the family. - Correct answer ANS: D Federally funded managed care networks and community health centers are required to have interpreters Accessible for clients with limited English proficiency. A commercial telephone interpreter service has Been shown to be as effective as an "in-person" interpreter. Relying on family members or community Members may not be reliable and may jeopardize patient confidentiality. This interpreter is answering for The clients without hearing what they have to say, which can compromise care. 4. The primary care pediatric nurse practitioner provides well child care for a community of immigrant Children from Central America. The pediatric nurse practitioner is surprised to learn that some of the Families are Jewish and not Catholic. This response is an example of cultural: A. collectivism. B. constructivism. C. essentialism. D. individualism. - Correct answer ANS: C 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 P a g e 7 | 155 B. global awareness. C. system application. D. system awareness. - Correct answer ANS: A Global application involves having a willingness and ability to adjust to the needs of clients, families, and Communities both nationally and globally. Global awareness involves knowledge of diseases, political, And economic factors worldwide that affect health. System application involves assisting clients to Overcome institutional barriers to effective interventions. System awareness is knowledge of these Barriers. 1. During a well-child exam, the primary care pediatric nurse practitioner learns that the parents of a Young child fight frequently about finances. The parents state that they do not fight in front of the Child and feel that the situation is temporary and related to the father's job layoff. What will the nurse? Practitioner do? a. Reassure them that the child is too young to understand. b. Recommend that they continue to not argue in front of the child. c. Suggest counseling to learn ways to handle stress. d. Tell them that the conflict will resolve when the situation changes. - Correct answer ANS: C Marital problems can result in child behavior difficulties and anxieties, and conflict can be picked up by The child. The parents should try to learn to modify unhealthy behaviors, such as increased conflict during Stressful situations. Even when children do not understand, they pick up on cues from the parents about Anxiety and stress and can internalize these feelings. Avoiding arguments in front of the child does not Alleviate the underlying conflict and stress. The behavior of fighting during this stressful situation may Indicate a pattern of response to stress and will only recur with each subsequent stressful period. 2. The primary care pediatric nurse practitioner conducts a well-baby exam on an infant and notes mild Gross motor delays but no delays in other areas. Which initial course of action will the nurse Practitioner recommend? a. Consult a developmental specialist for a more complete evaluation. b. Prepare the parents for a potentially serious developmental disorder. c. Refer the infant to an early intervention program for physical therapy. d. Teach the parents to provide exercises to encourage motor development. - Correct answer ANS: D The child who has mild delays in only one area may be managed initially by having the parent provide Appropriate exercises. If this is not effective, or if delays become more severe, referrals for evaluation or Early intervention services are warranted. A mild delay does not necessarily signal a serious disorder, so This action is not indicated. 3. The primary care pediatric nurse practitioner sees a developmentally delayed toddler for an initial Visit. The family has just moved to the area and asks the nurse practitioner about community services P a g e 10 | 155 And resources for their child. What should the nurse practitioner do initially? a. Ask the parents if they have an individualized family service plan (IFSP). b. Consult with a physician to ensure the child gets appropriate care. c. Inform the family that services are provided when the child begins school. d. Refer the family to a social worker for assistance with referrals and services. - Correct answer ANS: A Families with children who have developmental delays are eligible for early intervention services and Should have IFSPs in place. This family may have one from their previous community, and it can be used As a starting point to determine needs. It is not necessary to consult with a physician to coordinate Community resources. Early intervention is provided from birth, according to federal law. Until the Specific referrals are known, the social worker is not consulted. 4. The primary care pediatric nurse practitioner is examining a newborn infant recently discharged from The neonatal intensive care unit after a premature birth. The parent is upset and expresses worry about Whether the infant will be normal. What will the nurse practitioner do in this situation? a. Explain to the parent that developmental delays often do not manifest at first. b. Perform a developmental assessment and tell the parent which delays are evident. c. Point out the tasks that the infant can perform while conducting the assessment. d. Refer the infant to a developmental specialist for a complete evaluation. - Correct answer ANS: C When discussing developmental delays with parents, it is important to be positive and to initially focus on 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. P a g e 11 | 155 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." 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 Children should involve shared decision making and individualized care and not "cookbook" approaches. P a g e 12 | 155 At 6 months, infants delight in vocalizing sounds that they learn by imitation but do not ascribe meaning To the sounds they make. Infants can say "mama" but without meaning. Babies make sounds on purpose By imitating what they hear. A preference for one sound early in speech does not indicate a hearing Deficit. 7. The primary care pediatric nurse practitioner is performing a well-baby examination on a 2- month-old Infant who has gained 25 grams per day in the last interval. The mother is nursing and tells the nurse 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 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 P a g e 15 | 155 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. 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. P a g e 16 | 155 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. 1. 5. The parent of a 24-month-old child asks the primary care pediatric nurse Practitioner when toilet training should begin. How will the pediatric nurse practitioner Respond? a. a. "Begin by reading to your child about toileting." b. b. "Most children are capable by age 2 years." c. c. "Tell me about your child's daily habits." d. d. "We should assess your child's motor skills." - Correct answer ANS: C To assess the parent's understanding of toilet readiness, the nurse practitioner will ask the Parents about the child's daily habits and routines to see if the child has predictable patterns That can be the basis for toilet training. While providing storybooks about toileting can help Children learn, the first step is to assess toilet readiness. Even though many children are Capable at this age, evaluating personal readiness is key to beginning toilet training. Assessment of motor skills may be a second step. 1. 6. The primary care pediatric nurse practitioner is counseling the parents of a toddler About appropriate discipline. The parents report that the child is very active and curious, and They are worried about the potential for injury. What will the pediatric nurse practitioner? Recommend? a. a. Allow the child to explore and experiment while providing appropriate limits. b. b. be present while the child plays to continually teach the child what is Appropriate. C. c. Let the child experiment at will and to make mistakes in order to learn. d. d. Say "no" whenever the child does something that is not acceptable. - Correct answer ANS: A The child who is securely attached uses the parents as a base from which to safely explore the World. Toddlers learn by doing and need to experiment to gain mastery over the environment. It Is important that parents are present for safety, but parents should not be ever-present and Controlling. Parents should be close by and should intervene if the child is at risk for injury. Continual criticism and the use of the word "no" can make the toddler feel powerless. 1. 7. 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 P a g e 17 | 155 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, 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 P a g e 20 | 155 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. D. to encourage mixed-gender interactions in order to promote development of sexual values. - Correct answer ANS: C At age 10, children usually develop an intense same-gender relationship with a peer. This is how the child Learns to expand the self, shares feelings, and learns how others manage problems. It does not indicate Later sexual orientation and is not a characteristic of experimentation with sexuality. It is not necessary to Encourage mixed-gender interactions. 8. During a well-child exam on a 5-year-old child, the primary care pediatric nurse practitioner assesses The child for school readiness. Which finding may be a factor in limiting school readiness for this? Child? a. Adherence to daily family routines and regular activities b. Having two older siblings who attend the same school c. Parental concerns about bullying in the school d. The child's ability to recognize four different colors - Correct answer ANS: C Parental expectation is the strongest predictor of school success in children. Parents who are worried About what may happen in school can transmit this anxiety to the child. Children who have a secure Family life with daily routines will do better in school. Having older siblings who attend school increases Success. Children at this age are expected to know four colors, so this is an indication of school readiness. 9. The primary care pediatric nurse practitioner is evaluating recurrent stomach pain in a school- age Child. The child's exam is normal. The nurse practitioner learns that the child reports pain most Evenings after school and refuses to participate in sports but does not have nausea or vomiting. The Child’s grandmother recently had gallbladder surgery. Which action is correct? a. Encourage the child to keep a log of pain, stool patterns, and dietary intake b. Order radiologic studies and laboratory tests to rule out systemic causes c. Reassure the child and encourage resuming sports when symptoms subside d. Refer the child to a counselor to discuss anxiety about health problems - Correct answer ANS: A The PNP suspects a somatic disorder after a normal exam and should encourage the child to keep a food Or pain diary to help manage symptoms. The PNP should not "musicalize" the problem with tests. The Child should be encouraged to resume sports and participate in normal activities. If the symptoms persist, Referral for counseling is warranted. 10. During a well-child exam of a school-age child, the primary care pediatric nurse practitioner learns That the child has been having angry episodes at school. The nurse practitioner observes the child to P a g e 21 | 155 Appear withdrawn and sad. Which action is appropriate? a. Ask the child and the parent about stressors at home b. Make a referral to a child behavioral specialist c. Provide information about anger management d. Suggest consideration of a different classroom - Correct answer ANS: A School-age children are learning to manage emotions and need help to manage their feelings in acceptable Ways. A variety of stressors, including parental divorce, substance abuse, bullying in school, and early Responsibilities, can cause anxiety in the child, who may not manage these feelings well. Until the Underlying cause is better understood, management options cannot be determined, so referrals to Specialists, information about anger management, or moving to a different classroom may not be Indicated. 11. The primary care pediatric nurse practitioner is examining a school-age child who complains of Frequent stomach pain and headaches. The parent reports that the child misses several days of school Each month. The child has a normal exam. Before proceeding with further diagnostic tests, what will? The nurse practitioner initially ask the parent? A. About the timing of the symptoms each day and during the week b. How well the child performs in school and in extracurricular activities c. If the parent feels a strong need to protect the child from problems d. Whether there are any unusual stressors or circumstances at home - Correct answer ANS: A Children with school refusal or school phobia often have symptoms that gradually improve as the day Progresses and often disappear on weekends. The PNP should ask about the frequency and duration of the Symptoms to evaluate this pattern. The other options are important questions when management of school Phobia has begun as a way of understanding underlying causes for the reluctance to go to school. 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. P a g e 22 | 155 Commonly done among adolescents and is not a way of fitting in with a peer group. Because it indicates Underlying distress, adolescents must get help identifying these causes. Many have a history of physical, Sexual, or emotional abuse. Although individuals who engage in SIB are more likely to attempt suicide in The future, the act itself is not a suicide attempt. 8. The parent of a 14-year-old child tells the primary care pediatric nurse practitioner that the adolescent Has expressed a desire to be a vegetarian, is refusing all meat served at home, and wants the family to Eat vegetarian meals. What will the nurse practitioner tell the parent? a. Do not allow a vegetarian diet in order to maintain appropriate limits for the adolescent. b. Provide vegetarian options for the adolescent that preserve adequate nutrition and protein intake. c. Suggest that the adolescent prepare appropriate vegetarian dishes to complement family meals. d. Tell the adolescent that a vegetarian diet may be considered in adulthood but not while living at Home. - Correct answer ANS: C Early adolescents begin to develop their own value system and may try value systems other than the one That they have learned from their family, which is a normal part of establishing personal identity. The Parent may allow expression of other values, such as a vegetarian diet, as long as nutritional needs are met And the adolescent takes responsibility for preparing the food. 9. The primary care pediatric nurse practitioner is performing an exam on an adolescent male who asks About sexual identity because of concern that a friend is worried about being gay. Which response will? The nurse practitioner make in this situation? a. Provide the teen with a questionnaire to gain information about his sexuality. b. Remind the adolescent that mandatory reporting requires disclosure to parents. c. Suggest that the adolescent discuss sexual concerns with his parents. d. Tell the adolescent that, unless he is at risk, what he says will be confidential. - Correct answer ANS: D Adolescents should be encouraged to divulge information about their sexuality to providers by assuring Them that confidentiality will be maintained unless the health of the child or others is at risk. The Adolescent may be trying to ask questions about himself in a manner that doesn't implicate his own Sexuality, so the PNP should attempt to gain his confidence. Questionnaires may be useful when Collecting information, but this adolescent has already begun a discussion about the topic. An adolescent Who is concerned about being gay may not be ready to come out to his parents. 10. The primary care pediatric nurse practitioner is performing a well-child exam on a 17-year- old female Whose mother is present during the history? The mother expresses concern that her daughter wishes to Have an eyebrow piercing and states that she is opposed to the idea. What will the nurse practitioner? Do? a. Provide information about piercings and encourage continued discussion. b. Remind the adolescent that her mother is responsible for her health. P a g e 25 | 155 c. State that piercings are relatively harmless and are an expression of individuality. d. Suggest that she wait until she is 18 years old and can make her own decisions. - Correct answer ANS: A Adolescents who pierce their noses or have strange haircuts may be irritating to parents, but these are Ways of expressing individuality and help them to achieve psychosocial milestones. The fact that the teen And her mother are discussing this is a good sign that the adolescent isn't in complete rebellion. The PNP Should provide accurate health information and encourage continued dialogue. Although it is true that Piercings are relatively harmless, the PNP shouldn't "side" with the teen during an open discussion or tell The teen that the mother is "in charge." 11. The mother of a 16-year-old male was recently divorced after several years of an abusive relationship And tells the primary care pediatric nurse practitioner that the adolescent has begun skipping school 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 P a g e 26 | 155 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. 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 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. P a g e 27 | 155 10. The primary care pediatric nurse practitioner is performing a focused problem assessment on a child Who has asthma and learns that one of the child's parents smokes around the child in spite of being 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 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 P a g e 30 | 155 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. 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 P a g e 31 | 155 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? a. a. Breastfed infants have lower serum cholesterol levels than those who are not Breastfed. b. b. maternal cholesterol levels affect the cardiovascular risk of breastfed babies. c. c. maternal dietary cholesterol intake does not affect the infant's serum Cholesterol values. D. d. She should limit her dietary cholesterol to prevent hyperlipidemia in her infant. - Correct answer ANS: C Changes in the maternal diet do not produce changes in cholesterol values in infants. Breastfed Infants tend to have higher cholesterol levels than other infants, but cholesterol is necessary for Brain and retinal development. 1. 7. The mother of a 15-month-old infant tells the primary care pediatric nurse Practitioner that she wishes to continue nursing her child for another year, if possible. What Will the nurse practitioner recommend? a. a. Breastfeed only at bedtime to establish meal patterns. b. b. Clean the toddler's teeth each time after breastfeeding. c. c. Offer the breast just prior to meals to maintain milk supply. D. d. The toddler should continue to be breastfed "on demand." - Correct answer ANS: B One drawback to breastfeeding toddlers is the effect of prolonged contact with lactose on the Teeth. Mothers should be cautioned to consult with a dentist and to clean the toddler's teeth. The Mother may choose when and how often to breastfeed but should not allow "on demand" Feedings. The breast should be offered after meals. 1. 8. The primary care pediatric nurse practitioner performs an initial well baby exam On a 1-week-old infant who is breastfeeding and who is at birth weight. The mother tells the Nurse practitioner that her baby is already sleeping 5 or 6 hours at night. What will the nurse? Practitioner recommend? a. a. Consultation with a lactation specialist to assess intake b. b. pumping her breast during the night to maintain milk supply c. c. supplementing the last feeding of the day with formula d. d. waking the infant up at least every 3 hours to nurse - Correct answer ANS: D Newborn infants should nurse every 2 to 3 hours in order to establish a routine and stimulate Milk supply. The infant has regained birth weight, which is expected by age 2 weeks, so weight Is not a concern and a lactation consultation is not warranted. The infant should continue to Nurse during the night, so there is no need for the mother to pump her breasts or to supplement With formula. Using formula from a bottle also causes nipple confusion and should be avoided. 1. 9. The primary care pediatric nurse practitioner performs a well-child assessment on A 6-month-old infant whose mother reports having less breast milk because of stressors P a g e 32 | 155 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 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 35 | 155 9. The primary care pediatric nurse practitioner is discussing toileting issues with the parent of a 3-year- old toddler who reports that the child has been toilet trained for several months but has recently been refusing to have bowel movements and is becoming constipated. What will the nurse practitioner do? a. Ask the parent about bathroom facilities in the child's day care. b. Refer the child to a gastroenterologist for evaluation of pathology. c. Suggest putting the child in diapers and resuming toilet training in a few weeks. d. Tell the parent that this represents a developmental delay. - Correct answer ANS: A The child has bowel dysfunction that may be related to restricted access to bathroom facilities, causing the child to actively try to prevent bowel movements. The fact that the child previously had control indicates a behavioral cause. It is not necessary to refer to a specialist. Putting the child in diapers and resuming toilet training later is useful for the child who is unable to toilet train. Without further evaluation, the PNP cannot determine that there is a developmental delay. 10. The primary care pediatric nurse practitioner is concerned that a toddler may have vesicoureteral reflux based on a history of dysfunctional voiding patterns and a series of urinary tract infections. Which intervention is appropriate? a. Initiating a bladder retraining program b. Ordering a voiding cystourethrogram c. Referral to a urologist for evaluation d. Treatment with prophylactic antibiotics - Correct answer ANS: C If symptomatic vesicoureteral reflux is suspected, the PNP should refer the child to a urologist for diagnosis and initiation of treatment. A bladder retraining program does not treat the underlying cause. The urologist must order the VCUG and will decide if prophylactic antibiotics are indicated 11. The primary care pediatric nurse practitioner is counseling the parent of an 8-year-old child who has primary nocturnal enuresis. The nurse practitioner recommends an enuresis alarm, but the parent wishes to use medication. What will the nurse practitioner tell the parent? a. Anticholinergic medications are most commonly used for enuresis. b. Drug therapy is an effective way to achieve long-term control. c. Drug therapy is safest when the nasal spray form is used. d. The combination of alarm therapy and intermittent drug therapy is best. - Correct answer ANS: D Drug therapy in combination with alarm therapy is effective, but parents must be cautioned to use drug therapy only when the child must be dry at night, such as when on a sleepover. Anticholinergic medications can cause constipation, which may exacerbate the problem and are not recommended as first- line treatments. Drug therapy alone can result in relapse of nocturnal enuresis when the drug is withdrawn and is not effective for long-term control. The nasal spray form of desmopressin has a black box warning because of a risk of hyponatremia. 1. The primary care pediatric nurse practitioner is performing a well child exam on a 4-month-old infant P a g e 36 | 155 who is nursing exclusively. The mother reports that the infant has had a marked decrease in the number of stools each day, from 3 to 5 stools each day to only one stool every other day. How will the nurse practitioner respond? a. Ask the mother to describe the color and consistency of the stools. b. Explain to the mother that breastfed infants should have daily stools. c. Recommend using a glycerin suppository as needed. d. Suggest to the mother that she increase her intake of fluids. - Correct answer ANS: A It is common for older breastfed infants to stool less frequently. The PNP should assess the color and consistency of the stools to make sure that they are normal. As long as infants are happy, thriving, and free from clinical signs of GI distress, parents can be reassured that this is normal. It is not necessary to use a glycerin suppository or ask the mother to increase fluids in the absence of clinical pathology. 2. The primary care pediatric nurse practitioner is evaluating a 5-year-old child who has frequent soiling of stool associated with stomach aches and decreased appetite for the past 2 months. The parent states that the child has two or fewer formed bowel movements each week and has been toilet trained for about 2 years. Which initial assessment will the nurse practitioner make? a. History of neurogenic conditions b. Recent adjustments in the family c. Recent illnesses, fluid intake, changes in diet d. Toilet training history - Correct answer ANS: C 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." P a g e 37 | 155 1. 11. The primary care pediatric nurse practitioner sees a 3-year-old child whose parents report is a picky eater in spite of their continued efforts to provide nutritious meals. The parents ask whether a multivitamin is necessary. How will the nurse practitioner respond? a. a. Ask the parents to provide a 3-day food diary. b. b. Prescribe a daily multivitamin with iron. c. c. Reinforce the need to meet DRIs each day. d. d. Tell them that supplements are unnecessary - Correct answer ANS: A Although most children who are "picky eaters" eat a balanced diet over time, it is worth assessing the situation using a 3-day diet history to determine whether key nutrients are being missed and if the child needs an MV supplement. MVs are not usually necessary and iron is not given unless there is a deficiency. It is not necessary to meet DRIs every day. Supplements may be necessary after data is collected. 1. 12. When counseling an adolescent with a family history of hyperinsulinemia and type 2 diabetes, the primary care pediatric nurse practitioner will recommend avoiding a. a. baked potato chips. b. b. canned vegetables. c. c. high-fiber cereals. d. d. processed breads. - Correct answer ANS: D High-glycemic foods, such as soda, sweetened juices, and processed breads, pastries, and crackers are more quickly converted to serum glucose and stimulate a sharp rise in insulin production and a subsequent rapid shift into hypoglycemia. To help prevent this in a child with a family history of this disorder, the PNP should recommend avoiding processed breads, pastries, and crackers. High levels of fructose and low fiber intake also contributes to this phenomenon. Baked potato chips, canned vegetables, and high-fiber cereals do not contribute to excess insulin production. 1. The primary care pediatric nurse practitioner is performing a pre-participation sports physical examination on a 14-year-old male who will be on the wrestling team at school. What will the nurse practitioner include when discussing healthy practices with this adolescent? a. Risks associated with repeatedly losing and gaining weight b. The need for an electrocardiogram or echocardiogram prior to participation c. The need to consume 20 to 30 grams of protein after exercise d. To consume water with CHO prior to activity lasting up to an hour - Correct answer ANS: A Wrestlers often try to lose weight rapidly prior to wrestling matches to put themselves into a lower weight category. It is important to teach young athletes about the risks associated with repeated weight loss and gain. ECG and echocardiograms are not recommended as a requirement for all pre-participation physical exams unless there is an indication for doing so, such as with syncope or murmurs. Athletes do not need to consume 10 to 20 grams of protein after exercise complex carbohydrates are recommended to improve muscle glycogen resynthesis. Plain water is recommended before, during, and after all activity lasting up to an hour. - Correct answer 2. The primary care pediatric nurse practitioner counseling the parent of an overweight school- age child about improving overall fitness. What will the nurse practitioner include? a. Encourage the child to begin by engaging in swimming or cycling. b. Exercise will help lower total cholesterol and low-density lipoproteins. c. School-age children need 60 minutes of moderate exercise daily. d. Strength training exercises are not safe for school-age children. - Correct answer ANS: A P a g e 40 | 155 The AAP suggests that overweight children initially participate in activities that place less stress on weight-bearing joints, such as swimming or cycling. Exercise helps raise HDL levels but does not reduce total cholesterol or LDL levels. School-age children need 60 minutes of physical activity but not necessarily exercise each day. Strength training exercises are safe, but powerlifting and maximal weight training are not, because of effects on developing bones. 3. The parents of a pre-pubertal female who is on the local swim team tell the primary care pediatric nurse practitioner that their daughter wants to begin a strength training program to help improve her 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 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. P a g e 41 | 155 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? 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 P a g e 42 | 155 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 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 P a g e 45 | 155 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 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 P a g e 46 | 155 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 open eyes, and saying things that don't make sense. What will the nurse practitioner recommend? a. Establishing a graduated extinction program and good sleep hygiene b. Making sure that stairs are blocked and doors are locked c. Referral to a sleep disorder clinic for evaluation of a parasomnia d. To awaken the child when these occur and asking about nightmares - Correct answer ANS: B Parents of children with sleep walking should be assured that this is relatively benign but should make sure the house is secure so the child will not cause self-harm. Graduated extinction and sleep hygiene are used for children who have difficulty initiating or maintaining sleep. Referral to a sleep disorder clinic may be warranted if the child has an episode of leaving the house or some other dangerous activity. The child should be guided back to bed without awakening. 4. The parent of a 4-year-old who has difficulty initiating and maintaining sleep has tried several nonpharmacological methods with variable success and asks about medications. What will the primary care pediatric nurse practitioner recommend? a. Diphenhydramine b. Lorazepam c. Melatonin d. Zolpidem - Correct answer ANS: C Medications to treat dyssomnias are generally discouraged in children, since they have side effects and since the mainstay of treatment is behavioral therapy and sleep hygiene. If medications are used, melatonin is the most commonly prescribed. Diphenhydramine can lead to parasomnias in some children. Benzodiazepines, such as lorazepam, can cause dependence. Sedatives, such as zolpidem, have high levels of side effects. 5. A child with Down syndrome who has sleep-disordered breathing with obstructive sleep apnea continues to have symptoms in spite of tonsillectomy and adenoidectomy and treatment with a leukotriene receptor antagonist medication and a nasal steroid spray. The primary care pediatric nurse practitioner will refer the child to a sleep disorder clinic to discuss which therapy? a. Craniofacial surgery b. Oral appliances c. Positive airway pressure therapy d. Supplemental oxygen - Correct answer ANS: C Positive airway pressure therapy can be used to treat sleep-disordered breathing in children who have failed other therapies and even developmentally delayed children show improvement in behaviors after this therapy. Craniofacial surgery may be used in the presence of maxillofacial deformities that affect P a g e 47 | 155 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 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 this young age is reflexive and not conscious and intentional. It is not a form of priapism. 3. During a well child exam on a 13-year-old female, the primary care pediatric nurse practitioner notes that the child is at Tanner Stage 3. During the exam, when the nurse practitioner initiates a P a g e 50 | 155 conversation about healthy sexuality education, the parent states that this topic is "off limits." What will the nurse practitioner do? a. Ask the adolescent whether she wishes to discuss these matters since she is becoming an adult. b. Separate the parent from the adolescent to discuss the adolescent's concerns in private. c. Spend private time with the parent to discuss how sexuality education reduces the risk of early sexual intercourse and risky sexual behaviors. d. Tell the parent that this information is a routine part of adolescent well child examinations and must be included. - Correct answer ANS: C Research has shown that sexuality education leads to a reduction in early onset of sexual intercourse and risky sexual behaviors. It is important for the PNP to be sensitive to the values of the family but also to advocate for the child. The child should be told, especially when she shows an interest in sexual relationships, that she may seek care independently of her parent and that it will remain confidential. When possible, the parent's wishes should be taken into account and both the adolescent and the parent should be encouraged to begin an open dialogue about these matters. 4. The primary care pediatric nurse practitioner is counseling the parents of a 13-year-old female who has Down syndrome about sexual maturation. What will the nurse practitioner tell these parents? a. It is important to discuss and support healthy sexuality. b. Providing too much information about sexuality may be confusing given the child's cognitive level of understanding. c. Suppressing periods with contraceptives will lessen their daughter's distress. d. They should give her information about periods but not about sexuality. - Correct answer ANS: A Persons with disabilities have the same desires to make decisions and foster fulfilling relationships with others as other people have. Unless healthy sexuality is taught and supported, unhealthy and abusive sexuality is more likely to occur. Parents should give information when it is desired and delivered in a manner appropriate to the child's level of understanding. Suppressing periods only ignores the issue but does not change the increased feelings that accompany puberty. 5. During a well child examination of a 6-year-old girl, the primary care pediatric nurse practitioner notes that the child becomes embarrassed and resists taking off her underwear for the exam. What should the nurse practitioner infer from this observation? a. The child has been sexually molested. b. The child is feeling violated by the examiner. c. The parent is exhibiting regressive behavior. d. This is a normal reaction in a child of this age. - Correct answer ANS: D Young school-age children can be extremely modest and embarrassed and resist taking off their clothes for an examiner. Since this is normal, it does not indicate a history of sexual abuse unless other signs are present. Older school-age children more commonly feel violated during an exam, not younger children. This response of increased modesty is age-appropriate and not regressive. P a g e 51 | 155 6. The primary care pediatric nurse practitioner is providing anticipatory guidance to the parent of a school-age boy. The parent expresses concerns that the child prefers to play with dolls, is worried that the child will be a homosexual, and asks what can be done to prevent this from happening. What will the nurse practitioner tell this parent? a. Homosexual identity formation cannot be predicted by early childhood behavior. b. Masculinizing boys from an early age helps to determine heterosexual orientation. c. Sexual orientation identification begins late in adolescence and not in childhood. d. The development of sexual orientation is generally a multifaceted process. - Correct answer ANS: D The etiology and age of preferred sexual orientation is unknown, and the sequential developmental signs are debated. The development of sexual orientation is most likely multifaceted and cannot be predicted by one phenomenon, such as playing with dolls alone. Early childhood behavior can predict homosexual orientation as girls may feel "unfeminine" and boys may exhibit feminine tendencies. It is clear that psychosocial components and parenting do not cause or prevent homosexuality. 7. The primary care pediatric nurse practitioner is performing a well child examination on a 3- year-old. 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 P a g e 52 | 155 a. cohabitating parents. b. grandparents. c. homosexual parents. d. single parents. - Correct answer ANS: A Adolescents living in cohabitating households are more likely to smoke and drink in comparison with adolescents living in married or single parent households. Children living with homosexual parents and children living with grandparents do not have this increased risk. 3. The parent of an adolescent female tells the primary care pediatric nurse practitioner that the child may be the victim of cyber-bullying at school but won't talk about it with her parents. What is the nurse practitioner's initial response? a. Ask about the adolescent's school performance and friends. b. Interview the adolescent separately from the parent. c. Reassure the parent that suicide is a rare response to bullying. d. Suggest that the parent discuss this with the school counselor. - Correct answer ANS: B When bullying is suspected, it is ideal to interview the youth separately from the parent, even though it is necessary to get the history from both, since children are often reluctant to discuss bullying with their parents. Asking about school performance and friends is part of the history but not a priority. Reassuring the parent that suicide is rare minimizes the parent's concerns. Suggesting that the parent discuss this with the school shows an unwillingness to consider the problem as part of the child's overall health. 4. During a well child examination on an infant who has colic, the primary care pediatric nurse practitioner learns that the infant's mother is 17 years old and that the father, who is in the military, was deployed to wartime duty shortly after the baby was born. To determine the immediate risk of child maltreatment for this infant, the nurse practitioner will ask about : a. childrearing and parenting styles. b. role responsibilities of the parents. c. spiritual beliefs and religious practices. d. the location of extended family members. - Correct answer ANS: D Assessment of resources, including the support of extended family members, is a key dimension of family functioning. In this case, the mother is young and alone and may lack the skills needed to cope with an infant with colic. Childrearing and parenting styles can affect the emotional and physical health of children who misbehave or who are learning how to behave in the world. An assessment of role responsibilities is important when there are disagreements about shared responsibilities. Assessing spiritual beliefs helps to determine the values ascribed to events. While all of these are important assessments, there is an urgent need to determine the level of support available to this mother. 5. The primary care pediatric nurse practitioner is counseling a family whose parents are divorcing. To help support the children and reduce their stress through this process, the nurse practitioner will recommend a. allowing children to choose the custodial parent. b. being open about ongoing parental conflicts. c. establishing a single custody living arrangement. d. maintaining a civil relationship when discussing children. - Correct answer ANS: D P a g e 55 | 155 Children make more successful adjustments and suffer less stress when parents are able to develop a civil relationship that focuses on what is best for them. Custody arrangements vary and may change over time and should be determined by what is best for the children. Custody disputes and exposure to parental conflict place additional stress on children and can increase their feelings of insecurity 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 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 P a g e 56 | 155 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 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 P a g e 57 | 155 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." 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 P a g e 60 | 155 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 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 P a g e 61 | 155 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 without restricting the history is the initial focus. 2. The parent of a 4-year-old child reports that the child seems to be having trouble adjusting to a new day care and reportedly is always engaging in solitary play when the parent arrives to pick up the child. What will the primary care pediatric nurse practitioner do? a. Ask the parent if the child is slow to warm up to other new situations. b. Reassure the parent that parallel play is common among preschool-age children. c. Recommend that the parent spend time encouraging the child to play with others. d. Suggest that the day care center may be neglecting the child. - Correct answer ANS: A Shyness is a pattern of social inhibition with unfamiliar people, novel objects, or novel situations. If the child shows this pattern in other situations, shyness is most likely the cause of this behavior. Parallel play is common among toddlers and not preschoolers. Parent should be supportive and not push children to interact. Because this shyness is a common pattern in this age child, it is not necessary to suggest that neglect is occurring, unless there are other signs. 3. During a well child examination on a 4-month-old infant, the primary care pediatric nurse practitioner evaluates mental health issues. Which statement by the parent indicates a potential problem with the parent-infant relationship? a. "I can sense a difference in my baby's cries." b. "I let my baby cry a while to learn to be patient." c. "My baby prefers to nurse in a darkened room." d. "My baby seems very sensitive to loud noises." - Correct answer ANS: B When parents respond promptly to their baby's needs, infants develop the ability to wait for care and typically provide less intense distress signals. Parents who are attentive to their babies' signals, preferences, and sensitivities are more in tune with their infants' needs. 4. A newly divorced mother of a toddler reports that the child began having difficulty sleeping and nightmares along with exhibiting angry outbursts and tantrums 2 months prior. The primary care pediatric nurse practitioner learns that the child refuses to play with usual playmates and often spends time sitting quietly. What will the nurse practitioner do initially? a. Ask the mother about the child's relationship with the father. b. Consult with a child psychiatrist to prescribe medications. c. Recommend cognitive behavioral or psychodynamic therapy. d. Refer the family to a child behavioral specialist for counseling. - Correct answer ANS: A The child exhibits signs of PTSD. Because the parents are newly divorced, the PNP should evaluate the child's previous interactions with the father to determine whether violence occurred. If PTSD is likely, referral to social service agencies may be warranted. Pediatric mental health specialists may be involved once a diagnosis is established and may order medications. 5. A 9-year-old child exhibits school refusal and a reluctance to attend sleepovers with classmates. The P a g e 62 | 155 fluoxetine. What other treatment is important to protect against suicide risk? a. Addition of risperidone therapy 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 tantrums, and poor sleep. OCD results in recurring thoughts, images, or impulses. Patients with PANDAS have OCD- and Tourette-like symptoms. SAD causes difficulties separating from caregivers and being away from home. 14. A 14-year-old female comes to the clinic with amenorrhea for 3 months. A pregnancy test is negative. The adolescent's body weight is at 82% of expected for height and age. The mother reports that her daughter often throws up and refuses to eat most foods. Which condition does the primary care pediatric nurse practitioner suspect? P a g e 65 | 155 a. Anorexia nervosa b. Bulimia nervosa c. Depression d. Substance abuse - Correct answer ANS: A Children with anorexia nervosa are usually underweight. Refusal to maintain body weight at least 85% expected for age and height or failure to gain weight during growth periods so that weight drops below 85% expected is one of the diagnostic criteria of anorexia. Some may throw up frequently, but children with bulimia nervosa are generally average weight or overweight. Depression and substance abuse may be comorbidities, but these signs are consistent with anorexia nervosa. 15. The parent of a school-age child is concerned because the child has started to express anger about a grandparent's death even though this occurred when the child was a toddler. What will the primary care pediatric nurse practitioner tell the parent? a. Anger is an abnormal reaction to bereavement and loss in this age child. b. Counseling is needed since the child has had sufficient time to resolve this issue. c. Grief and bereavement lasting longer than a year may require medication. d. The significance of this loss must be reworked at each developmental level. - Correct answer ANS: D At any given developmental stage, children resolve the effect of the death only at that developmental level and thus must rework the significance of the loss at each stage of development. Anger is a common reaction to loss in school-age children. Counseling and medication are not indicated since this is a normal response. 16. The primary care pediatric nurse practitioner attempts to learn more about the emotional health of an 18-month-old child through which assessment strategy? a. Asking the child to tell a story using dolls and other props b. Asking the child to draw a picture of him- or herself and other family members c. Interviewing the child separately from caretakers and parents d. Observation of the child with caretakers in structured and unstructured situations - Correct answer ANS: D The PNP can observe infants and toddlers with caretakers in both structured and unstructured situations to determine strengths and limitations of each partner in the interaction. Asking children to tell stories is more appropriate for older toddlers and preschoolers. Preschoolers may be asked to draw pictures. Interviewing children separately from caretakers is more appropriate with school-age children and adolescents. 17. The parent of a school-age girl reports that the child has difficulty getting ready for school and is often late because of a need to check and recheck whether her teeth are clean and her room light has been turned off. What will the primary care pediatric nurse practitioner recommend to this parent? a. Cognitive-behavioral therapy b. Deferral of treatment until symptoms worsen c. Medication management with an SSRI P a g e 66 | 155 d. Referral to a child psychiatrist - Correct answer ANS: A Cognitive-behavioral therapy is used for mild to moderate symptoms of OCD. Children who have mild symptoms that do not interfere with their lives can defer treatment, but this is not the case in this situation. Medication and referral to a child psychiatrist are used for more severe symptoms. 18. A 13-year-old child has exhibited symptoms of mild depression for several weeks. The parent reports feeling relieved that the symptoms have passed but concerned that the child now seems to have boundless energy and an inability to sit still. What will the primary care pediatric nurse practitioner do? a. Administer an ADHD diagnostic scale and consider an ADHD medication. b. Consult with a child psychiatrist to prescribe an antidepressant medication. c. Reassure the parent that this behavior is common after mild depressive symptoms 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 P a g e 67 | 155 necessary to treat with an anti-viral medication. A broad-spectrum antibiotic will only increase the risk of antibiotic resistance. Writing a prescription for the parents to fill if needed is not recommended; parents may give an antibiotic believing that it is indicated when it is not. 8. The primary care pediatric nurse practitioner is counseling an adolescent who was recently hospitalized for an asthma exacerbation and learns that the child usually forgets to use twice- daily inhaled corticosteroid medications that are supposed to be given at 0800 and 2000 each day. Which strategy may be useful in this case to improve adherence? a. Ask the adolescent to identify two times each day that may work better. b. Consider having the school nurse supervise medication administration. c. Prescribing a daily oral corticosteroid medication instead. d. Suggest that the parent enforce the medication regimen each day. - Correct answer ANS: A When working with adolescents who take medication, it is important to allow the adolescent to have input into dosing schedules and what works for them. Having the school nurse supervise does not allow autonomy and creates continued dependency. Daily oral corticosteroids are not used for maintenance. The PNP should assist the family with transitioning the adolescent from parent to teen administration and not suggest that parents enforce medication rules. 1. A 10-month-old infant who is new to the clinic has chronic hepatitis B infection. What will the primary care pediatric nurse practitioner do to manage this infant's disease? a. Consult a pediatric infectious disease specialist. b. Prescribe interferon-alfa. c. Provide supportive care. d. Consider use of lamivudine. - Correct answer ANS: A A specialist in hepatitis B in children should be consulted for children with chronic hepatitis B infection because of the risk for developing hepatocellular carcinoma. Interferon-alfa and lamivudine are not used in infants. Supportive care only is not recommended. 2. The primary care pediatric nurse practitioner is performing an initial well child exam on a 3- year-old child recently adopted from Africa. The adoptive parent has a record of immunizations indicating that the child is fully vaccinated. What will the nurse practitioner do? a. Administer a booster dose of each vaccine to ensure immunity. b. Find out whether the vaccines were provided by reliable suppliers. c. Perform antibody titers and reimmunize the child. d. Record the vaccines in the child's electronic medical record. - Correct answer ANS: C Even though suppliers of vaccines worldwide produce vaccines that are of adequate quality, vaccine handling can be suspect. The PNP should perform titers and reimmunize if in doubt. If the child has not been adequately vaccinated, the PNP will need to administer each series based on catch-up dosing for age. If the child has been adequately immunized, boosters are not indicated. Performing titers is the best way to assess full immunity, since suppliers can be suspect. 3. A 3-year-old child who attends day care has had a fever, nausea, and vomiting several weeks prior P a g e 70 | 155 and now has darkened urine and constipation along with hepatomegaly and right upper quadrant tenderness. What treatment is warranted for this child? 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 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 P a g e 71 | 155 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 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 P a g e 72 | 155 Infants treated with parenteral acyclovir for neonatal herpetic infections should remain on oral acyclovir for 6 months. The PNP should obtain regular ANC levels and temporarily discontinue acyclovir if neutropenia occurs until the neutrophil count recovers. New lesions should be cultured, but routine skin cultures are not indicated. Oral acyclovir suppressive therapy for 6 months after parenteral treatment of any classification of acute neonatal disease has been shown to reduce the recurrences of mucocutaneous lesions and improve neuro-developmental outcomes. 17. A child whose family has been camping in a region with endemic Lyme disease suffered several tick bites. The parents report removing the ticks but are not able to verify the type or the length of time the ticks were attached. The child is asymptomatic. What is the best course of action? a. Administer a prophylactic single dose of doxycycline. b. Perform serologic testing for IgG or IgM antibodies. c. Prescribe amoxicillin three times daily for 14 to 21 days. d. Teach the parents which signs and symptoms to report. - Correct answer ANS: D Prophylaxis should not be given if the type of tick or the timeline for attachment cannot be verified however, parents should be encouraged to report signs of Lyme disease if they occur. Prophylaxis is given if the tick is reliably identified as a nymph or adult Ixodes scapularis species. Serologic testing may be performed if symptoms occur. Amoxicillin tid for 2 to 3 weeks is indicated for early localized disease. - Correct answer 18. A child who is immunocompromised has a fever and a rash consisting of macules, papules, and pustules. What will the primary care pediatric nurse practitioner do? a. Administer varicella immune globulin (VariZIG). b. Hospitalize the child for intravenous acyclovir. c. Order intravenous immunoglobulin as an outpatient. d. Prescribe oral acyclovir for the duration of the illness. - Correct answer ANS: B The description of the rash the immunocompromised child has been exposed to is that of varicella. Intravenous acyclovir should be given to immunocompromised individuals. Immune globulin is not effective after the disease has progressed. Oral acyclovir is expensive and not routinely recommended for most children. 19. A preschool-age child is brought to clinic for evaluation of a rash. The primary care pediatric nurse practitioner notes an intense red eruption on the child's cheeks and circumoral pallor. What will the nurse practitioner tell the parents about this rash? a. This rash may be a prodromal sign of rubella or roseola. b. The child will need immunization boosters to prevent serious disease. c. This is a benign rash with no known serious complications. d. Expect a lacy, maculopapular rash to develop on the trunk and extremities. - Correct answer ANS: D This "slapped cheek" rash is consistent with fifth disease, or erythema infectiosum, and will be followed by a lacy, maculopapular all-over rash. It is not a prodrome of rubella or roseola, and immunizations are P a g e 75 | 155 not indicated. Although it is mostly benign, there can be serious sequelae, especially for pregnant women. 20. The primary care pediatric nurse practitioner is examining a 2-month-old infant with fever and cough. A WBC is 14,000/mm3 and a chest radiograph is normal. The infant is nursing well and having normal stools. What would be an appropriate next step? a. Admitting the infant to the hospital for LP and IV antibiotics b. Obtaining a blood culture, erythrocyte sedimentation rate, and C-reactive protein c. Performing a catheterized urinalysis to screen for leukocytes and nitrites d. Prescribing empiric, broad-spectrum antibiotics with close follow-up - Correct answer ANS: C A catheterized urinalysis to rule out UTI is appropriate to help determine the cause of infection. The infant has a reassuring WBC and chest X-ray, so it is not necessary to admit to the hospital or to perform blood cultures. Antibiotics are indicated only if bacterial infection is suspected. 21. A 2-month-old infant will receive initial immunizations, and the parent asks about giving medications to increase the infant's comfort and minimize fever. What will the primary care pediatric nurse practitioner recommend? a. Administering ibuprofen or acetaminophen as needed b. Avoiding antipyretics if possible to attain better immunity c. Giving ibuprofen and acetaminophen only after the vaccines d. Pre-treating the infant with both ibuprofen and acetaminophen - Correct answer ANS: A Although some studies have detected lower antibody responses in infants and children who were given antipyretics before or after routine vaccinations, the lowered response did not influence persistent immunological memory and did not cause a decrease in vaccine protection. Parents may administer acetaminophen or ibuprofen before or after vaccines as needed. There is no evidence that a combination of acetaminophen and ibuprofen is more effective. 22. According to recent research, which populations may have higher rates of under- immunization than others? a. Those with higher rates of Asians b. Those with higher rates of graduate degrees c. Those with lower rates of poverty d. Those with lower rates of primary providers - Correct answer ANS: B Rates of under-immunization were increased in populations with an increased percentage of graduate degrees in a study of geographic clusters of under-immunized communities in northern California. Populations having a higher percentage of Asians have increased immunization rates. Higher levels of poverty are associated with under-immunization. The study did not look at the effect of the number of primary providers. 23. The primary care pediatric nurse practitioner is reviewing medical records for a newborn that is new to the clinic. The toddler's mother was found to be HIV positive during her pregnancy with this child and received antiretroviral therapy during pregnancy. The child was born by cesarean section, begun P a g e 76 | 155 on anti-retroviral prophylaxis, and did not breastfeed. What is the correct management for this child? a. Consult with a pediatric HIV specialist. b. Discontinue cART after 4 weeks of age. c. Obtain a CD4+ cell count and HIV RNA levels. d. Reinforce the need to give cART for life. - Correct answer ANS: A PNPs may manage infants exposed in utero to HIV but should do so in consultation with a pediatric HIV specialist. cART should be given for 6 weeks. Lab work is ordered according to protocol at the direction of the specialist. Many children who are treated according to the protocol do not become HIV positive. 24. A child is brought to the clinic with a fever, headache, malaise, and a red, annular macule surrounded by an area of clearing and a larger, erythematous annular ring. The child complains of itching at the site. What will the primary care pediatric nurse practitioner do to determine the diagnosis? a. Ask about recent tick bites b. Obtain a skin culture c. Order blood cultures d. Perform serologic testing - Correct answer ANS: A The presence of an erythema migrans rash with a positive history is diagnostic for Lyme disease, and no further testing is necessary. Because Borrelia burgdorferi is transmitted to humans through ticks, asking about recent tick bites is paramount to making this diagnosis. Skin and blood cultures are not indicated. Serology testing for IgG and IgM antibodies may be performed if the child is symptomatic without the characteristic EM rash. 25. A 9-month-old infant has had a fever of 103°F for 2 days and now has a diffuse, maculopapular rash that blanches on pressure. The infant's immunizations are up-to-date. What will the primary care pediatric nurse practitioner do? a. Administer immunoglobulin G to prevent fulminant illness. b. Perform serologic testing for human herpes virus -6 and human herpes virus -7. c. Reassure the parent that this is a mild, self-limiting disease. d. Recommend avoiding contact with pregnant women. - Correct answer ANS: C The infant has symptoms consistent with roseola infantum, which is a benign, self-limiting disease. It is not necessary to administer IgG or perform serologic testing or to avoid contact with pregnant women. 26. The parent of an infant asks why some vaccines, such as MMR, are not given along with the other series of immunizations at 2, 4, and 6 months of age. What will the primary care pediatric nurse practitioner tell this parent? a. Febrile seizures are more likely in younger infants with some vaccines. b. Maternal antibodies neutralize some vaccines and are delayed until 12 months. c. The risk of adverse effects is lower for some vaccines after the first year. d. Too many vaccines at once can overwhelm the infant's immune system. - Correct answer ANS: B Maternal antibodies may neutralize certain vaccines, so some are delayed until the child is 1 year old. Febrile seizures and adverse reactions are not more likely in younger infants. There is no evidence that a P a g e 77 | 155 antibiotics started pending cultures. Empiric treatment is not indicated. Vaccination is not helpful once the disease has started. Outpatient lab work is not indicated. 1. 1. The parent of a school-age child reports that the child usually has allergic rhinitis symptoms beginning each fall and that non-sedating antihistamines are only marginally effective, especially for nasal obstruction symptoms. What will the primary care pediatric nurse practitioner do? a. a. Order an intranasal corticosteroid to begin 1 to 2 weeks prior to pollen season. b. b. Prescribe a decongestant medication as adjunct therapy during pollen season. c. c. Recommend adding diphenhydramine to the child's regimen for additional relief. d. d. Suggest using an over-the-counter intranasal decongestant. - Correct answer ANS: A Intranasal corticosteroids are a key component in long-term therapy to manage symptoms associated with AR. These should be begun 1 to 2 weeks prior to the beginning of pollen season. Decongestants are not recommended for long-term use because of side effects. Diphenhydramine causes daytime drowsiness. 1. 2. The primary care pediatric nurse practitioner sees a child for follow-up care after hospitalization for ARF. The child has polyarthritis but no cardiac involvement. What will the nurse practitioner teach the family about ongoing care for this child? a. a. Aspirin is given for 2 weeks and then tapered to discontinue the medication. b. b. Prophylactic amoxicillin will need to be given for 5 years. c. c. Steroids will be necessary to prevent development of heart disease. d. d. The child will need complete bedrest until all symptoms subside. - Correct answer ANS: A ASA is given for arthritis for 2 weeks and then will be tapered. Children with ARF will need penicillin prophylaxis, not amoxicillin. Steroids are sometimes used for symptomatic relief but do not prevent chronic heart disease. Bed rest is indicated only when cardiac symptoms occur. 1. 3. A school-age child with asthma is seen for a well child checkup and, in spite of "feeling fine," has pronounced expiratory wheezes, decreased breath sounds, and an FEV1 less than 70% of personal best. The primary care pediatric nurse practitioner learns that the child's parent administers the daily medium-dose ICS but that the child is responsible for using the SABA. A treatment of 4 puffs of a SABA in clinic results in marked improvement in the child's status. What will the nurse practitioner do? a. a. Have the parent administer all of the child's medications. b. b. Increase the ICS medication to a high-dose preparation. c. c. Reinforce teaching about the importance of using the SABA. d. d. Teach the child and parent how to use home PEF monitoring. - Correct answer ANS: D Home PEF monitoring is useful for children to identify when symptoms are worsening. This child does not appear to notice the presence of airway tightness or wheezing and so might benefit from PEF monitoring to know when to use the SABA. School-age children should be learning how to manage their chronic disease, so having the parent administer all medications is not the best choice, especially since use of the SABA is still dependent on the child's report of symptoms. Since the child responded well to administration of the SABA, increasing the dose of ICS should not be done unless better management is not effective. Reinforcing the teaching is part of the plan but, unless the child is aware of symptoms, may not occur. 1. 4. A child has a fever and arthralgia. The primary care pediatric nurse practitioner learns that the child had a sore throat 3 weeks prior and auscultates a murmur in the clinic. Which test will the nurse practitioner order? a. a. Anti-DNase B test b. b. ASO titer c. c. Rapid strep test d. d. Throat culture - Correct answer ANS: B This child has symptoms and a history consistent with ARF. The ASO titer peaks in 3 to 6 weeks and will confirm a recent strep infection. The anti-DNase B test will also confirm a recent strep infection, but this doesn't peak until 6 to 8 weeks after the initial infection. A rapid strep P a g e 80 | 155 test and throat culture do not differentiate the carrier state from a true infection. 1. 5. The primary care pediatric nurse practitioner is prescribing ibuprofen for a 25 kg child with JIA who has oligoarthitis. If the child will take 4 doses per day, what is the maximum amount the child will receive per dose? a. a. 200 mg b. b. 250 mg c. c. 400 mg d. d. 450 mg - Correct answer ANS: B The maximum dose is 40 mg/kg/day divided into 3 to 4 doses. 25 kg × 40 mg = 1000/4 = 250 mg. 1. 6. A school-age child who uses a SABA and an inhaled corticosteroid medication is seen in the clinic for an acute asthma exacerbation. After 4 puffs of an inhaled short-acting B2-agonist (SABA) every 20 minutes for three treatments, spirometry testing shows an FEV1 of 60% of the child's personal best. What will the primary care pediatric nurse practitioner do next? a. a. Administer an oral corticosteroid and repeat the three treatments of the inhaled SABA. b. b. Admit the child to the hospital for every 2 hour inhaled SABA and intravenous steroids. c. c. Give the child 2 mg/kg of an oral corticosteroid and have the child taken to the emergency department. d. d. Order an oral corticosteroid, continue the SABA every 3 to 4 hours, and follow closely. - Correct answer ANS: D Children with an incomplete response (FEV1 between 40% and 69% of personal best) should be given oral steroids and instructed to continue the SABA every 3 to 4 hours with close follow- up. Hospitalization is not necessary unless severe distress occurs. An FEV1 less than 40% after treatment indicates a need to be seen in the ED. 1. 7. An adolescent who has asthma and severe perennial allergies has poor asthma control in spite of appropriate use of a SABA and a daily high-dose inhaled corticosteroid. What will the primary care pediatric nurse practitioner do next to manage this child's asthma? a. a. Consider daily oral corticosteroid administration. b. b. Order an anticholinergic medication in conjunction with the current regimen. c. c. Prescribe a LABA/inhaled corticosteroid combination medication. d. d. Refer to a pulmonologist for omalizumab therapy. - Correct answer ANS: D Children older than 12 years who have moderate to severe allergy-related asthma and who react to perennial allergens may benefit from omalizumab as a second-line treatment when symptoms are not controlled by ICSs. The PNP should refer children to a pulmonologist for such treatment. Daily oral corticosteroid medications are not recommended because of the adverse effects caused by prolonged use of this route. Anticholinergic medications are generally used for acute exacerbations during in-patient stays or in the ED. A LABA/ICS combination will not produce different results. 1. 8. A 4-month-old infant has a history of reddened, dry, itchy skin. The primary care pediatric nurse practitioner notes fine papules on the extensor aspect of the infant's arms, anterior thighs, and lateral aspects of the cheeks. What is the initial treatment? a. a. Moisturizers b. b. Oral antihistamines c. c. Topical corticosteroids d. d. Wet wrap therapy - Correct answer ANS: A Moisturization is the first-line therapy to interrupt the itch-scratch-itch cycle. Oral antihistamines are used mostly to allow sleep during nighttime pruritus. Topical corticosteroids are used if moisturization is not effective. Wet wrap therapy is used to treat flares with recalcitrant disease. P a g e 81 | 155 1. 9. An 8-year-old child is diagnosed with systemic lupus erythematosus (SLE), and the child's parent asks if there is a cure. What will the primary care pediatric nurse practitioner tell the parent? a. a. Complete remission occurs in some children at the age of puberty. b. b. Periods of remission may occur but there is no permanent cure. c. c. SLE can be cured with effective medication and treatment. d. d. The disease is always progressive with no cure and no remissions. - Correct answer ANS: B Periods of remission do occur in some children with SLE for unknown reasons, but there is no permanent remission or cure. For some children with Juvenile Idiopathic Arthritis (JIA), complete remission occurs at puberty. 1. 10. The primary care pediatric nurse practitioner is examining a school-age child who has had several hospitalizations for bronchitis and wheezing. The parent reports that the child has several coughing episodes associated with chest tightness each week and gets relief with an albuterol metered-dose inhaler. What will the nurse practitioner order? a. a. Allergy testing b. b. Chest radiography c. c. Spirometry testing d. d. Sweat chloride test - Correct answer ANS: C Spirometry testing is the gold standard for diagnosing asthma and is then used on a regular basis to monitor, evaluate, and manage asthma. Allergy testing should be considered but is not diagnostic of asthma. Chest radiography should not be routine. A sweat chloride test is used based on history. 1. 11. The primary care pediatric nurse practitioner examines a child who has had stiffness and warmth in the right knee and left ankle for 7 or 8 months but no back pain. The nurse practitioner will refer the child to a rheumatology specialist to evaluate for a. a. enthesitis-related JIA. b. b. oligoarticular JIA. c. c. polyarticular JIA. d. d. systemic JIA. - Correct answer ANS: B Oligoarticular JIA is characterized by mild, painless asymmetric joint involvement without systemic symptoms. Enthesitis-related JIA involves arthritis of the lower limbs, especially the hips, intertarsal joints, and sacroiliac joints, with swelling, tenderness, and warmth. Polyarticular JIA involves 5 or more joints. Systemic JIA presents with systemic symptoms, such as fever. 1. 12. A child who has been diagnosed with asthma for several years has been using a short-acting B2-agonist (SABA) to control symptoms. The primary care pediatric nurse practitioner learns that the child has recently begun using the SABA two or three times each week to treat wheezing and shortness of breath. The child currently has clear breath sounds and an FEV1 of 75% of personal best. What will the nurse practitioner do next? a. a. Add a daily inhaled corticosteroid. b. b. Administer 3 SABA treatments. c. c. Continue the current treatment. d. d. Order an oral corticosteroid. - Correct answer ANS: A The child is showing a need to step up treatment based on the frequency of symptoms, greater than twice each week. The PNP should order an inhaled corticosteroid maintenance medication to control symptoms and reduce the need for a SABA. The child is not having an acute exacerbation, so does not need 3 SABA treatments. Oral corticosteroids are given for moderate obstruction, <70%. 1. 13. The primary care pediatric nurse practitioner is evaluating an 11-month-old infant who has had three viral respiratory illnesses causing bronchiolitis. The child's parents both have seasonal allergies and ask whether the infant may have asthma. What will the nurse practitioner tell the parents? a. a. "Although it is likely, based on family history, it is too soon to tell." P a g e 82 | 155 1. 21. The primary care pediatric nurse practitioner is managing care for a child who has JIA who has a positive ANA. Which specialty referral is critical for this child? a. a. Cardiology b. b. Ophthalmology c. c. Orthopedics d. d. Pain management - Correct answer ANS: B An ophthalmology consultation is critical for children with JIA who have a positive ANA. Uveitis occurs in up to 35% of children with JIA who have a positive ANA. Other specialists may be consulted for specific symptoms. 1. 22. The parent of a school-age child who is diagnosed with oligoarticular JIA asks the primary care pediatric nurse practitioner what exercises the child may do to help reduce symptoms. What will the nurse practitioner recommend? a. a. Running b. b. Swimming c. c. Weights d. d. Yoga - Correct answer ANS: B Swimming is an excellent exercise for children with JIA because water therapy and the use of heat or cold reduce pain and stiffness, unless they have severe anemia or cardiac involvement. 1. The primary care pediatric nurse practitioner sees a 12-month-old infant who is being fed goat's milk and a vegetarian diet. The child is pale and has a beefy-red, sore tongue and oral mucous membranes. Which tests will the nurse practitioner order to evaluate this child's condition? a. Hemoglobin electrophoresis b. RBC folate, iron, and B12 levels c. Reticulocyte levels d. Serum lead levels - Correct answer ANS: B Infants and children who are fed goat's milk or who are on a strict vegetarian diet are at risk for folic acid and vitamin B12 deficiency. These should be evaluated, along with iron, to rule out IDA. Hemoglobin electrophoresis is used to evaluate diseases associated with altered hemoglobin, such as beta- thalassemia and sickle cell anemia, neither of which is indicated by this child's history. Reticulocyte levels are evaluated to evaluate transient erythroblastopenia of childhood, a condition that frequently follows a viral infection. Serum lead levels are not indicated based on this history. 2. A 2-year-old child who has SCA comes to the clinic with a cough and a fever of 101.5°C. The child currently takes penicillin V prophylaxis 125 mg orally twice daily. What will the primary care pediatric nurse practitioner do? a. Admit the child to the hospital to evaluate for sepsis. b. Give intravenous fluids and antibiotics in clinic. c. Increase the penicillin V dose to 250 mg. d. Order a chest radiograph to rule out pneumonia. - Correct answer ANS: A Fever and pulmonary symptoms are two conditions warranting referral or emergency admission to the hospital to rule out sepsis and acute chest syndrome. Increasing the dose of penicillin V or giving IV antibiotics is not indicated. 3. The primary care pediatric nurse practitioner evaluates a 5-year-old child who presents with pallor and obtains labs revealing a hemoglobin of 8.5 g/dL and a hematocrit of 31%. How will the nurse practitioner manage this patient? P a g e 85 | 155 a. Prescribe elemental iron and recheck labs in 1 month. b. Reassure the parent that this represents mild anemia. c. Recommend a diet high in iron-rich foods. d. Refer to a hematologist for further evaluation. - Correct answer ANS: A The child has mild to moderate iron-deficiency anemia and will need iron supplementation. The hemoglobin, hematocrit, and reticulocytes should be reevaluated in 4 weeks after initiation of treatment. The child needs iron supplementation, so reassurance alone is not indicated. It is difficult to get iron from foods, so supplementation will be needed. Children with hemoglobin levels less than 4 g/dL and some children with hemoglobin levels less than 7 g/dL must be referred. 4. The primary care pediatric nurse practitioner is examining a 5-year-old child who has had recurrent fevers, bone pain, and a recent loss of weight. The physical exam reveals scattered petechiae, lymphadenopathy, and bruising. A complete blood count shows thrombocytopenia, anemia, and an elevated white cell blood count. The nurse practitioner will refer this child to a specialist for a. bone marrow biopsy. b. corticosteroids and IVIG. c. hemoglobin electrophoresis. d. immunoglobulin testing. - Correct answer ANS: A This child has symptoms and initial lab tests consistent with leukemia and should be referred to a pediatric hematologist-oncologist for a bone marrow biopsy for a definitive diagnosis. Corticosteroids and IVIG are given for severe ITP. Hgb electrophoresis is used to diagnose SCA. Immunoglobulins are evaluated when immune deficiency syndromes are suspected. 5. The pediatric nurse practitioner provides primary care for a 30-month-old child who has sickle cell anemia who has had one dose of 23-valent pneumococcal vaccine. Which is an appropriate action for health maintenance in this child? a. Administer an initial meningococcal vaccine. b. Begin folic acid dietary supplementation. c. Decrease the dose of penicillin V prophylaxis. d. Give a second dose of 23-valent pneumococcal vaccine. - Correct answer ANS: A Invasive bacterial infection is the leading cause of death in young children with SCA. Meningococcal vaccine should be given initially for all children over the age of 2 years and a booster dose given every 5 years after that. Folic acid supplementation is often used for adults but not for children unless there is a documented deficiency. Penicillin V prophylaxis is started at 2 months of age, with the dose increased at age 3 years. The 23-valent pneumococcal polysaccharide second dose is given 5 years after the first. 6. The primary care pediatric nurse practitioner reviews hematology reports on a child with beta- thalassemia minor and notes an Hgb level of 8 g/dL. What will the nurse practitioner do? a. Evaluate serum ferritin. b. Order Hgb electrophoresis. c. Prescribe supplemental iron. d. Refer for RBC transfusions. - Correct answer ANS: A P a g e 86 | 155 Children with beta-thalassemia minor may have low hemoglobin without iron deficiency so, before prescribing iron, the PNP should measure serum iron levels or serum ferritin. Hgb electrophoresis is indicated in a child whose diagnosis is unknown to diagnose this disorder. Supplemental iron should only be ordered when there is documented iron deficiency. RBC transfusions are controversial and used only for more severe iron deficiency. 7. A school-age child comes to the clinic for evaluation of excessive bruising. The primary care pediatric nurse practitioner notes a history of an upper respiratory infection 2 weeks prior. The physical exam is negative for hepatosplenomegaly and lymphadenopathy. Blood work reveals a platelet count of 60,000/mm3 with normal PT and aPTT. How will the nurse practitioner manage this child's condition? a. Admit to the hospital for IVIG therapy. b. Begin a short course of corticosteroid therapy. c. Refer to a pediatric hematologist. d. Teach to avoid NSAIDs and contact sports. - Correct answer ANS: D This child has symptoms, a history, and lab work that indicate idiopathic thrombocytopenic purpura. Since platelets are greater than 20,000/mm3, management without specific therapy may be done on an outpatient basis by teaching the family to avoid things that contribute to bleeding. IVIG therapy is used for children with active, severe bleeding. Corticosteroids are given for platelet counts less than 20,000/mm3. Referral to a hematologist is necessary for more severe cases. 8. A toddler who presents with anemia and reticulocytopenia has a history of a gradual decrease in energy and increase in pallor beginning after a recent viral infection. How will the primary care pediatric nurse practitioner treat this child? a. Closely observe the child's symptoms and lab values. b. Consult with a pediatric hematologist. c. Prescribe supplemental iron for 4 to 6 months. d. Refer for transfusions to correct the anemia. - Correct answer ANS: A This child has symptoms and a history consistent with transient erythroblastopenia of childhood (TEC), which is usually self-limited. The PNP should monitor the child closely without treatment unless the anemia gets worse. Any of the other options may be necessary if the child's condition worsens. 9. The primary care pediatric nurse practitioner is managing care for a child diagnosed with iron- deficiency anemia who had an initial hemoglobin of 8.8 g/dL and hematocrit of 32% who has been receiving ferrous sulfate as 3 mg/kg/day of elemental iron for 4 weeks. The child's current lab work reveals elevations in Hgb/Hct and reticulocytes with a hemoglobin of 10.5 g/dL and a hematocrit of 36%. What is the next step in management of this patient? a. Continue the current dose of ferrous sulfate and recheck labs in 1 to 2 months. b. Discontinue the supplemental iron and encourage an iron-enriched diet. c. Increase the ferrous sulfate dose to 4 to 6 mg/kg/day of elemental iron. d. Refer the child to a pediatric hematologist to further evaluate the anemia. - Correct answer ANS: A This child has mild to moderate anemia and is showing a good response to the current dose of iron. P a g e 87 | 155 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 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 P a g e 90 | 155 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 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. P a g e 91 | 155 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. 11. An adolescent female who is sexually active and who has not had the HPV vaccine asks if she may have it. What will the primary care pediatric nurse practitioner tell her? a. Getting the vaccine now will still protect her from HPV oncogenic types even if already exposed b. Receiving the HPV vaccine series will replace the need for regular cervical cancer screening c. She will need to have Papanicolaou and pregnancy screening prior to receiving the vaccine d. The vaccine will not protect her from any HPV oncogenic types acquired previously - Correct answer ANS: D There is no protection for HPV oncogenic types acquired prior to the vaccine. The vaccine does not eliminate the need for cervical cancer screening. It is not necessary to perform PAP or pregnancy testing prior to vaccine administration. 12. A child with a history of a pustular rash at the site of a cat scratch on one arm now has warm, tender, swollen axillary lymph nodes on the affected side. The primary care pediatric nurse practitioner notes induration and erythema of these nodes. What will the nurse practitioner do? a. Obtain a complete blood count and C-reactive protein. b. Order an immunofluorescent assay (IFA) for serum antibodies. c. Perform a needle aspiration of the affected lymph nodes. d. Prescribe a 5-day course of azithromycin. - Correct answer ANS: B IFA shows a good correlation with cat-scratch fever disease and is useful for a more definitive diagnosis. A complete blood count and C-reactive protein are non-specific indicators of disease. Needle aspiration is only necessary to determine whether local lymph nodes are infected. Antibiotics are not given unless nodes are infected. 13. An 18-month-old child has bronchopulmonary dysplasia. To help prevent pneumococcal disease, which vaccine will be ordered? a. PCV7 b. PCV13 c. PCV23 d. PCV33 - Correct answer ANS: B PCV13 is recommended for all children under age 5 years. PCV7 was replaced by PCV13 in 2010. PCV23 is used in children over age 2 years who are at higher risk of pneumococcal disease. this child will P a g e 92 | 155 b. Obtaining a blood culture, erythrocyte sedimentation rate, and C-reactive protein c. Performing a catheterized urinalysis to screen for leukocytes and nitrites d. Prescribing empiric, broad-spectrum antibiotics with close follow-up - Correct answer ANS: C A catheterized urinalysis to rule out UTI is appropriate to help determine the cause of infection. The infant has a reassuring WBC and chest X-ray, so it is not necessary to admit to the hospital or to perform blood cultures. Antibiotics are indicated only if bacterial infection is suspected. 21. A 2-month-old infant will receive initial immunizations, and the parent asks about giving medications to increase the infant's comfort and minimize fever. What will the primary care pediatric nurse practitioner recommend? a. Administering ibuprofen or acetaminophen as needed b. Avoiding antipyretics if possible to attain better immunity c. Giving ibuprofen and acetaminophen only after the vaccines d. Pre-treating the infant with both ibuprofen and acetaminophen - Correct answer ANS: A Although some studies have detected lower antibody responses in infants and children who were given antipyretics before or after routine vaccinations, the lowered response did not influence persistent immunological memory and did not cause a decrease in vaccine protection. Parents may administer acetaminophen or ibuprofen before or after vaccines as needed. There is no evidence that a combination of acetaminophen and ibuprofen is more effective. 22. According to recent research, which populations may have higher rates of under- immunization than others? a. Those with higher rates of Asians b. Those with higher rates of graduate degrees c. Those with lower rates of poverty d. Those with lower rates of primary providers - Correct answer ANS: B Rates of under-immunization were increased in populations with an increased percentage of graduate degrees in a study of geographic clusters of under-immunized communities in northern California. Populations having a higher percentage of Asians have increased immunization rates. Higher levels of poverty are associated with under-immunization. The study did not look at the effect of the number of primary providers. 23. The primary care pediatric nurse practitioner is reviewing medical records for a newborn that is new to the clinic. The toddler's mother was found to be HIV positive during her pregnancy with this child and received antiretroviral therapy during pregnancy. The child was born by cesarean section, begun on anti-retroviral prophylaxis, and did not breastfeed. What is the correct management for this child? a. Consult with a pediatric HIV specialist. b. Discontinue cART after 4 weeks of age. c. Obtain a CD4+ cell count and HIV RNA levels. d. Reinforce the need to give cART for life. - Correct answer ANS: A PNPs may manage infants exposed in utero to HIV but should do so in consultation with a pediatric HIV P a g e 95 | 155 specialist. cART should be given for 6 weeks. Lab work is ordered according to protocol at the direction of the specialist. Many children who are treated according to the protocol do not become HIV positive. 24. A child is brought to the clinic with a fever, headache, malaise, and a red, annular macule surrounded by an area of clearing and a larger, erythematous annular ring. The child complains of itching at the site. What will the primary care pediatric nurse practitioner do to determine the diagnosis? a. Ask about recent tick bites b. Obtain a skin culture c. Order blood cultures d. Perform serologic testing - Correct answer ANS: A The presence of an erythema migrans rash with a positive history is diagnostic for Lyme disease, and no further testing is necessary. Because Borrelia burgdorferi is transmitted to humans through ticks, asking about recent tick bites is paramount to making this diagnosis. Skin and blood cultures are not indicated. Serology testing for IgG and IgM antibodies may be performed if the child is symptomatic without the characteristic EM rash. 25. A 9-month-old infant has had a fever of 103°F for 2 days and now has a diffuse, maculopapular rash that blanches on pressure. The infant's immunizations are up-to-date. What will the primary care pediatric nurse practitioner do? a. Administer immunoglobulin G to prevent fulminant illness. b. Perform serologic testing for human herpes virus -6 and human herpes virus -7. c. Reassure the parent that this is a mild, self-limiting disease. d. Recommend avoiding contact with pregnant women. - Correct answer ANS: C The infant has symptoms consistent with roseola infantum, which is a benign, self-limiting disease. It is not necessary to administer IgG or perform serologic testing or to avoid contact with pregnant women. 26. The parent of an infant asks why some vaccines, such as MMR, are not given along with the other series of immunizations at 2, 4, and 6 months of age. What will the primary care pediatric nurse practitioner tell this parent? a. Febrile seizures are more likely in younger infants with some vaccines. b. Maternal antibodies neutralize some vaccines and are delayed until 12 months. c. The risk of adverse effects is lower for some vaccines after the first year. d. Too many vaccines at once can overwhelm the infant's immune system. - Correct answer ANS: B Maternal antibodies may neutralize certain vaccines, so some are delayed until the child is 1 year old. Febrile seizures and adverse reactions are not more likely in younger infants. There is no evidence that a large number of vaccines can overwhelm the infant's immune system. 27. A school-age child has fever of 104°F, sore throat, vomiting and malaise. The primary care pediatric nurse practitioner observes that the tonsils, oropharynx, and palate are erythematous and covered with exudate. the tongue is coated and red and there is a red, sandpaper-like rash on the child's neck, P a g e 96 | 155 trunk, and extremities. A rapid strep test is positive. What will the nurse practitioner do to manage this child's illness? a. Administer intramuscular ceftriaxone. b. Hospitalize for further diagnostic tests. c. Prescribe oral amoxicillin. d. Refer to a pediatric infectious disease specialist. - Correct answer ANS: C Scarletina is caused by erythrogenic toxin from Group A streptococcus. Treatment is the same as for Group A streptococcus unless complications occur. IM antibiotics are not indicated. The child does not need hospitalization or referral to a specialist. 28. A 5-year-old child who has a history of pertussis infection as an infant is in the clinic for immunizations prior to kindergarten. Which vaccine will be given? a. DTaP b. DTP c. Td d. Tdap - Correct answer ANS: A The duration of immunity after infection with pertussis in unknown and is thought to be short, so immunization for pertussis must still be provided. The DTP, with whole-cell pertussis vaccine is given in other countries but not in the U.S. Td does not contain pertussis. Tdap is given after age 7 years. 29. A toddler is receiving long-term antibiotics to treat osteomyelitis. Which laboratory test will the primary care pediatric nurse practitioner order to monitor response to therapy in this child? a. Blood cultures b. Erythrocyte sedimentation rate (ESR) c. Serum procalcitonin (Pro-CT) d. White blood count (WBC) - Correct answer ANS: B ESR is a late measure of inflammation and is useful in helping monitor response to therapy, especially when long-term antibiotics are used. Blood cultures will most likely be negative during antibiotic treatment. Pro-CT is used to differentiate viral from bacterial infections. The WBC will most likely decrease over time with a treated infection and is not useful for monitoring response to therapy. 30. A 3-year-old child whose immunizations are up-to-date has been exposed to measles because of a localized outbreak among unvaccinated children. The parent reports that contact with infected children occurred within the last 2 days at a birthday party. What is the best course of action? a. Administer the MMR vaccine to help prevent disease. b. Give antiviral medications at the first sign of symptoms. c. Give the child a dose of immune globulin to mitigate the response. d. Reassure the parent that most exposed children will not get measles. - Correct answer ANS: A The measles vaccine can be given to those exposed if given within 72 hours of exposure. IG may be given in those without prior measles vaccine. Antiviral medications are not effective. Nine of 10 children who are unimmunized or under-immunized will contract the disease if exposed. 31. An 18-month-old child who developed upper respiratory symptoms 1 day prior is brought to the clinic with a high fever, chills, muscle pains, and a dry, hacking cough. A rapid influenza test is negative and a viral culture is pending. What will the primary care pediatric nurse practitioner do? a. Consider therapy with rimantadine. b. Hospitalize for supportive treatment. P a g e 97 | 155