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. P a g e 1 | 174 c. The rate of household poverty is lower than in other economically developed nations. d. Young children who attend preschool or day care have higher food insecurity. - Correct answer ANS: B Obesity rates are a major concern for child health in the U.S. but recently have stabilized in the rate of Increase and have declined among 2- to 5-year-olds between 2004 and 2013. Globalism has an increasing Effect on child health in the U.S. The rate of household poverty in the U.S. is higher than in other Economically developed nations. Young children who attend preschool or day care have lower food Insecurity. 5. Which region globally has the highest infant mortality rate? a. Indonesia B. Southern Asia c. Sub-Saharan Africa d. Syria - Correct answer ANS: C Although Sub-Saharan Africa and Southern Asia together account for 81% of the infant mortality rate Globally, Sub-Saharan Africa has the highest infant mortality rate in the world. 1. The parent of a toddler is concerned that the child may have autism. The primary care pediatric nurse Practitioner completes a Modified Checklist for Autism in Toddlers (M-CHAT) tool, which indicates Several areas of concern. What will the nurse practitioner do? a. Administer a Childhood Autism Rating Scale (CARS) in the clinic. b. Consult a specialist to determine appropriate early intervention strategies. c. Refer the child to a behavioral specialist for further evaluation. d. Tell the parent that this result indicates that the child has autism. - Correct answer ANS: C The M-CHAT is a screening tool and is useful for detecting behaviors that may indicate autism. This Instrument has been found to have acceptable sensitivity, specificity, and significant positive predictive 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 P a g e 2 | 174 Household, and significant behavioral and emotional problems. Which tool will the nurse practitioner Use to record this information? a. CRAFFT b. Eco map c. Genogram d. Pedigree - Correct answer ANS: C The genogram is an approach to developing a family database to provide a graphic representation of Family structure, roles, and problems of recurring significance in a family. The CRAFFT tool is used to Assess substance abuse in adolescents. The coma is used to identify relationships in the family and Community that are supportive or harmful. The pedigree is used to identify potential genetic disorders. 10. The primary care pediatric nurse practitioner evaluates a school-age child whose body mass index (BMI) is greater than the 97th percentile. The nurse practitioner is concerned about possible metabolic Syndrome and orders laboratory tests to evaluate this. Which diagnosis will the nurse practitioner Document for this visit? a. Metabolic syndrome b. Nutritional alteration: more than required c. Obesity d. Rule out type 2 diabetes mellitus - Correct answer ANS: C A problem should never be included on the problem list that is not supported by subjective and objective Data found and recorded in the database. This child has a BMI that suggests obesity, so this may be used As a diagnosis. Metabolic syndrome is a diagnosis that is determined by laboratory data, which has not Been evaluated yet. Nutritional alteration is a NANDA diagnosis and not acceptable for reimbursement. "Rule out" should not be used as a diagnosis, but may be considered part of a plan. 11. The primary care pediatric nurse practitioner performs a developmental assessment on a 3-year-old Child and notes normal cognitive, fine-motor, and gross-motor abilities. The child responds Appropriately to verbal commands during the assessment but refuses to speak when asked questions. The parent tells the nurse practitioner that the child talks at home and that most other adults can Understand what the child says. The nurse practitioner will: A. ask the parent to consider a possible speech delay and report any concerns. B. continue to evaluate the child's speech at subsequent visits. C. refer the child for a speech and hearing evaluation. D. tell the parent to spend more time in interactive conversations with the child. - Correct answer ANS: B Development should be monitored over time and within the context of the child's overall well- being, Rather than at an isolated testing session. The child has normal development in observed measures and P a g e 5 | 174 Appears to hear and understand well. By parental report, the child is able to speak. The PNP should Continue to evaluate speech over time, since this refusal to speak may be associated with shyness or Intimidation in the clinic. It is not necessary to tell the parent that the child has a possible speech delay. Unless an actual speech delay is observed, a referral is not indicated, nor is it necessary to implement a Home therapy. 12. The primary care pediatric nurse practitioner is performing a well-child assessment on an adolescent And is concerned about possible alcohol and tobacco use. Which assessment tool will the nurse Practitioner use? a. CRAFFT b. HEEADSSS c. PHQ-2 d. RAAPS - Correct answer ANS: A The CRAFFT tool is a six-question tool used to screen for adolescent substance abuse. The HEEADSSS Is used as a psychosocial screening tool. The PHQ-2 is a rapid screen for depression. The RAAPS is used To assess risk behaviors that contribute to most morbidity, mortality, and social problems in teens. 13. The primary care pediatric nurse practitioner is assessing a toddler whose weight and body mass index (BMI) are below the 3rd percentile for age. The nurse practitioner learns that the child does not have Regular mealtimes and is allowed to carry a bottle of juice around at all times. The nurse practitioner Plans to work with this family to develop improved meal patterns. Which diagnosis will the nurse Practitioner use for this problem? a. Failure to thrive b. Home care resources inadequate c. Nutrition alteration - less than required d. Parenting alteration - Correct answer ANS: D Because the PNP is planning to intervene by helping the parents to provide appropriate food habits, the Correct diagnosis should be "Parenting alteration." "Failure to thrive" is a medical diagnosis and requires A medical and social evaluation to rule out organic causes or detect neglect. "Home care resources 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? P a g e 6 | 174 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 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 P a g e 7 | 174 Not mean identifying one's own culture as inferior. Practitioners who are culturally competent are open to The influence of other cultures. 8. A Somalia immigrant mother is concerned that her 8-year-old child is underweight. The primary care Pediatric nurse practitioner notes that the child's weight is at the 25th percentile. After realizing that The mother is comparing her child to a group of American-born children who are overweight, the Pediatric nurse practitioner is able to convince the mother that this is a normal weight. Which domain Of cultural competence does this represent? a. Global b. Interpersonal c. Intrapersonal d. Organizational - Correct answer ANS: B The interpersonal domain of cultural competence refers to how cultural competence is manifested Between and among individuals and includes all relationships within the health care setting. The PNP Becomes aware of cultural norms in body weight and uses this knowledge to discuss healthy weights with The parent. The global domain recognizes a movement toward integration and interconnection of the World population in economic, political, technological, and sociocultural terms. The intrapersonal domain Refers to an understanding of the self to understand one's own cultural background. The organizational Domain is knowledge of institutional culture and how it affects health care. 9. The primary care pediatric nurse practitioner prescribes a twice daily inhaled corticosteroid for a 12- Year-old child. At a well-child visit, the child reports not using the medication on a regular basis. Which response by the pediatric nurse practitioner demonstrates an understanding of client- centered? Care? a. Asking the child to describe usual daily routines and schedules b. Referring the family to a social worker to help with medication compliance c. Reviewing the asthma action plan with the parent and the child d. Teaching the child how the medication will help to control asthma symptoms - Correct answer ANS: A In a client-centered relationship, there is reciprocal communication and understanding. The PNP should Be able to understand the client's perspective and unique situation. The first step is to evaluate possible Reasons for no adherence and not to make referrals or re-educate until potential barriers have been Identified and negotiation with the client has occurred. 10. The parents of a special needs child tell the primary care pediatric nurse practitioner that they are Planning a 3-month visit to their home country in Africa. The pediatric nurse practitioner assists the P a g e 10 | 174 Family to obtain a sufficient supply of medications and formula and to make sure that the child's Equipment can be transported and used during the trip and at the destination. This is an example of A. global application. 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 P a g e 11 | 174 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 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 P a g e 12 | 174 This infant lost about 8% of its birth weight, which is normal and, since discharge home, has gained at Least 15 grams per day, which is also normal. The PNP should schedule a weight check in a week to make Sure the infant regains its birth weight, since most should regain this in 10 to 14 days and since this loss of Birth weight is at the high end of normal. It is not necessary to refer to a lactation consultant or Supplement with formula, since the infant is gaining weight adequately. 2. The parent of a newborn infant asks the primary care pediatric nurse practitioner when to intervene to Help the infant's future intellectual growth. What will the nurse practitioner tell the parent? a. Cognitive learning begins during the toddler years. b. Intellectual growth begin when speech develops. c. Language and literacy skills begin at birth. d. Preschool is an optimal time to begin general learning. - Correct answer ANS: C General learning and acquisition of skills for later reading and writing begin at birth, not in kindergarten Or first grade, and these skills grow with everyday loving interactions between infants and caregivers. Cognitive learning changes during toddler years but begins at birth. Intellectual growth is not tied to Speech alone. 3. During an assessment of a 4-week-old infant, the primary care pediatric nurse practitioner learns that a Breastfed infant nurses every 2 hours during the day but is able to sleep for a 4-hour period during the Night. The infant has gained 20 grams per day in the interval since last seen in the clinic. What will the Nurse practitioner recommend? a. Continuing to nurse the infant using the current pattern b. Nursing the infant for longer periods every 4 hours c. Supplementing with formula at the last nighttime feeding d. Waking the infant every 2 hours to nurse during the night - Correct answer ANS: A Infants who are encouraged to breastfeed every 2 to 3 hours may have one longer stretch of 4 hours at Night. This infant is gaining between 0.5 and 1 gram per day, which is appropriate. It is not necessary to Alter the pattern of nursing or to supplement with formula. 4. The mother of a 6-week-old breastfeeding infant tells the primary care pediatric nurse practitioner that Her baby, who previously had bowel movements with each feeding, now has a bowel movement once Every third day. What will the nurse practitioner tell her? a. Her baby is probably constipated. b. It may be related to her dietary intake. c. She should consume more water. d. This may be normal for breastfed babies. - Correct answer ANS: D Infants begin to have fewer bowel movements and may have bowel movements ranging from once or P a g e 15 | 174 Twice daily to once every other day when breastfed. Unless there are other signs, the baby is probably not Constipated. The mother does not need to change her intake of foods or water, unless constipation is Present. 5. The mother of a 3-month-old child tells the primary care pediatric nurse practitioner that it is "so Much fun" now that her infant coos and smiles and wants to play. What is important for the nurse? Practitioner to teach this mother? a. Appropriate ways to stimulate and entertain the infant b. How to read the infant's cues for overstimulation c. The importance of scheduling "play dates" with other infants d. To provide musical toys to engage the infant - Correct answer ANS: B By 3 months, infants demonstrate a social smile and will become more active, alert, and responsive. Parents may mistakenly assume that the infant can handle more activity and stimulation when this occurs, And the PNP should teach caregivers how to recognize infant cues for the need to rest or to have Decreased stimulation. 6. The mother of a 6-month-old infant is distressed because the infant can say "dada" but not "mama" And asks the primary care pediatric nurse practitioner why this is when she is the one who spends More time with the infant. How will the nurse practitioner respond? a. "At this age, your baby does not understand the meaning of sounds." b. "Babies at this age cannot make the 'ma' sound." c. "Most sounds made by babies at this age are accidental." d. "This may mean that your baby doesn't hear well." - Correct answer ANS: A 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 P a g e 16 | 174 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 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. P a g e 17 | 174 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. a. To begin brushing the infant's teeth with toothpaste B. b. To consider weaning the infant from breastfeeding C. c. To discontinue giving fluoride supplements D. 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. 1. 8. During a well-child assessment of an 18-month-old child, the primary care Pediatric nurse practitioner observes the child point to a picture of a dog and say, "Want Puppy!" The nurse practitioner recognizes this as an example of a. a. holophrastic speech. b. b. receptive speech. c. c. semantic speech. d. d. telegraphic speech. - Correct answer ANS: D Syntax, or the structure of words in sentences or phrases, is developed in stages between the Ages of 8 months and 3.5 years. Telegraphic speech begins at about 18 months of age when Children speak in phrases with many words omitted, so that the sentence sounds like a Telegram. Holophrastic speech is the use of a single word to express a complete idea. Receptive speech refers to the ability to understand a word without necessarily being able to Use the word. Semantics is the understanding that words have specific meanings. 1. 9. The primary care pediatric nurse practitioner is evaluating a 2-year-old with a Documented speech delay. Screenings to assess motor skills and cognition are normal, and The child passed a recent hearing test. What will the pediatric nurse practitioner do next? a. a. Ask the child's parents whether they read to the child. b. b. Give parents educational materials to encourage speech. c. c. Refer the child to an early intervention program. d. d. Suggest that they purchase age-appropriate music videos. - Correct answer ANS: A Language development requires oral-motor ability, auditory perception, and cognitive ability, Which this child has been shown to have, as well as the psychosocial-cultural environment to Motivate the child to engage in language use. The PCPNP's initial step should be to determine Whether the parents provide such an environment. Educational materials may be used after it is Determined that these are useful. Early intervention may be used if the speech delay persists. Music videos do not necessarily engage the child in expression of speech. 1. 10. The mother of a 3-year-old child takes the child to a play group once a week. She expresses concern that the child plays with toys but does not interact with the other Toddlers. What will the primary care pediatric nurse practitioner counsel the mother? A. a. The child probably is very shy but will outgrow this tendency with repeated Exposure to other children. B. b. The toddler may have a language delay that interferes with socialization with P a g e 20 | 174 Other children. c. c. Toddlers may be interested in other children but usually do not engage in Interactive play. d. d. Toddlers need more structured play to encourage interaction and socialization With others. - Correct answer ANS: C Parallel play is common among toddlers who, although they may be fascinated by other Children, generally do not engage with peers in an interactive manner. This does not mean that The child is shy or has a language delay, although in preschool years, the development of Symbolic language increases interactive play. Children need both structured and free play, but Structured play will not increase interaction during this normally parallel period. 1. The primary care pediatric nurse practitioner is preparing to conduct a well-child assessment of an 8- Year-old child. How will the nurse practitioner begin the exam? a. Ask the child about school, friends, home activities, and sports b. Discuss the purpose of the visit and explain the procedures that will be performed c. Offer age-appropriate information about usual developmental tasks d. Provide information about healthy nutrition and physical activities - Correct answer ANS: A To build rapport with the child and parent, the PNP will begin by asking direct questions to the child, Encouraging the child to share information about daily routines. The other answers list aspects of the well Child visit that can be introduced after the initial conversation. 2. The primary care pediatric nurse practitioner is examining a 6-year-old child who attends first grade. The child reports "hating" school. The parent states that the child pretends to be sick frequently in Order to stay home from school. To further assess this situation, the nurse practitioner will first ask the Child: A. about school performance and grades. B. why school is so distressing. C. to name one or two friends. D. whether bullying is taking place. - Correct answer ANS: C The earliest school-age psychosocial milestone occurs when children learn to separate easily from family, Allowing them to go to school. Mastery of these skills enables them to develop and maintain peer Friendships. Social interaction skills are necessary in order to develop mastery over school activities. Asking the child to describe why school is distressing may not elicit information, since the child may not Be able to articulate this. Bullying is not the only reason for disliking school, but, if it is, will emerge During a discussion about friends and schoolmates. 3. A school-age child has begun refusing all cooked vegetables. What will the primary care pediatric? Nurse practitioner recommend to the parent? a. Allow the child to make food choices since this is usually a phase b. Ensure that the child has three nutritious meals and two nutritious snacks each day c. Prepare vegetables separately for the child to encourage adequate intake P a g e 21 | 174 d. Teach the child how important it is to eat healthy fruits and vegetables - Correct answer ANS: B Children have food jags that are generally self-limited. The parent's responsibility is to provide three Nutritious meals and two nutritious snacks each day so that all available choices are acceptable. Allowing Food choices may result in an overabundance of non-nutritious foods selected. It is not necessary to Prepare separate dishes for a child who is going through a temporary phase. Teaching the child about Nutrition is important but will not likely have much impact during this phase. 4. The parent of a 6-year-old child expresses concern that the child may have ADHD. Which screening Tool will the primary care pediatric nurse practitioner use to evaluate this possibility? a. Behavioral and Emotional Screening System for Children (BESS-2) b. Behavioral Assessment for Children - 2nd ed. (BASC-2) c. Conner's 3 Parent and Teacher Rating Scale D. Pediatric Symptom Checklist (PSC) - Correct answer ANS: C The Conner's Parent and Teacher Rating Scale is used to assess ADHD symptoms in children aged 6 to 18 years. The BESS-2 is used to evaluate social emotional and mental health in children. The BASC-2 is Used to further assess children who have positive findings on the BESS-2. The PSC is used to assess Cognitive, emotional, and behavioral problems in children. 5. The primary care pediatric nurse practitioner performs a physical examination on a 12- year-old child And notes poor hygiene and inappropriate clothes for the weather. The child's mother appears clean And well dressed. The child reports getting 6 to 7 hours of sleep each night because of texting with Friends late each evening. What action by the nurse practitioner will help promote healthy practices? a. Discuss setting clear expectations about self-care with the mother b. Give the child information about sleep and self-care c. Reassure the mother that this "non-compliance" is temporary d. Tell the mother that experimenting with self-care behaviors is normal - Correct answer ANS: A Parents of school-age children should be advised to set clear limits for their children for cleanliness, 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? P a g e 22 | 174 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. b. Prescribe oral contraceptives pills to regulate her periods. c. Reassure her that this is perfectly normal at her age. d. Refer her to an endocrinologist for hormonal evaluation. - Correct answer ANS: A Although it can take 18 to 24 months for adolescents to establish regulatory cycles, periods can also be Affected by athletic activity that decreases body fat. The PNP should assess the percentage of lean body Mass, which should be 75% or less to maintain regular ovulatory cycles. OCPs are useful for regulating Periods if this persists and other causes are ruled out. It is not necessary to refer her to an endocrinologist Unless problems persist in spite of standard management. 2. The parent of a 14-year-old child tells the primary care pediatric nurse practitioner that the child skips Classes frequently in spite of various disciplinary measures, such as grounding and extra homework And is earning Cs and Ds in most classes. What will the nurse practitioner recommend? a. Counseling for emotional problems P a g e 25 | 174 b. Development of an Individual Education Plan c. Evaluation for possible learning disorders d. Referral for a behavioral disorder - Correct answer ANS: C Frequent school absenteeism, class skipping, and other types of school avoidance may indicate a problem With cognitive ability and should be assessed. When cognitive disorders are ruled out, other issues, such As behavioral and emotional problems may be considered. IEPs are used for children who have identified Special physiological or cognitive needs and may be useful if a cognitive disorder is identified. 3. The primary care pediatric nurse practitioner is performing a well-child exam on a 12-year- old female Who has achieved early sexual maturation? The mother reports that she spends more time with her Older sister's friends instead of her own classmates. What will the nurse practitioner tell this parent? a. Early-maturing girls need to identify with older adolescents to feel a sense of belonging. b. Girls who join an older group of peers may become sexually active at an earlier age. c. Spending time with older adolescents indicates a healthy adjustment to her maturing body. d. The association with older adolescents will help her daughter to gain social maturity. - Correct answer ANS: B While it is true that early maturing females may join an older group of peers to feel that they fit in, the Ones who do put themselves at risk for risky behaviors, including sexual activity. Although many teens Feel awkward when they mature at different rates than their peers, joining a group of older peers Demonstrates a poor adjustment and does not promote social maturity. 4. The primary care pediatric nurse practitioner is performing a well-child assessment on a 13-year-old Female whose mother asks when her daughter's periods may start? Which information will the nurse Practitioner use to help estimate the onset of periods? a. The age of the mother's menarche b. The patient's age at thelarche c. When adrenarche occurred d. Whether linear growth has stopped - Correct answer ANS: B Thelarche, or the development of breast budding, generally precedes menarche by 2.5 years, so this Should be determined when attempting to predict this milestone. The age of the mother at menarche is not A reliable indicator. Adrenarche is related to adrenal and not gonadal development and is less valid than Other secondary sex characteristics in assessing sexual maturation. Rapid linear growth usually begins After thelarche and peaks about a year later but is not used to predict menarche. 5. The mother of a 15-year-old adolescent female tells the primary care pediatric nurse practitioner that Her daughter has extreme mood swings prior to her periods, which the adolescent vehemently denies. P a g e 26 | 174 When asked if she notices anything different just before her periods, the adolescent points to her Mother and says, "She gets really hard to live with." This demonstrates which characteristic of Adolescent thinking? a. Apparent hypocrisy b. Imaginary audience c. Overthinking d. Personal fable - Correct answer ANS: A Apparent hypocrisy is the notion that rules apply differently to adolescents than to others. The adolescent Who chalks up the conflict with her mother related to her premenstrual mood swings does not see her own Role in the conflict. Imaginary audience is the perception that everyone is thinking about them. Personal Fable is the idea that they are special. Overthinking involves making things more complicated than they Need to be. 6. During a well-child assessment of a 13-year-old male, the primary care pediatric nurse practitioner Notes small testicles and pubic and axillary hair. To further evaluate these findings, the nurse Practitioner will ask the patient about A. alcohol and tobacco use. B. changes in voice. C. increase in height and weight. D. participation in sports. - Correct answer ANS: D The initial sign of puberty in males is testicular enlargement. If this does not precede other changes, the PNP should consider whether the boy is taking exogenous anabolic steroids, common among those who Wish to improve athletic ability. These findings are not concerning for alcohol or tobacco use. Voice Changes and rapid growth may occur with pubic hair development, but the primary concern is anabolic Steroid use. 7. The parent of an adolescent reports noting cutting marks on the teen's arms and asks the primary care Pediatric nurse practitioner what it means. What will the nurse practitioner tell this parent? A. Cutting is a way of dealing with emotional distress. b. It is a method of fitting in with other adolescents. c. The behavior is common and will usually stop. d. This type of behavior is a type of suicide attempt. - Correct answer ANS: A Self-injurious behavior (SIB) is used as a coping strategy to relieve distress, anger, and stress. It is not 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. P a g e 27 | 174 The maintenance stage of change, the primary care pediatric nurse practitioner will A. go over with the adolescent about the health risks associated with smoking. B. recommend avoiding friends who smoke and making new friends. C. remind the adolescent about the struggles associated with quitting smoking. 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 P a g e 30 | 174 Behavioral change model is useful for changing behaviors to promote health. The health promotion model Has a focus on health promotion and not disease promotion. The Trans theoretical model identifies the Stages of change. 4. The primary care pediatric nurse practitioner is assessing the health literacy of the parent of a toddler. Which tool will the nurse practitioner use to estimate reading level? a. Flesch-Kincaid Readability Test b. Gunning Fog Index c. Number of children's books in the home d. SMOG - Correct answer ANS: D The best tool to estimate reading level is the SMOG. The Gunning Fog Index and the Flesch-Kincaid Readability Test are used as well but are not considered the best indices. The number of children's books In the home can be asked as a screen but is not a reliable estimate of true literacy. 5. The primary care pediatric nurse practitioner examines an infant whose weight is below the 3rd Percentile and whose mother does not comply with the feeding regimen. When attempting to enlist the Help of the infant's grandmother, the grandmother says, "My daughter was like this when she was a Baby and she turned out all right." Which approach will the nurse practitioner take to improve the Outcome for this infant? a. Ask the grandmother about her daughter's health during childhood. b. Explain that the condition is potentially serious if not treated. c. Give the grandmother and mother information about normal growth. d. Refer the family to a social worker to investigate possible neglect. - Correct answer ANS: A This family has an altered perception of health and health behaviors based on their own experience with The condition. The grandmother considers this infant's weight similar to her own daughter's and assumes That things will resolve. The PNP should evaluate the mother's health to see if any problems occurred. Giving more information or trying to alarm the family will not be effective if their perception is that Everything is normal. It is not necessary to refer to a social worker unless the condition persists. 6. An adolescent who is overweight expresses a desire to lose weight in order to participate in sports but Tells the primary care pediatric nurse practitioner that he doesn't want to give up sweets and soft Drinks because he enjoys them too much. Which stage of change does this represent? a. Action b. Contemplation c. Precontemplation d. Preparation - Correct answer ANS: B The contemplation stage occurs when the individual is aware that a problem exists and struggles with the P a g e 31 | 174 Costs and energy required for change. This client knows what to do but doesn't want to give up the Enjoyment of certain treats. The action phase occurs when behaviors to eliminate the problem occur. The Precontemplation stage occurs when the individual wishes to change but is resistant to change without Clear reason for being so. The preparation stage occurs when the individual makes small behavior Changes, such as giving up sweetened soda first, in preparation for commitment to the actual plan. 7. The primary care pediatric nurse practitioner provides patient teaching for children newly diagnosed With irritable bowel syndrome (IBS). At which stage of development will children be able to? Understand the link between stress and the symptoms of the disease? a. Concrete-operational stage b. Formal-operational stage c. Pre-conceptual stage d. Sensorimotor stage - Correct answer ANS: B In the formal-operational stage, children can understand how the body works and how illness may be Related to the body and the environment. It is late in this stage when children can conceptualize the mind And body interactions of illness. In the concrete-operational stage, children do not yet distinguish between The body and the mind. The pre-conceptual stage is characterized by a perception that people must be near The cause of an illness. The sensorimotor stage, causes are not considered. 8. The primary care pediatric nurse practitioner is counseling an obese 16-year-old client about weight Management. The adolescent says, "I know I need to lose weight, but I don't want to give up all my Favorite foods." When using motivational interviewing techniques, how will the nurse practitioner Respond? a. "Do you think there are any foods you could limit or do without for a while?" b. "I hear you telling me that you really don't have a desire to lose weight." c. "If you can't give up these foods, you won't see the benefits of weight loss." d. "In the long run, the sacrifices you make today will improve your health." - Correct answer ANS: A Motivational interviewing (MI) uses persuasion, rather than coercion, drawing out the individual's Motivation for change in order to build a collaborative partnership between the client and the counselor. This adolescent has indicated an understanding of the need to lose weight but doesn't want to give up Favorite foods. The PNP asks if there are any foods, allowing the client to choose possible options. In Answer B, the PNP does not acknowledge the client's motivations. In the other two answers, the PNP Doesn’t allow choices. 9. The primary care pediatric nurse practitioner is working with a 12-year-old female who has poor P a g e 32 | 174 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 Infection than infant’s breastfed for less time. However, infants who breastfeed exclusively for 9 Months or for longer than 12 months may have increased risks for food hypersensitivities and Atopic dermatitis. Breast milk is a poor source of vitamin D and iron. 1. 5. The primary care pediatric nurse practitioner sees a 3-day-old nursing infant Whose newborn metabolic screen is positive for galactosemia? The nurse practitioner refers The newborn to a specialist for immediate evaluation and will tell the mother a. a. to continue to breastfeed her infant. b. b. to give the infant a cow's milk formula. c. c. to supplement breast milk with formula. d. d. to stop breastfeeding immediately. - Correct answer ANS: D Infants with galactosemia cannot consume GA lactose, which is in both cow's milk and breast Milk. Since there is a potential for a life-threatening response, the mother should be instructed to Stop nursing immediately. 1. 6. The mother of a nursing infant expresses concern about whether high-cholesterol Foods will increase her infant's risk of hyperlipidemia. What will the primary care pediatric? Nurse practitioner tell her? P a g e 35 | 174 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 Associated with pumping and returning to work. The nurse practitioner will provide resources To promote pumping and a. a. discuss adding other foods to the baby's diet. b. b. encourage the mother to increase her fluid intake. c. c. prescribe a multivitamin containing iron. d. d. suggest offering only breast milk to the infant. - Correct answer ANS: A After 6 months, infants should continue to breastfeed while taking other nutrients, at least up to P a g e 36 | 174 1 year of age. The mother should be encouraged to continue breastfeeding while adding other Nutrients. The mother has successfully breastfed up to this point and increasing fluids is not the Source of the problem. 1. 10. The primary care pediatric nurse practitioner is counseling the mother of a Newborn about breastfeeding her infant. Which supplements will the nurse practitioner? Recommend? a. a. Fat-soluble vitamins b. b. Iron c. c. Multivitamins with iron d. d. Vitamin D - Correct answer ANS: D The level of vitamin D in breast milk may not be adequate for breastfed infants, so it should be Given as a supplement. Human milk has more than adequate amounts of other vitamins. Iron is Not present, but this is generally added at 6 months of age, when solid foods are added to the Diet. 1. 11. The primary care pediatric nurse practitioner learns that the mother of a newborn Infant is being tested for tuberculosis after a positive TB skin test. What will the nurse? Practitioner tell the mother who states a desire to breastfeed her baby? a. a. Breast milk is contraindicated if the mother has tuberculosis. B. b. She may continue to nurse her baby since the risk of transmission is low. C. c. That she can express breast milk and feed that to her infant D. d. To give formula until results of tuberculosis testing are known - Correct answer ANS: C A maternal diagnosis of active, untreated TB is a contraindication to nursing, but expressed Breast milk may be fed to the infant. The mother may feed expressed breast milk The milk itself Is not contraindicated. Until active TB is ruled out, the mother should not breastfeed her infant. It Is not necessary to feed formula if the mother can provide expressed breast milk. - Correct answer 1. 12. The mother of a newborn infant asks the primary care pediatric nurse Practitioner about pumping her breasts when she returns to work in 2 months. What will the Nurse practitioner include in teaching this mother? a. a. frozen breast milk may be stored up to 3 months in a 0° F freezer. B. b. Once she begins pumping the infant should drink only pumped breast milk. c. c. Pumped breast milk must be discarded after 3 days when stored in the Refrigerator. d. d. Unused defrosted breast milk may be stored in the refrigerator for 48 hours. - Correct answer ANS: A Frozen breast milk may be stored up to 3 months in a well-regulated freezer. It is not necessary To use only pumped breast milk once this begins. Refrigerated breast milk may be stored up to 8 Days. Once frozen breast milk is thawed it should be used within 24 hours. 3. The primary care pediatric nurse practitioner is evaluating a 4-year-old female child for enuresis. The P a g e 37 | 174 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. 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 an urologist for evaluation d. Treatment with prophylactic antibiotics - Correct answer ANS: C P a g e 40 | 174 If symptomatic vesicoureteral reflux is suspected, the PNP should refer the child to an 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 decompressing has a black box warning Because of a risk of hypernatremia. 1. The primary care pediatric nurse practitioner is performing a well-child exam on a 4- month-old infant 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? P a g e 41 | 174 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, mash able table foods when able to self-feed." d. d. "Infants must be able to grasp and feed themselves from a spoon to do this." - Correct answer ANS: C Baby-led weaning is a concept where infants feed themselves, soft, mash able table foods that They grasp rather than being spoon-fed, allowing the infant more control. Foods given either by Spoon or finger-fed will meet the child's nutritional needs. More research is needed to determine If this method affords protection from obesity by improving self-regulation. Infants must be able To sit without support and to reach and grasp for objects. 1. 3. The parent of a 12-month-old infant asks the primary care pediatric nurse Practitioner why 2% cow's milk is recommended instead of whole milk. What will the nurse? Practitioner tell this parent? a. a. Whole milk is usually not fortified with vitamin D. b. b. 2% milk is higher in essential proteins and minerals. c. c. Young children don't need the extra calories found in whole milk. d. d. Younger children need a limited amount of fats. - Correct answer ANS: D P a g e 42 | 174 Represent nutrients that do not have implications specific to menstruating females or vegans. 1. 10. The primary care pediatric nurse practitioner is examining a toddler who is below The 3rd percentile for weight even though the parents claim that the child eats "constantly." What will the nurse practitioner do initially? a. a. evaluate the child's feeding and elimination behaviors and ask the family to Describe mealtime routines. b. b. Recommend giving a multivitamin and offering high-calorie foods, such as ice Cream. c. c. Refer the child to a feeding evaluation clinic for a swallow study and evaluation Of possible GERD. d. d. Suggest that the parents supplement the child's food intake with a high-calorie Formula. - Correct answer ANS: A When a child doesn't thrive, it is first necessary to evaluate feeding and elimination behaviors And mealtime routines to determine what the child's actual intake is along with the types of Foods that are eaten. Only after the underlying causes are discovered will the PNP prescribe Treatment options. 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 P a g e 45 | 174 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 resynthesize. 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 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 P a g e 46 | 174 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. 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 plyometric and strength training 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. Plyometric 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? P a g e 47 | 174 b. Moderate daily exercise such as walking for 20 minutes daily with increasing intensity as blood Pressure drops c. Vigorous aerobic exercise combined with maximal strength training to lower blood pressure d. Vigorous aerobic exercise only to reduce blood pressure and then to maintain lowered blood Pressure - Correct answer ANS: A Regular to vigorous physical activity for 30 minute 3 days per week helps to lower blood pressure. Resistance training may be combined with aerobic exercise after blood pressure is lowered to help Maintain lowered blood pressure. Strength training is contraindicated in children with hypertension. 13. The primary care pediatric nurse practitioner is discussing fitness and exercise with the parents of a 5- Year-old child who ask what kinds of activities are developmentally appropriate for their child. What Will the nurse practitioner recommend? a. Bike riding b. Interactive play c. Martial arts d. Organized sports - Correct answer ANS: A Bike riding away from traffic or with parents is a good activity for the preschool to early school-age child. Interactive play is recommended for toddlers. Martial arts and organized sports are recommended for School-age children. 14. The parent of a child newly diagnosed with epilepsy asks the primary care pediatric nurse practitioner If the child will ever be able to participate in gym or sports. What will the nurse practitioner? Recommend? a. Bicycle riding is not safe for children with seizures. b. Contact sports should be avoided. c. Direct supervision of some activities is necessary. d. Underwater sports are not recommended. - Correct answer ANS: C Children with epilepsy may participate in most sports but may require direct supervision in some cases to Reduce the risk of injury to self or others if a seizure should occur during sports. Bicycle riding, contact Sports, and underwater sports may be engaged in, but certain precautions must be taken (e.g. Supervision). 15. The primary care pediatric nurse practitioner is examining a 17-year-old male who is on his high School swim team. The adolescent is concerned about "lumps" on his chest. The nurse practitioner Notes a marked increase in weight since the last visit along with worsening of the adolescent's acne. Given this set of symptoms, which performance-enhancing substance will the nurse practitioner be? Most concerned about and ask about? P a g e 50 | 174 A. Creative b. Dehydroepiandrosterone (DHEA) c. Ephedra d. Growth hormone - Correct answer ANS: B DHEA is a prohormone that is converted to either testosterone or stone and will cause adverse changes Similar to anabolic steroids, such as increased weight, gynecomastia, and acne. Creative 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 athlete’s 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? P a g e 51 | 174 a. The child may continue to participate in soccer. b. The child should limit activity to non-aerobic sports. c. This condition is a contraindication for all sports. d. This condition predisposes the child to sudden cardiac death. - Correct answer ANS: A Vocal cord dysfunction causes shortness of breath and must be managed but does not prevent children From participation in sports. It does not indicate underlying cardiac problems and does not mean children Should avoid any sport that may increase heart or respiratory rates. 19. The primary care pediatric nurse practitioner is offering anticipatory guidance to the parents of a 6- Year-old child who has Down syndrome. What will the nurse practitioner tell the parents about? Physical activity and sports in school? a. Children with Down syndrome get frustrated easily when engaging in sports. b. Children with Down syndrome should not participate in strenuous aerobic activity. c. Their child should have a cervical spine evaluation before participation in sports. d. Their child should only participate in sports sanctioned by the Special Olympics. - Correct answer ANS: C Because up to 40% of children with Down syndrome have a hypermobility or instability between C1-C2 And up to 61% have occipito-atlantal hypermobility, they should undergo radiological evaluation of the Cervical spine to be cleared for strenuous sports. Many children and adolescents with intellectual and Developmental disabilities (including those with Down, fragile X, Turner, or Klinefelter syndromes or Autism) are capable of performing exercise or strenuous activities. Special needs children should be Encouraged to participate in sports to increase physical abilities and increase self- confidence. Children With Down syndrome may benefit from strenuous aerobic activity and may participate in any sports once 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 confessional 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. P a g e 52 | 174 To keep a sleep log and will teach the parent that which amount of sleep per day is optimal for this Infant? a. 10 to 12 hours B. 12 to 15 hours C. 15 to 18 hours D. 18 to 20 hours - Correct answer ANS: B Newborns sleep a total of 15 to 18 hours per day. 8. The parent of a school-age child who is overweight tells the primary care pediatric nurse practitioner That the child seems to crave high-calorie, high-carbohydrate foods, even when full. The nurse Practitioner learns that the child is often irritable and sleepy at school in spite of sleeping 9 or 10 Hours each night. What will the nurse practitioner recommend? a. Assessment of lepton and ghrelin hormone levels b. Consultation with a dietician to develop an appropriate diet c. Referral to a sleep disorder clinic for a sleep study d. Taking one or two naps each day to increase the amount of sleep - Correct answer ANS: C Obstructive sleep apnea has been suggested to be a contributing factor to the pathogenesis of obesity by Inducing lepton resistance and increasing ghrelin levels, two hormones that regulate satiety. The child Shows symptoms of these abnormalities by craving high-calorie comfort foods. The child should be Evaluated for this underlying cause. Assessment of these hormone levels is not routinely done. Consultation with a dietician may be necessary at some point but does not get at the underlying problem. Increasing sleep time with naps has not been shown to counteract the obesity effect. 9. The parent of a school-age child tells the primary care pediatric nurse practitioner that the child is Restless most nights and complains often that bugs are in the bed. After consultation with a sleep Disorder specialist and subsequent evaluation of a ferritin level of 30, the nurse practitioner may Expect to treat this child with A. clonazepam. B. ferrous sulfate. C. gabapentin. D. sertraline. - Correct answer ANS: B A ferritin level of less than 50 is associated with periodic limb movements. The treatment for this is Ferrous sulfate 3 mg/kg per day. Clonazepam and gabapentin may be ordered if ferritin levels are normal And other organic causes of PLM have been ruled out. Sertraline may make PLM worse. 10. An adolescent exhibits mild depressive symptoms and tells the primary care pediatric nurse Practitioner that he is most concerned about difficulty falling and staying asleep. The adolescent does P a g e 55 | 174 Not want to take medication to treat the depressive symptoms. What will the nurse practitioner? Recommend? a. A program of sleep hygiene and gradual sleep extension b. A sedative-narcotic will help both sleep and depression c. Cognitive therapy can help the adolescent to sleep better d. Using an antidepressant will improve sleep patterns - Correct answer ANS: A Depression is linked to sleep problems and both predict and are predicted by a diagnostic cluster that Includes ODD, GAD, and depression. One study found that gradual sleep extension combined with sleep Extension advice had a beneficial effect on depressive symptoms of adolescents with chronic sleep Reduction. Sedatives will not affect depression. Cognitive therapy is useful for insomnia related to Anxiety. Antidepressants do not necessarily treat insomnia. 11. The primary care pediatric nurse practitioner is performing a well-child examination on a 4-year-old Child. The parent reports that the child snores frequently, often awakens during the night, and seems Cranky during the day. What will the nurse practitioner tell this parent? a. Most sleep disorders are benign and will be outgrown. b. Sleep disorders are symptomatic of underlying behavior problems. c. Sleep disorders at this age can have long-term impacts on learning. d. The child will need longer daytime naps to compensate for lost sleep. - Correct answer ANS: C Behavioral sleep disorders and sleep-disordered breathing before age 5 can result in increased special Education needs in children by 8 years of age. Sleep disorders are not usually benign or outgrown. Sleep Disorders can result in behavioral difficulties but are not symptomatic of behavioral problems. Sleep- Disordered breathing disrupts all sleep Napping will not produce adequate quality sleep. - Correct answer 12. The parent of a 3-year-old child tells the primary care pediatric nurse practitioner that the child has Never been able to fall asleep without a parent in the room. The child has a new sibling and the parent Is concerned that the toddler's cries will awaken the infant. What will the nurse practitioner counsel? The parent? a. Leaving the room as the child is falling asleep and returning at intervals to check on the child b. Offering a reward for each night the child falls asleep without the parent in the room c. Putting the child to bed at the same time every night and ignoring all sleep interfering behaviors 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 P a g e 56 | 174 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 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. P a g e 57 | 174 which parents and adults love and care for their children. It is not necessary to be explicit but to establish a good history of communication and to explain complex issues to children at a level of the child's understanding. In this way, the child will know that parents are accessible and open to discussion of complex and/or puzzling issues. 9. During a well child examination, a 15-year-old female tells the primary care pediatric nurse practitioner that some of her friends have begun having sex. She has a boyfriend but denies engaging in sex with him. What will the nurse practitioner do initially? a. Ask her for her definitions of "sex." b. Discuss the risks of sexually transmitted diseases. c. Find out if she is considering sexual relations. d. Give her information about contraception. - Correct answer ANS: A Many adolescents do not equate oral or anal intercourse with sex, so it is important to find out how this patient defines sex. The other options also may be considered depending on the situation, however, clarity about the words used in the discussion are most important initially for the nurse practitioner to focus the subsequent conversation appropriately. 1. 1. The mother of a 15-year-old female expresses concerns that her daughter may be sexually active because she's had a steady boyfriend for over a year. The primary care pediatric nurse practitioner learns that the family is Catholic and that the mother had an abortion when she was 16 years old. What will the nurse practitioner do initially? a. a. Explore the mother's feelings about her own past experience. b. b. Offer to prescribe contraception to prevent pregnancy. c. c. Recommend that the mother discuss this with her daughter. d. d. Suggest that the mother talk to a priest about her daughter. - Correct answer ANS: A An initial step when assisting families to manage ethical and behavioral issues is to assist parents and children in values clarification. Before offering other suggestions, the PNP should help the mother to clarify her own feelings. The other options may be necessary after values are clarified. 1. 2. The primary care pediatric nurse practitioner sees a 6-year-old child after a hospitalization for injuries sustained in a motor vehicle accident (MVA) in which the child's grandfather was killed. The parent states that it is difficult to get the child to stop talking about the accident and is worried that the child will have permanent emotional scars. What will the nurse practitioner suggest? a. a. Assure the child that he is safe and this won't happen again. b. b. Encourage the child to express and examine feelings. c. c. Reassure the child that his grandfather is in heaven. d. d. Redirect these conversations to happier topics. - Correct answer ANS: B Management goals when health crises occur should focus on helping children and families make sense of the events and to better understand what is happening to help regain control. Helping the child to express and examine feelings will help him to put what happened in perspective. Assuring the child that accidents won't happen again is false and can lead to even more distress in the future. Telling the child that the grandparent is in heaven doesn't address P a g e 60 | 174 all his fears about the accident. Redirecting the conversation to happier topics minimizes the child's concerns. 1. 3. The primary care pediatric nurse is performing a well child examination on an adolescent who was adopted as a toddler. The parent reports that the child had been removed from an abusive home at age 3 years. What will the nurse practitioner evaluate in light of possible long-term effects of this early situation? a. a. Cognitive and psychosocial development b. b. Mental health and suicide risk c. c. Moral development and conscience formation d. d. Spirituality, faith, and religious affiliation - Correct answer ANS: B Findings of early research suggest that epigenetic changes may mediate the effect of prenatal and infant environment on mental health and disease in older children and adults. Adult suicide victims who were abused as children show decreased levels of a genetic marker of a stress reduction gene, suggesting that child abuse may have an epigenetic effect leading to prolonged stress and mental disorders. 1. 4. During a well child examination of a school-age child from a family who recently immigrated from Africa, the primary care pediatric nurse practitioner learns that the child has been involved in many arguments at school. The parents are concerned that their child will never fit in with classmates. How will the nurse practitioner address this situation? a. a. Assess the conditions in the country of origin prior to immigration. b. b. Recommend counseling to determine underlying causes of this behavior. c. c. Stress that this may be a normal response to feeling different at school. d. d. Suggest that the child may be responding to being bullied by others. - Correct answer ANS: A Many children who exhibit signs of spiritual distress can express this by being angry or withdrawn. Trauma or violence to the self or to others can contribute to spiritual distress. The PNP should evaluate conditions in the country of origin since it is likely that the family may have escaped war or persecution prior to immigration. Once underlying conditions are known, the PNP can recommend options or try to explain the behavior to parents. 1. 5. While the primary care pediatric nurse practitioner is discussing anticipatory guidance with the mother of a 12 month old, the child repeatedly pulls objects out of the mother's purse. Each time, the mother slaps the child's hands as she takes the objects away. What will the nurse practitioner recommend to help the mother manage this child's misbehavior in a developmentally appropriate manner? a. a. Keep her purse up high and out of the child's reach. b. b. Place acceptable objects in her purse for the child to find. c. c. Say "No!" instead of slapping the child's hands. d. d. Use timeout each time the child gets into the purse. - Correct answer ANS: A Parents should provide a developmentally appropriate environment to minimize children's misbehavior. Children at this age who are naturally curious will explore the environment and will seek out objects within their reach. It is easier to put the purse up high than to have to repeatedly say "No." Putting acceptable objects in her purse only reinforces the undesired behavior. 1. The primary care pediatric nurse practitioner is performing an examination on a 2-year-old child who P a g e 61 | 174 has been placed in emergency foster care with a grandparent after the child's mother has been arrested for drug use. The child has a history of asthma with frequent exacerbations because of parental smoking. What is a priority for the nurse practitioner at this visit? a. Evaluation of financial resources, medical insurance, and access to health care and medications b. Providing a list of websites and community-based support groups for grandparents parenting grandchildren c. Referral to a social worker to help the child deal with emotional conflict related to separation from the parent d. Teaching the grandparent about the need for consistency in routines and discipline for the child - Correct answer ANS: A A high percentage of grandparents who parent grandchildren have financial difficulties and most cannot claim grandchildren as dependents for health care. This child has a chronic disease and will need medication and possibly hospitalization, so the PNP should assess resources and access to care. The other options are important but are not a priority in the initial visit. 2. Adolescent children are more likely to smoke cigarettes and drink alcohol if they live with 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. P a g e 62 | 174 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 precedence over the need to evaluate a potential role conflict. Referrals to community health may be necessary if problems arise. 12. The primary care pediatric nurse practitioner is examining a young child who has cerebral palsy. Which part of the family history raises concerns about potential child maltreatment? a. Child attends day care b. Limited financial resources c. Mother works outside the home P a g e 65 | 174 d. No membership in a church - Correct answer ANS: B Limited financial resources can put a strain on caring for a child with special needs whose medical needs are expensive. The fact that the mother works outside the home and the child attends day care may actually provide some respite from the strain of caring for a special needs child. Families may have strong spiritual values whether they attend church or not. 13. The mother of two school-age children tells the primary care pediatric nurse practitioner that she and the children's father are divorcing and asks for advice to help the children cope with the situation. The nurse practitioner will counsel her to a. allow visitation only on weekends. b. maintain her own social life. c. notify the children's teachers. d. use a social support network. - Correct answer ANS: D The availability of a social support system is a key factor in coping with divorce. Visitation patterns should be consistent and collaborative but not necessarily only on certain days. Although the mother should eventually maintain a social life, it is not a key early on to helping children cope with a divorce. Notifying teachers does not necessarily help children to cope. 14. The primary care pediatric nurse practitioner is examining an infant who has otitis media and learns that the mother and child are homeless. Besides assisting the mother to obtain medication to treat this illness, what is a priority during this visit? a. Assisting the mother to obtain transportation for health care needs b. Determining well child examination history and immunization status c. Making sure the family has access to WIC and food stamps resources d. Obtaining a tuberculosis skin test and scheduling a return office visit - Correct answer ANS: B Even if a health care visit is in response to a crisis that cannot be denied, assessment of homeless patients should include well child care and immunizations on the operating principle that every child should receive the maximum health care possible. The other options may be part of ongoing assistance and evaluation of homeless families, but the initial response should be evaluation of well child needs. 15. The primary care pediatric nurse practitioner is discussing newborn care with a mother who is pregnant with triplets. When counseling the mother about feeding issues, the nurse practitioner will recommend a. developing a plan to rotate breastfeeding for her infants. b. making sure that the triplets are on the same feeding schedule. c. pumping her breasts so she can feed breastmilk to all three. d. supplementing with formula to ensure adequate nutrition. - Correct answer ANS: A P a g e 66 | 174 Mothers of multiples can breastfeed their infants. With more than two infants, the mother should develop a rotation schedule. While it is recommended to attempt to get the babies on the same schedules for feeding and sleeping, this is not always possible and not necessary. Infant suckling is the best way to increase milk supply. Supplementation is not recommended unless her milk supply is inadequate. 1. A parent who encourages competitiveness in a child who excels at a single sport but not in others may also encourage a sense of a. competence. b. insecurity. c. significance. d. worthiness. - Correct answer ANS: B Children who gain praise for external measures, such as performance of a sport, may end up unduly comparing themselves with others and feel insecure, inferior, and inadequate, even as they continue to excel in this sport. Competence comes from feeling capable and confident and able to approach new tasks. Significance comes from having a sense of belonging and being accepted unconditionally this child's self-worth is dependent on performance in a sport. Worthiness is based on an understanding of having a purpose in life and is also unconditional. - Correct answer 2. The parent of a 15-year-old male is concerned that he refuses to eat meals with the family and consumes only protein drinks. The adolescent is on the track team at school and spends much of his time training and working out. The primary care pediatric nurse practitioner notes that his weight and BMI have dropped from the 20th percentile to the 3rd percentile in the past year. This child most likely has a problem with a. body image. b. personal identity. c. role performance. d. self-esteem. - Correct answer ANS: A Children with disturbed body image may have concerns related to appearance, body size, function, or potential. Possible behaviors include eating disorders and a preoccupation with the perfect body. Children with body image problems become overly concerned with appearance and compare themselves to others. This child is losing weight and working out too often to try to change his body. Children with personal identity issues internalize negative perceptions of others and manifest feelings of inferiority. Children with role performance problems feel incompetent and are hesitant to try new things or become P a g e 67 | 174 1. During a well child assessment of a preschool-age child, the parent voices concerns that, because the child has behavior problems at school, the child may have a mental health disorder. Which initial approach will provide the best information? a. Ask the parent whether other caregivers have voiced similar concerns. b. Interview the child separately from the parent to encourage sharing of feelings. c. Take time to actively listen to the parent's and child's perceptions of the problem. d. Use a validated screening tool to ensure that all aspects of behaviors are evaluated. - Correct answer ANS: C Providers can get a clearer picture of the situation by taking the time to sit down and actively listen to both the parent's and child's concerns about the issue. It is important to remember that many parents have been trying to cope with the problem for some time, so asking for validation from others may be viewed as belittling. School-age children and adolescents should be interviewed separately to encourage sharing of information. Validated screening tools may be used later, but allowing parents to voice concerns 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. P a g e 70 | 174 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 parent is concerned because the child has recently begun sleeping in the parents' bed. Which initial action by the primary care pediatric nurse practitioner is appropriate? a. Assess for environmental stress, parental dysfunction, and maternal depression. b. Ask about recent traumatic events that may have precipitated this behavior. c. Consider a possible pediatric autoimmune neuropsychiatric disorder cause. d. Recommend firm insistence on school and activity attendance. - Correct answer ANS: A This child shows symptoms of separation anxiety disorder. Environmental stress, parental dysfunction, and maternal depression are risk factors for this disorder. Assessing for traumatic events is necessary if PTSD is suspected. Pediatric autoimmune neuropsychiatric disorder manifests with OCD- and Tourette- like symptoms. If the child does have separation anxiety disorder (SAD), treatment and not discipline is warranted. 6. An adolescent has recently begun doing poorly in school and has stopped participating in sports and other extracurricular activities. During the history interview, the adolescent reports feeling tired, having difficulty concentrating, and experiencing a loss of appetite for the past few weeks but cannot attribute these changes to any major life event. Which is an important next step in managing this patient? a. Administering a diagnostic rating scale for depression b. Considering a short-term trial of an antidepressant medication c. Determining suicidal ideation and risk of suicide d. Referring the adolescent to a mental health specialist - Correct answer ANS: C Because this adolescent exhibits clear signs of depression, the first goals of management are to determine P a g e 71 | 174 suicidal risk and to intervene to prevent suicide since the risk of suicide is greatest during the first 4 weeks of a depressive episode. A diagnostic rating scale may help in diagnosing the depression, but assessing suicide risk is a priority. Antidepressant medications may be useful but are best initiated by a mental health specialist. The initial response in adolescents should be to determine suicide risk to decide whether to admit to inpatient therapy or refer to a mental health specialist. 7. A child has a difficult temperament. What will the primary care pediatric nurse practitioner tell the parent about managing this child's behavior? a. A difficult temperament is its own risk factor for maladjustment disorders. b. Children with difficult temperaments need strict adherence to rules. c. Having a difficult temperament limits intelligence and emotional maturity d. It is important for the parent to learn to manage criticism and power struggles. - Correct answer ANS: D Children with difficult temperaments tend to engender parental criticism and irritability, power struggles, and restrictive parenting, and this dynamic leads to difficulties with psychosocial adjustment. Parents of children with difficult temperaments must be aware of behavioral manifestations as temperament expressions in order to reframe their own responses to these behaviors. A difficult temperament alone is not a risk factor for maladjustment. Restrictive parenting only increases power struggles and maladaptive behaviors. Temperament is unrelated to IQ but does affect academic outcomes because of behavior issues in school. 8. A toddler has begun hitting and biting other children at a day care center and is exhibiting temper tantrums and bad language at home. The parent reports that these behaviors began shortly after a sibling was born. What will the primary care pediatric nurse practitioner do? a. Advise the parent that the child is exhibiting early symptoms of ADHD. b. Engage the parent in positive parenting strategies to facilitate appropriate child coping. c. Recommend evaluating the child for conduct or oppositional defiant disorder. d. Suggest putting the child in another day care center to ameliorate the problems. - Correct answer ANS: B Children with social aggression may exhibit the behaviors described above. When social aggression is a response to acute stress, such as the birth of a sibling, the problem usually resolves if parents use positive parenting strategies and facilitate developmentally appropriate child coping efforts. These are not symptoms of ADHD. Conduct disorder (CD) symptoms usually manifest in the preschool age. Oppositional defiant disorder (ODD) is characterized by disobedience rather than aggressiveness. Moving the child to another day care or school does not solve the problem. P a g e 72 | 174 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 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. P a g e 75 | 174 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 giving two doses per day, so a once daily for 5 days medication is ideal. It is not necessary to give an IM P a g e 76 | 174 injection unless the child refuses to take the medication. Reinforcing the need to adhere to the plan is important but does not address the underlying difficulty associated with scheduling. 2. The primary care pediatric nurse practitioner is considering use of a relatively new drug for a 15- month-old child. The drug is metabolized by the liver, so the nurse practitioner will consult a pharmacologist to discuss giving the drug: a. less often or at a lower dose. b. more often or at a higher dose. c. via a parenteral route. d. via the oral route. - Correct answer ANS: A Infants metabolize drugs more slowly than older children due to decreased levels of oxidases and conjugating enzymes produced in the immature liver, so they may need drugs given less often or at lower doses to avoid toxicity. The route does not necessarily play a role in this case. 3. The parent of a school-age child who has asthma tells the primary care pediatric nurse practitioner that the child often comes home from school with severe wheezing after gym class and needs to use his metered-dose inhaler right away. What will the nurse practitioner do? a. Recommend that the child go to the school nurse when symptoms start. b. Review the child's asthma action plan and possibly increase his steroid dose. c. Suggest asking the school to excuse the child from gym class. d. Write the prescription for two metered-dose inhalers with spacers. - Correct answer ANS: D When children have to take a medication at school or day care, the PNP should dispense two units of the medication so that one can remain at school and one at home to avoid missed doses. The school nurse will not be able to order a medication that the child does not have available. The child is missing his rescue medication and just needs access to his inhaler. It is not necessary to excuse the child from gym class if his symptoms can be controlled. 4. A pharmaceutical company has developed a new drug that was tested only on adults. The FDA has declared this drug to have potential benefits for ill children. According to the Pediatric Research Equity Act (PREA), what may the pharmaceutical company be required to do? a. Conduct pediatric drug studies to determine whether the drug is safe and effective in children. b. Provide labeling stating that the safety and efficacy of the drug is not established for children. c. Receive a patent extension for conducting pediatric studies to determine use in children. d. Survey existing data about the drug to determine potential use in the pediatric population. - Correct answer ANS: A The PREA gives the FDA more leverage over the types of new drugs developed for children and can require pharmaceutical companies to conduct pediatric drug trials if the FDA declares a drug as possibly P a g e 77 | 174 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 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 P a g e 80 | 174 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 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 P a g e 81 | 174 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. 10. A parent is concerned about vaccine adverse reactions. Based on an Institute of Medicine report, what will the primary care pediatric nurse practitioner tell the parent? a. Administering multiple vaccines may trigger the development of type 1 diabetes. b. The MMR may be linked to febrile seizures in immunocompromised children. c. There is some risk of CNS disorders associated with the hepatitis B vaccine. d. Vaccines containing thimerosol are linked to pervasive developmental disorders. - Correct answer ANS: B The IOM report found that febrile seizures and measles inclusion body encephalitis can occur in immunocompromised children. The IOM found no substantiated evidence that multiple vaccines trigger type 1 diabetes, hepatitis B vaccine is associated with increased risk of CNS disorders, or thimerosol- containing vaccines are linked to pervasive developmental disorders. P a g e 82 | 174 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 not indicated. Although it is mostly benign, there can be serious sequelae, especially for pregnant women. P a g e 85 | 174 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 P a g e 86 | 174 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 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 P a g e 87 | 174 during bacterial infections. 33. A 5-year-old child who received VariZIG after exposure to varicella while immunocompromised during chemotherapy is in the clinic 5 months after stopping chemotherapy for kindergarten vaccines. What will the primary care pediatric nurse practitioner order for this child? a. MMR and Tdap b. MMR, Varivax, Tdap c. Tdap only d. Varivax and Tdap - Correct answer ANS: B This child is eligible for all three vaccines. Varivax should be given 5 months after VariZIG, unless varicella disease occurred despite VariZIG administration. 34. A 7-year-old child whose immunizations are up-to-date has a fever, headache, stiff neck, and photophobia. What course of treatment is indicated? a. Empiric treatment with oral antibiotics or intramuscular ceftriaxone b. Hospitalization for diagnosis and treatment with antibiotics c. Immediate vaccination with meningococcal vaccine d. Outpatient lab work, including a CBC and blood and CSF cultures - Correct answer ANS: B Any child suspected of having meningococcal meningitis should be hospitalized immediately with IV 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. P a g e 90 | 174 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 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 P a g e 91 | 174 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. 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. P a g e 92 | 174 a. a. Begin treatment with intravenous methyl prednisone. b. b. Consider IVIG therapy if symptoms persist one more week. c. c. Order a baseline echocardiogram today and another in 2 weeks. d. d. Reassure the child's parents that this is a self-limiting disorder. - Correct answer ANS: C An echocardiogram should be obtained as soon as the diagnosis of Kawasaki disease (KD) is established, as a baseline study, with subsequent studies in 2 weeks and in 6 to 8 weeks. This child has fever and only two other symptoms, which may be consistent with atypical KD. Atypical KD is more common in very young children and in children over 9 years of age, and coronary artery involvement is found more frequently in children with atypical KD. Methyl prednisone is given for children with IVIG-resistant disease. IVIG should be begun ideally in the first 10 days of the illness. Although KD is a self-limiting disorder, the risk of coronary artery involvement is high, so this must be evaluated and treated. 1. 17. The primary care pediatric nurse practitioner is reviewing the rheumatology plan of care for a child who is diagnosed with SLE. Besides reinforcing information about prescribed medications, what will the nurse practitioner teach the family to help minimize flaring of episodes? a. a. Have the child rest between activities. b. b. Obtain regular ophthalmology exams. c. c. Participate in low-impact exercises. d. d. Use UVA and UVB sunscreen daily. - Correct answer ANS: D Sunlight is a known trigger of SLE so patients should be advised to use a UVA and UVB sunscreen both indoors and out. Resting between activities is recommended for children with JIA. Children should participate in low-impact activities, but this does not reduce the number of flares. Ophthalmology exams are recommended for children with JIA. 1. 18. The primary care pediatric nurse practitioner is performing a well-baby checkup on a 6-month-old infant and notes a candida diaper rash and oral thrush. The infant has had two ear infections in the past 2 months and is in the 3rd percentile for weight. What will the nurse practitioner do? a. a. Order a CBC with differential and platelets and quantitative immunoglobulins. b. b. Order candida and pneumococcal skin tests and lymphocyte surface markers. c. c. Refer the infant to an immunologist for evaluation of immunodeficiency. d. d. Refer the infant to an otolaryngologist to evaluate recurrent otitis media. - Correct answer ANS: A Infants with warning signs of immunodeficiency, such as recurrent infections, skin infections, and oral thrush, should be evaluated. The initial step is to order a CBC with differential, platelets, and immunoglobulins. If this is not helpful, referral to an immunologist for further testing, such as candida and pneumococcal skin tests and lymphocyte surface markers, is warranted. Referral to an otolaryngologist is not indicated. 1. 19. An adolescent who has exercise-induced asthma (EIA) is on the high school track team and has recently begun to practice daily during the school week. The adolescent uses 2 puffs of albuterol via a metered-dose inhaler 20 minutes before exercise but reports decreased effectiveness since beginning daily practice. What will the primary care pediatric nurse practitioner do? a. a. Counsel the adolescent to decrease the number of practices each week. b. b. Increase the albuterol to 4 puffs 20 minutes prior to exercise. P a g e 95 | 174 c. c. Order a daily inhaled corticosteroid medication. d. d. Prescribe cromolyn sodium in addition to the albuterol. - Correct answer ANS: C Children with EIA should use 2 puffs of a B2-agonist and/or cromolyn MDI 15 to 30 minutes prior to exercise, but, since tolerance may develop if a B2-agonist is used more than a few times a week, it should not be used as a controller monotherapy. Those who exercise regularly should use an ICS as a controller medication. Patients with asthma should be encouraged to exercise to improve overall health. Increasing the albuterol dose will not overcome the tolerance. And ICS is a preferred controller medication. 1. 20. An adolescent female reports poor sleep, fatigue, muscle and joint paint, and anxiety lasting for several months. The primary care pediatric nurse practitioner notes point tenderness at several sites. What will the nurse practitioner do next? a. a. Evaluate the adolescent's pain using a numeric pain scale. b. b. Obtain ANA, CBC, liver function, and muscle enzymes tests. c. c. Reassure the adolescent that this condition is not life-threatening. d. d. Refer the adolescent to a rheumatologist for further evaluation. - Correct answer ANS: D Children with widespread musculoskeletal pain and painful point tenderness may have fibromyalgia and should be referred. The Widespread Pain Index is used to define the degree of pain. Laboratory studies are of little benefit when diagnosing fibromyalgia. Even though children need reassurance that this disease is not life-threatening, this is not the next action. 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. P a g e 96 | 174 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? 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 P a g e 97 | 174