Burns: Pediatric Primary Care, 6th Edition
Chapter 2: Child and Family Health Assessment
Test Bank
Multiple Choice
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.
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. Ecomap
ANS: A
The three-generation pedigree is used to map out risks for genetic diseases in families, as
well as conditions with modifiable risk factors. The review of systems is used to evaluate
the history of the child’s body systems. The genogram is an approach to developing a
family database to provide a graphic representation of family structure, roles, and
problems of recurring significance in a family. The ecomap is used to identify
relationships in the family and community that are supportive or harmful.
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2
3. The primary care pediatric nurse practitioner is performing a well child check-up on a
20-month-old child. The child was 4 weeks premature and, according to a parentcompleted developmental questionnaire, has achieved milestones for a 15-month-old
infant. Which action is correct?
a. Perform an in-depth developmental assessment screen at this visit to evaluate this
child.
b. Reassure the parent that the child will catch up to normal development by age 2
years.
c. Re-evaluate this child’s development and milestone achievements at the 2-year
visit.
d. Refer the child to a specialty clinic for evaluation and treatment of developmental
delay.
ANS: A
This child should be at a 19-month adjusted age for prematurity so, according to the
parent screen, is 4 months behind. The PNP should perform a more in-depth screen to
evaluate this delay. Waiting to see if the child will “catch up” or assuring the parent that
this will happen will cause the delays to become more severe. A referral to a specialty
clinic should not be made solely on the basis of the parent-completed questionnaire but
only after further evaluation of possible delays.
4. When formulating developmental diagnoses for pediatric patients, the primary care
pediatric nurse practitioner may use which resource?
a. DC: 0-3R
b. ICD-10-CM
c. ICSD-3
d. NANDA International
ANS: A
The DC: 0-3R refers to the Diagnostic Classification of Mental Health and
Developmental Disorders of Infancy and Early Childhood and is useful for
developmental problem diagnosis. The ICD-10-CM is the International Classification of
Diseases-Tenth Revision, Clinical Modification and is useful for identifying physiologic
diseases. The ICSD-3 is the International Classification of Sleep Disorders – 3rd edition.
NANDA International is used to label problems in the functional health domain.
5. The primary care pediatric nurse practitioner is evaluating health literacy in the
mother of a new preschool-age child. How will the nurse practitioner assess this?
a. Ask the child how many books he has at home.
b. Ask the mother about her highest grade in school.
c. Ask the mother to determine the correct dose of a drug from a label.
d. Ask the mother to read a health information handout aloud.
ANS: A
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Test Bank
3
The “newest vital sign,” or health literacy, can be determined quickly by asking the
parent how many children’s books are in the home. Greater than 10 books in the home is
an independent positive predictor of adequate parent health literacy. The other questions
may determine a specific level of literacy in general but are not as efficient.
6. The primary care pediatric nurse practitioner learns that the mother of a 3-year-old
child has been treated for depression for over 5 years. Which aspect of this child’s
development will be of the most concern to the nurse practitioner?
a. Fine motor
b. Gross motor
c. Social/emotional
d. Speech and language
ANS: D
Maternal depression in the first year of life has been associated with poorer language
development at 3 years of age.
7. The primary care pediatric nurse practitioner sees a 3-year-old child who chronically
withholds stools, in spite of the parents’ attempts to stop the behavior, requiring
frequent treatments with laxative medications. Which diagnosis will the nurse
practitioner use to facilitate third-party reimbursement?
a. Altered elimination pattern
b. Elimination disorder
c. Encopresis
d. Parenting alteration
ANS: C
Encopresis is a medical diagnosis, classified in the ICD-10-CM, and is recognized for
reimbursement purposes. “Altered elimination pattern” and “Parenting alteration” are
NANDA International diagnoses and are not recognized for reimbursement. “Elimination
disorder” is a developmental diagnosis.
8. A child is in the clinic for evaluation of an asthma action plan. The primary care
pediatric nurse practitioner notes that the child’s last visit was for a pre-kindergarten
physical and observes that the child is extremely anxious. What will the nurse
practitioner do initially?
a. Ask the child’s parent why the child is so anxious.
b. Perform a physical assessment to rule out shortness of breath.
c. Reassure the child that there is nothing to be afraid of.
d. Review the purpose of this visit and any anticipated procedures.
ANS: D
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Test Bank
4
The PNP should remember that young children are learning “scripts” for health care
visits and may be stressed when recalling previous visits, especially if those involved
immunizations. The PNP should explain the purpose and any anticipated procedures for
this visit to help put the child at ease.
9. When meeting with a new family, the primary care pediatric nurse practitioner
develops a database that identifies family members and others living in the
household, relationships with others outside the household, and significant behavioral
and emotional problems. Which tool will the nurse practitioner use to record this
information?
a. CRAFFT
b. Ecomap
c. Genogram
d. Pedigree
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 ecomap
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
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
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Test Bank
5
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.
ANS: B
Development should be monitored over time and within the context of the child’s overall
well-being, rather than at an isolated testing session. The child has normal development
in observed measures and appears to hear and understand well. By parental report, the
child is able to speak. The PNP should continue to evaluate speech over time, since this
refusal to speak may be associated with shyness or intimidation in the clinic. It is not
necessary to tell the parent that the child has a possible speech delay. Unless an actual
speech delay is observed, a referral is not indicated, nor is it necessary to implement a
home therapy.
12. The primary care pediatric nurse practitioner is performing a well child assessment on
an adolescent and is concerned about possible alcohol and tobacco use. Which
assessment tool will the nurse practitioner use?
a. CRAFFT
b. HEEADSSS
c. PHQ-2
d. RAAPS
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
ANS: D
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Test Bank
6
Because the PNP is planning to intervene by helping the parents to provide appropriate
food habits, the correct diagnosis should be “Parenting alteration.” “Failure to thrive” is a
medical diagnosis and requires a medical and social evaluation to rule out organic causes
or detect neglect. “Home care resources inadequate” would be used if the PNP suspects
that the family lacks adequate funds to purchase food. “Nutrition alteration” is a NANDA
diagnosis and would be used if the PNP planned to consult with a dietician or give
nutritional information.
14. The primary care pediatric nurse practitioner is obtaining a medical history about a
child. To integrate both nursing and medical aspects of primary care, which will be
included in the medical history?
a. Complementary medications, alternative health practices, and chief complaint
b. Developmental delays, nutritional status, and linear growth patterns
c. Medication currently taking, allergy information, and family medical history
d. Speech and language development, beliefs about health, and previous illnesses
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.
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Burns: Pediatric Primary Care, 6th Edition
Chapter 4: Developmental Management in Pediatric Primary Care
Test Bank
Multiple Choice
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.
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.
ANS: D
The child who has mild delays in only one area may be managed initially by having the
parent provide appropriate exercises. If this is not effective, or if delays become more
severe, referrals for evaluation or early intervention services are warranted. A mild delay
does not necessarily signal a serious disorder, so this action is not indicated.
3. The primary care pediatric nurse practitioner sees a developmentally delayed toddler
for an initial visit. The family has just moved to the area and asks the nurse
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Test Bank
2
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.
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.
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.
ANS: B
Discipline involves training or education that molds appropriate behavior and is used to
teach the child what is permitted and encouraged. Providing an appropriate outlet for
drawing helps to teach the child where to use the crayons. Using washable markers
allows the parents to clean the walls but does not teach the child appropriate behaviors.
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Test Bank
3
Timeout and taking away the crayons are forms of punishment, or a loss of privileges,
that are administered as a form of retribution.
6. The primary care pediatric nurse practitioner enters an exam room and finds a 2month-old infant in a car seat on the exam table. The infant’s mother is playing a
game on her smart phone. The nurse practitioner interprets this behavior as :
a. a sign that the mother has postpartum depression.
b. extremely concerning for potential parental neglect.
c. of moderate concern for parenting problems.
d. within the normal range of behavior in early parenthood.
ANS: C
A parent who seems disinterested in a child raises moderate concerns for parenting
problems. It does not necessarily signal postpartum depression. It is not a mark for
extreme concern. It is not within the expected range of behaviors.
7. During a well child assessment of an 18-month-old child, the primary care pediatric
nurse practitioner observes the child becoming irritable and uncooperative. The
parent tells the child to stop fussing. What will the nurse practitioner do?
a. Allow the parent to put the child in a “timeout.”
b. Ask the parent about usual discipline practices.
c. Offer the child a book or a toy to look at.
d. Stop the exam since the child has reached a “meltdown.”
ANS: C
The child has exhibited early signs of misbehavior. At this stage, distraction and active
engagement may be used to stop more problems from occurring. It is not necessary to use
a timeout because the child hasn’t reached the point where cooperation is impossible. The
PNP should model appropriate interventions by offering the child a distraction and may
ask the parent about discipline practices later in the visit. The child is not at a
“meltdown” state.
8. The primary care pediatric nurse practitioner performs a physical examination on a 9month-old infant and notes two central incisors on the lower gums. The parent states
that the infant nurses, takes solid foods three times daily, and occasionally takes water
from a cup. What will the pediatric nurse practitioner counsel the parent to promote
optimum dental health?
a. To begin brushing the infant’s teeth with toothpaste
b. To consider weaning the infant from breastfeeding
c. To discontinue giving fluoride supplements
d. To make an appointment for an initial dental examination
ANS: D
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Test Bank
4
The American Academy of Pediatric Dentistry recommends a first dental examination at
the time of eruption of the first tooth and no later than 12 months old. Parents should be
counseled to clean the infant’s teeth but with water only. Weaning from breastfeeding is
not indicated, although mothers should not let the infant nurse while sleeping to prevent
milk from bathing the teeth. Fluoride supplements should not be discontinued.
9. The primary care pediatric nurse practitioner has a cohort of patients who have
special health care needs. Which is an important role of the nurse practitioner when
caring for these children?
a. Care coordination and collaboration
b. Developing protocols for parents to follow
c. Monitoring individual education plans (IEPs)
d. Providing lists of resources for families
ANS: A
Care coordination is one of the key elements for children with special health care needs.
PNPs are especially suited for this role and have the unique skills to function as care
coordinators. Care for these children should involve shared decision making and
individualized care and not “cookbook” approaches. The PNP may advocate for
children’s health care needs for the IEP but does not monitor these. The PNP should not
just give parents lists of phone numbers but should assist them to make appointments.
10. A single mother of an infant worries that living in a household with only one parent
will cause her child to be maladjusted. To help address the mother’s concerns, the
primary care pediatric nurse practitioner will suggest :
a. developing consistent daily routines for the child.
b. exposing her child to extended family members when possible.
c. not working outside the home during the first few years.
d. taking her child to regular play date activities with other children.
ANS: A
Providers can teach parents that providing predictable, consistent, and loving care helps
an infant to learn trust and help influence positive brain development. Involving extended
family members and going to play dates are good ways to socialize children but are not
essential to learning trust. It may not be possible for her to be a stay-at-home mother.
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Burns: Pediatric Primary Care, 6th Edition
Chapter 5: Developmental Management of Infants
Test Bank
Multiple Choice
1. The primary care pediatric nurse practitioner performs a well baby examination on a
7-day-old infant who is nursing well, according to the mother. The nurse practitioner
notes that the infant weighed 3250 grams at birth and 2990 grams when discharged on
the second day of life. The infant weighs 3080 grams at this visit. Which action is
correct?
a. Follow up at the 2-month checkup.
b. Refer to a lactation consultant.
c. Schedule a weight check in 1 week.
d. Suggest supplementing with formula.
ANS: C
This infant lost about 8% of its birth weight, which is normal and, since discharge home,
has gained at least 15 grams per day, which is also normal. The PNP should schedule a
weight check in a week to make sure the infant regains its birth weight, since most should
regain this in 10 to 14 days and since this loss of birth weight is at the high end of
normal. It is not necessary to refer to a lactation consultant or supplement with formula,
since the infant is gaining weight adequately.
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.
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
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2
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
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.
ANS: D
Infants begin to have fewer bowel movements and may have bowel movements ranging
from once or 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
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.
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3
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.”
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 breastmilk 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.
ANS: C
Infants may have a growth spurt at 6 to 8 weeks, and mothers who are breastfeeding may
be concerned that they are not making enough milk when they notice that the infant is
fussy and wanting to nurse more often. The PNP should reassure the mother that this is
expected. It is not necessary, since the infant is gaining weight appropriately, for the
mother to keep a log. The mother should follow the infant’s cues for feeding since the
extra suckling will increase the milk supply to meet the growing infant’s needs.
8. The primary care pediatric nurse practitioner is performing a well child examination
on a 9-month-old infant whose hearing is normal but who responds to verbal cues
with only single syllable vocalizations. What will the nurse practitioner recommend
to the parents to improve speech and language skills in this infant?
a. Provide educational videos that focus on language.
b. Read simple board books to the infant at bedtime.
c. Sing to the child and play lullabies in the baby’s room.
d. Turn the television to Sesame Street during the day.
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.
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4
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.
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.
ANS: A
When developmental screening indicates an infant is not progressing at the expected rate,
additional testing to determine the degree of delay is necessary. A referral may be needed
if a delay is determined. This is not normal for this degree of prematurity; infants should
develop a pincer grasp by 9 to 10 months of age.
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Burns: Pediatric Primary Care, 6th Edition
Chapter 6: Developmental Management of Early Childhood
Test Bank
Multiple Choice
1. 1. The parent of a 4-year-old points to a picture and says, “That’s your sister.” The child
responds by saying, “No! It’s my baby!” This is an example of which type of thinking in
preschool-age children?
a. a.
Animism
b. b.
Artificialism
c. c.
Egocentrism
d. d.
Realism
ANS: D
Children at this age are developing their ability to establish causality. Nominal realism occurs
when children think that one type of thing can only be called by one name. All dogs are dogs and
not various breeds. Animism refers to the belief that objects possess person-like qualities.
Artificialism occurs when children think things are caused by a controlling force. Egocentrism is
when children see things only as they relate to themselves.
1. 2. The primary care pediatric nurse practitioner performs a developmental assessment on a
32-month-old child. The child’s parent reports that about 70% of the child’s speech is
intelligible. The pediatric nurse practitioner observes that the child has difficulty pronouncing
“t,” “d,” “k,” and “g” sounds. Which action is correct?
a. a.
Evaluate the child’s cognitive abilities.
b. b.
Obtain a hearing evaluation.
c. c.
Reassure the parent that this is normal.
d. d.
Refer the child to a speech therapist.
ANS: C
Intelligibility of speech reaches about 66% between the ages of 24 and 36 months.
Tongue-contact sounds are more intelligible by age 5 years. This child exhibits normal speech
for age. It is not necessary to perform a cognitive assessment based on these findings. Referrals
for hearing and speech evaluations are not indicated, since these findings are within normal
limits.
1. 3. The primary care pediatric nurse practitioner is offering anticipatory guidance to the
parents of a 12-month-old child. The parents are bilingual in Spanish and English and have
many Spanish-speaking relatives nearby. They are resisting exposing the child to Spanish out
of concern that the child will not learn English well. What will the pediatric nurse
practitioner tell the parents?
a. a.
Children who learn two languages simultaneously often confuse them in
conversation.
b. b.
Children with multi-language proficiency do not understand that others cannot do
this.
c. c.
Learning two languages at an early age prevents children from developing a
dominant language.
d. d.
Most bilingual children are able to shift from one language to another when
appropriate.
ANS: D
Most children who are bilingual are able to sort out the languages in conversation but may “code
switch” at times for clarity as they speak. They seem to understand that not everyone has this
ability. Most children who are bilingual develop a dominant language.
1. 4. The parents of a 3-year-old child are concerned that the child has begun refusing usual
foods and wants to eat mashed potatoes and chicken strips at every meal and snack. The
child’s rate of weight has slowed, but the child remains at the same percentile for weight on a
growth chart. What will the primary care pediatric nurse practitioner tell the parents to do?
a. a.
Allow the child to choose foods for meals to improve caloric intake.
b. b.
Place a variety of nutritious foods on the child’s plate at each meal.
c. c.
Prepare mashed potatoes and chicken strips for the child at mealtimes.
d. d.
Suggest cutting out snacks to improve the child’s appetite at mealtimes.
ANS: B
Young children should have three meals and two nutritious snacks each day. The parents’
responsibility is to provide nutritious foods and allow children to choose how much they will eat.
Children who are allowed to choose foods will likely make selections that are not healthy.
Parents should be discouraged from preparing separate meals for their children. Snacks are
necessary to maintain adequate intake and energy.
1. 5. The parent of a 24-month-old child asks the primary care pediatric nurse practitioner
when toilet training should begin. How will the pediatric nurse practitioner respond?
a. a.
“Begin by reading to your child about toileting.”
b. b.
“Most children are capable by age 2 years.”
c. c.
“Tell me about your child’s daily habits.”
d. d.
“We should assess your child’s motor skills.”
ANS: C
To assess the parent’s understanding of toilet readiness, the nurse practitioner will ask the
parents about the child’s daily habits and routines to see if the child has predictable patterns that
can be the basis for toilet training. While providing storybooks about toileting can help children
learn, the first step is to assess toilet readiness. Even though many children are capable at this
age, evaluating personal readiness is key to beginning toilet training. Assessment of motor skills
may be a second step.
1. 6. The primary care pediatric nurse practitioner is counseling the parents of a toddler about
appropriate discipline. The parents report that the child is very active and curious, and they
are worried about the potential for injury. What will the pediatric nurse practitioner
recommend?
a. a.
Allow the child to explore and experiment while providing appropriate limits.
b. b.
Be present while the child plays to continually teach the child what is appropriate.
c. c.
Let the child experiment at will and to make mistakes in order to learn.
d. d.
Say “no” whenever the child does something that is not acceptable.
ANS: A
The child who is securely attached uses the parents as a base from which to safely explore the
world. Toddlers learn by doing and need to experiment to gain mastery over the environment. It
is important that parents are present for safety, but parents should not be ever-present and
controlling. Parents should be close by and should intervene if the child is at risk for injury.
Continual criticism and the use of the word “no” can make the toddler feel powerless.
1. 7. The primary care pediatric nurse practitioner performs a physical examination on a
9-month-old infant and notes two central incisors on the lower gums. The parent states that
the infant nurses, takes solid foods three times daily, and occasionally takes water from 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
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.
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.
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
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.
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.
Burns: Pediatric Primary Care, 6th Edition
Chapter 7: Developmental Management of School-Age Children
Test Bank
Multiple Choice
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
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.
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
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Test Bank
2
c. Prepare vegetables separately for the child to encourage adequate intake
d. Teach the child how important it is to eat healthy fruits and vegetables
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 nonnutritious 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)
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
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.
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Test Bank
3
6. The parents of a 12-year-old child are concerned that some of the child’s older
classmates may be a bad influence on their child, who, they say, has been raised to
believe in right and wrong. What will the primary care pediatric nurse practitioner tell
the parent?
a. Allowing the child to make poor choices and accept consequences is important for
learning values
b. Children at this age have a high regard for authority and social norms, so this is
not likely to happen
c. Moral values instilled in the early school-age period will persist throughout
childhood
d. The pressures from outside influences may supersede parental teachings and
should be confronted
ANS: D
Although early school-age children learn values from their parents, these may be
challenged as children learn that others have different values. Parents must confront and
negotiate these issues daily with their children. While children may make poor choices
and subsequently learn from the consequences, it is best for parents to actively discuss
these issues with their children. Children do have a high regard for authority and social
norms but may easily transfer this authority to other, less reliable people, such as peers.
Moral values may not persist if other sources of authority become prominent.
7. The parent of a 10-year-old boy tells the primary care pediatric nurse practitioner that
the child doesn’t appear to have any interest in girls and spends most of his time with
a couple of other boys. The parent is worried about the child’s sexual identity. The
nurse practitioner will tell the parent
a. children at this age who prefer interactions with same-gender peers usually have a
homosexual orientation.
b. children experiment with sexuality at this age as a means of deciding later sexual
orientation.
c. this attachment to other same-gender children is how the child learns to interact
with others.
d. to encourage mixed-gender interactions in order to promote development of
sexual values.
ANS: C
At age 10, children usually develop an intense same-gender relationship with a peer. This
is how the child learns to expand the self, shares feelings, and learns how others manage
problems. It does not indicate later sexual orientation and is not a characteristic of
experimentation with sexuality. It is not necessary to encourage mixed-gender
interactions.
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Test Bank
4
8. During a well child exam on a 5-year-old child, the primary care pediatric nurse
practitioner assesses the child for school readiness. Which finding may be a factor in
limiting school readiness for this child?
a. Adherence to daily family routines and regular activities
b. Having two older siblings who attend the same school
c. Parental concerns about bullying in the school
d. The child’s ability to recognize four different colors
ANS: C
Parental expectation is the strongest predictor of school success in children. Parents who
are worried about what may happen in school can transmit this anxiety to the child.
Children who have a secure family life with daily routines will do better in school.
Having older siblings who attend school increases success. Children at this age are
expected to know four colors, so this is an indication of school readiness.
9. The primary care pediatric nurse practitioner is evaluating recurrent stomach pain in a
school-age child. The child’s exam is normal. The nurse practitioner learns that the
child reports pain most evenings after school and refuses to participate in sports but
does not have nausea or vomiting. The child’s grandmother recently had gallbladder
surgery. Which action is correct?
a. Encourage the child to keep a log of pain, stool patterns, and dietary intake
b. Order radiologic studies and laboratory tests to rule out systemic causes
c. Reassure the child and encourage resuming sports when symptoms subside
d. Refer the child to a counselor to discuss anxiety about health problems
ANS: A
The PNP suspects a somatic disorder after a normal exam and should encourage the child
to keep a food or pain diary to help manage symptoms. The PNP should not “medicalize”
the problem with tests. The child should be encouraged to resume sports and participate
in normal activities. If the symptoms persist, referral for counseling is warranted.
10. During a well child exam of a school-age child, the primary care pediatric nurse
practitioner learns that the child has been having angry episodes at school. The nurse
practitioner observes the child to appear withdrawn and sad. Which action is
appropriate?
a. Ask the child and the parent about stressors at home
b. Make a referral to a child behavioral specialist
c. Provide information about anger management
d. Suggest consideration of a different classroom
ANS: A
School-age children are learning to manage emotions and need help to manage their
feelings in acceptable ways. A variety of stressors, including parental divorce, substance
abuse, bullying in school, and early responsibilities, can cause anxiety in the child, who
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Test Bank
5
may not manage these feelings well. Until the underlying cause is better understood,
management options cannot be determined, so referrals to specialists, information about
anger management, or moving to a different classroom may not be indicated.
11. The primary care pediatric nurse practitioner is examining a school-age child who
complains of frequent stomach pain and headaches. The parent reports that the child
misses several days of school each month. The child has a normal exam. Before
proceeding with further diagnostic tests, what will the nurse practitioner initially ask
the parent?
a. About the timing of the symptoms each day and during the week
b. How well the child performs in school and in extracurricular activities
c. If the parent feels a strong need to protect the child from problems
d. Whether there are any unusual stressors or circumstances at home
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
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.
Copyright © 2017, Elsevier Limited. All rights reserved.
Burns: Pediatric Primary Care, 6th Edition
Chapter 8: Developmental Management of Adolescents
Test Bank
Multiple Choice
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.
ANS: A
Although it can take 18 to 24 months for adolescents to establish regulatory cycles,
periods can also be affected by athletic activity that decreases body fat. The PNP should
assess the percentage of lean body mass, which should be 75% or less to maintain regular
ovulatory cycles. OCPs are useful for regulating periods if this persists and other causes
are ruled out. It is not necessary to refer her to an endocrinologist unless problems persist
in spite of standard management.
2. The parent of a 14-year-old child tells the primary care pediatric nurse practitioner
that the child skips classes frequently in spite of various disciplinary measures, such
as grounding and extra homework and is earning Cs and Ds in most classes. What
will the nurse practitioner recommend?
a. Counseling for emotional problems
b. Development of an Individual Education Plan
c. Evaluation for possible learning disorders
d. Referral for a behavioral disorder
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 12year-old female who has achieved early sexual maturation. The mother reports that
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Test Bank
2
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.
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
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. 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
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Test Bank
3
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.
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.
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.
8. The parent of a 14-year-old child tells the primary care pediatric nurse practitioner
that the adolescent has expressed a desire to be a vegetarian, is refusing all meat
served at home, and wants the family to eat vegetarian meals. What will the nurse
practitioner tell the parent?
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Test Bank
4
a. Do not allow a vegetarian diet in order to maintain appropriate limits for the
adolescent.
b. Provide vegetarian options for the adolescent that preserve adequate nutrition and
protein intake.
c. Suggest that the adolescent prepare appropriate vegetarian dishes to complement
family meals.
d. Tell the adolescent that a vegetarian diet may be considered in adulthood but not
while living at home.
ANS: C
Early adolescents begin to develop their own value system and may try value systems
other than the one that they have learned from their family, which is a normal part of
establishing personal identity. The parent may allow expression of other values, such as a
vegetarian diet, as long as nutritional needs are met and the adolescent takes
responsibility for preparing the food.
9. The primary care pediatric nurse practitioner is performing an exam on an adolescent
male who asks about sexual identity because of concern that a friend is worried about
being gay. Which response will the nurse practitioner make in this situation?
a. Provide the teen with a questionnaire to gain information about his sexuality.
b. Remind the adolescent that mandatory reporting requires disclosure to parents.
c. Suggest that the adolescent discuss sexual concerns with his parents.
d. Tell the adolescent that, unless he is at risk, what he says will be confidential.
ANS: D
Adolescents should be encouraged to divulge information about their sexuality to
providers by assuring them that confidentiality will be maintained unless the health of the
child or others is at risk. The adolescent may be trying to ask questions about himself in a
manner that doesn’t implicate his own sexuality, so the PNP should attempt to gain his
confidence. Questionnaires may be useful when collecting information, but this
adolescent has already begun a discussion about the topic. An adolescent who is
concerned about being gay may not be ready to come out to his parents.
10. The primary care pediatric nurse practitioner is performing a well child exam on a 17year-old female whose mother is present during the history. The mother expresses
concern that her daughter wishes to have an eyebrow piercing and states that she is
opposed to the idea. What will the nurse practitioner do?
a. Provide information about piercings and encourage continued discussion.
b. Remind the adolescent that her mother is responsible for her health.
c. State that piercings are relatively harmless and are an expression of individuality.
d. Suggest that she wait until she is 18 years old and can make her own decisions.
ANS: A
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Test Bank
5
Adolescents who pierce their noses or have strange haircuts may be irritating to parents,
but these are ways of expressing individuality and help them to achieve psychosocial
milestones. The fact that the teen and her mother are discussing this is a good sign that
the adolescent isn’t in complete rebellion. The PNP should provide accurate health
information and encourage continued dialogue. Although it is true that piercings are
relatively harmless, the PNP shouldn’t “side” with the teen during an open discussion or
tell the teen that the mother is “in charge.”
11. The mother of a 16-year-old male was recently divorced after several years of an
abusive relationship and tells the primary care pediatric nurse practitioner that the
adolescent has begun skipping school and hanging out with friends at the local
shopping mall. When she confronts her child, he responds by saying that he hates her.
What will the nurse practitioner tell this mother?
a. Adolescence is marked by an inability to comprehend complex situations.
b. Adolescence is typically marked by tempestuous and transient episodes.
c. Adolescents normally have extreme, disruptive conflicts with parents.
d. Adolescents often need counseling to help them cope with life events.
ANS: D
Adolescent brains respond differently to toxic stress, so counseling is indicated to help
them manage serious events, such as family abuse and divorce. Early adolescents have
concrete thinking, but the formal operational thinking occurs later. “Storm and stress” are
not the norm in adolescence nor are disruptive periods of conflict.
12. The parent of a 16-year-old tells the primary care pediatric nurse practitioner that the
teen was recently caught smoking an electronic cigarette (e-cigarette). What will the
nurse practitioner tell this parent?
a. E-cigarette use may be a risk factor for later substance abuse.
b. Experimentation with e-cigarettes does not lead to future tobacco use.
c. Most teens who experiment with tobacco usually do not become addicted.
d. This form of nicotine ingestion is safer than regular cigarettes.
ANS: A
Although many adolescents consider e-cigarettes to be a safe form of tobacco use,
increasing evidence indicates that their use may be a significant risk factor for later
marijuana and substance abuse. The risk of dependence and addiction is the same for ecigarettes and other cigarettes, since both use nicotine. Only 41% of teens try tobacco;
80% of older adolescents do not smoke.
Copyright © 2017, Elsevier Limited. All rights reserved.
Burns: Pediatric Primary Care, 6th Edition
Chapter 29: Eye Disorders
Test Bank
Multiple Choice
1. The primary care pediatric nurse practitioner is treating an infant with lacrimal duct
obstruction who has developed bacterial conjunctivitis. After 2 weeks of treatment
with topical antibiotics along with massage and frequent cleansing of secretions, the
infant’s symptoms have not improved. Which action is correct?
a. Perform massage more frequently.
b. Prescribe an oral antibiotic.
c. Recommend hot compresses.
d. Refer to an ophthalmologist.
ANS: D
Infants treated for a secondary bacterial conjunctivitis with lacrimal duct obstruction who
do not improve after 1 to 2 weeks of topical antibiotic therapy must be referred to an
ophthalmologist for possible lacrimal duct probe. Performing the massage more often or
applying hot compresses will not help clear the infections. Oral antibiotics are not
indicated.
2. The primary care pediatric nurse practitioner performs a well child examination on a
9-month-old infant who has a history of prematurity at 28 weeks’ gestation. The
infant was treated for retinopathy of prematurity (ROP) and all symptoms have
resolved. When will the infant need an ophthalmologic exam?
a. At 12 months of age
b. At 24 months of age
c. At 48 months of age
d. At 60 months of age
ANS: A
Children who have a history of ROP requiring treatment, even if ROP has completely
resolved, will need yearly ophthalmologic follow-up. Less frequent follow-up is required
for children with ROP who did not require treatment.
3. A school-age child is hit in the face with a baseball bat and reports pain in one eye.
The primary care pediatric nurse practitioner is able to see a dark red fluid level
between the cornea and iris on gross examination, but the child resists any exam with
a light. Which action is correct?
a. Administer an oral analgesic medication.
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Test Bank
2
b. Apply a Fox shield and reevaluate the eye in 24 hours.
c. Instill anesthetic eyedrops into the affected eye.
d. Refer the child immediately to an ophthalmologist.
ANS: D
This child has a traumatic injury with hyphema to the eye, and an ophthalmologist must
examine the eye to rule out orbital hematoma or retinal detachment. Any further attempt
to examine the child may result in further injury. A Fox shield is used once more serious
injury is excluded.
4. During a well-baby assessment on a 1-week-old infant who had a normal exam when
discharged from the newborn nursery 2 days prior, the primary care pediatric nurse
practitioner notes moderate eyelid swelling, bulbar conjunctival injections, and
moderate amounts of thick, purulent discharge. What is the likely diagnosis?
a. Chemical-induced conjunctivitis
b. Chlamydia trachomatis conjunctivitis
c. Herpes simplex virus (HSV) conjunctivitis
d. Neisseria gonorrhea conjunctivitis
ANS: B
C. trachomatis conjunctivitis usually begins between 5 to 14 days of life and causes
moderate eyelid swelling, palpebral or bulbar conjunctivitis, and moderate, thick,
purulent discharge. Chemical-induced conjunctivitis manifests as nonpurulent discharge.
HSV is characterized by serosanguinous discharge. N. gonorrhea causes acute
conjunctival inflammation and excessive purulent discharge.
5. The primary care pediatric nurse practitioner applies fluorescein stain to a child’s eye.
When examining the eye with a cobalt blue filter light, the entire cornea appears
cloudy. What does this indicate?
a. The cornea has not been damaged.
b. There is too little stain on the cornea.
c. There is damage to the cornea.
d. There is too much stain on the cornea.
ANS: D
When fluorescein stain is applied and the entire cornea appears cloudy, it means that
there is too much of the stain. Damaged areas of the cornea should appear greenish after
staining with fluorescein dye.
6. During a well child assessment of an African-American infant, the primary care
pediatric nurse practitioner notes a dark red-brown light reflex in the left eye and a
slightly brighter, red-orange light reflex in the right eye. The nurse practitioner will
a. dilate the pupils and reassess the red reflex.
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Test Bank
3
b. order auto-refractor screening of the eyes.
c. recheck the red reflex in 1 month.
d. refer the infant to an ophthalmologist.
ANS: D
Any asymmetry, dark or white spots, opacities, or leukokoria should be referred
immediately to a pediatric ophthalmologist. The PNP does not dilate pupils or order autorefractor exams; these are done by an ophthalmologist. Because retinoblastoma is a
concern, any unusual finding should be immediately referred.
7. The primary care pediatric nurse practitioner performs a Hirschberg test to evaluate
a. color vision.
b. ocular alignment.
c. peripheral vision.
d. visual acuity.
ANS: B
The Hirschberg test, or corneal light reflex, assesses ocular mobility and alignment by
looking for symmetry of reflected light. Color vision testing is performed with Richmond
pseudo-isochromatic plates. Peripheral vision is tested by watching the child’s response
to objects as they are moved in and out of the visual fields. Visual acuity is performed
using eye charts or visual-evoked potential readings.
8. The primary care pediatric nurse practitioner performs a well baby assessment of a 5day-old infant and notes mild conjunctivitis, corneal opacity, and serosanguinous
discharge in the right eye. Which course of action is correct?
a. Administer intramuscular ceftriaxone 50 mg/kg.
b. Admit the infant to the hospital immediately.
c. Give oral erythromycin 30 to 50 mg/kg/day for 2 weeks.
d. Teach the parent how to perform tear duct massage.
ANS: B
The infant has symptoms consistent with HPV conjunctivitis and requires hospitalization
for topical and systemic antiviral medications to prevent spread to the central nervous
system, mouth, and skin. IM ceftriaxone is given for gonococcal conjunctivitis. Oral
erythromycin is given for chlamydial conjunctivitis. Tear duct massage is performed for
lacrimal duct obstruction.
9. The primary care pediatric nurse practitioner performs a vision screen on a 4-monthold infant and notes the presence of convergence and accommodation with mild
esotropia of the left eye. What will the nurse practitioner do?
a. Patch the right eye to improve coordination of the left eye.
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Test Bank
4
b. Reassure the parents that the infant will outgrow this.
c. Recheck the infant’s eyes in 2 to 4 weeks.
d. Refer the infant to a pediatric ophthalmologist.
ANS: D
Esotropia that continues or occurs at 3 to 4 months of age is abnormal, so the infant
should be referred to a pediatric ophthalmologist. The PNP does not determine whether
an eye patch should be used. Because it is abnormal at this age, the PNP will not reassure
the parents that the infant will outgrow this. Esotropia after 3 to 4 months of age must be
evaluated by a specialist and not reevaluated in 2 to 4 weeks.
10. A toddler exhibits exotropia of the right eye during a cover-uncover screen. The
primary care pediatric nurse practitioner will refer to a pediatric ophthalmologist to
initiate which treatment?
a. Botulinum toxin injection
b. Corrective lenses
c. Occluding the affected eye for 6 hours per day
d. Patching of the unaffected eye for 2 hours each day
ANS: D
Deviations are initially treated by patching the unaffected eye for 2 hours each day to
force the affected eye to move correctly. Botulinum toxin injection may be used with
some deviations but is not a first-line therapy. Corrective lenses alone improve amblyopia
in 27% of patients. The unaffected eye is patched; 2 hours per day is as effective as 6
hours per day.
11. A preschool-age child is seen in the clinic after waking up a temperature of 102.2°F,
swelling and erythema of the upper lid of one eye, and moderate pain when looking
from side to side. Which course of treatment is correct?
a. Admit to the hospital for intravenous antibiotics.
b. Obtain a lumbar puncture and blood culture.
c. Order warm compresses 4 times daily for 5 days.
d. Prescribe a 10- to 14-day course of oral antibiotics.
ANS: A
This child has periorbital cellulitis and must be hospitalized because of having pain with
movement of the eye, indicating orbital involvement. LP is performed on infants under 1
year of age. Warm compresses are used for mild cases. Oral antibiotics are not indicated.
12. A preschool-age child who attends day care has a 2-day history of matted eyelids in
the morning and burning and itching of the eyes. The primary care pediatric nurse
practitioner notes yellow-green purulent discharge from both eyes, conjunctival
erythema, and mild URI symptoms. Which action is correct?
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Test Bank
a.
b.
c.
d.
5
Culture the conjunctival discharge.
Observe the child for several days.
Order an oral antibiotic medication.
Prescribe topical antibiotic drops.
ANS: D
Young children with bacterial conjunctivitis may be treated with topical antibiotic drops.
Culturing the eyes is not necessary unless there is no improvement. While most cases of
bacterial conjunctivitis are self-limiting, using a topical antibiotic will hasten the return to
day care. Oral antibiotics are not indicated.
13. The primary care pediatric nurse practitioner observes a tender, swollen red furuncle
on the upper lid margin of a child’s eye. What treatment will the nurse practitioner
recommend?
a. Culture of the lesion to determine causative organism
b. Referral to ophthalmology for incision and drainage
c. Topical steroid medication
d. Warm, moist compresses 3 to 4 times daily
ANS: D
The child has symptoms of hordeolum, or stye. Although these often rupture
spontaneously, warm, moist compresses may hasten this process. It is not necessary to
culture the lesion unless symptoms do not resolve. Referral to ophthalmology is made if
the hordeolum does not rupture on its own. Steroids are not indicated.
14. A school-age child is seen in the clinic after a fragment from a glass bottle flew into
the eye. What will the primary care pediatric nurse practitioner do?
a. Refer immediately to an ophthalmologist.
b. Attempt to visualize the glass fragment.
c. Irrigate the eye with sterile saline.
d. Instill a topical anesthetic.
ANS: A
The PNP should never attempt to remove an intraocular foreign body or any projectile
object but should refer immediately to an ophthalmologist. Visualizing the object,
irrigating the eye, or instilling drops may further injure the eye.
15. A 14-year-old child has a 2-week history of severe itching and tearing of both eyes.
The primary care pediatric nurse practitioner notes redness and swelling of the eyelids
along with stringy, mucoid discharge. What will the nurse practitioner prescribe?
a. Saline solution or artificial tears
b. Topical mast cell stabilizer
c. Topical NSAID drops
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6
d. Topical vasoconstrictor drops
ANS: C
This child has symptoms of allergic conjunctivitis. Topical NSAIDs work for acute
symptoms to reduce inflammation and may be used in children over age 12 years. Saline
solution or artificial tears are useful for milder symptoms. Topical mast cell stabilizers
are useful for chronic symptoms and maintenance therapy. Topical vasoconstrictors
should be avoided because of rebound hyperemia.
16. During a well child exam on a 4-year-old child, the primary care pediatric nurse
practitioner notes that the clinic nurse recorded “20/50” for the child’s vision and
noted that the child had difficulty cooperating with the exam. What will the nurse
practitioner recommend?
a. Follow up with a visual acuity screen in 6 months.
b. Refer to a pediatric ophthalmologist.
c. Re-test the child in 1 year.
d. Test the child’s vision in 1 month.
ANS: D
Children age 4 years and older who have difficulty cooperating with a vision screen
should be retested in 1 month; if they continue to have difficulty cooperating, they should
be referred for a formal examination. Children who are 3 years old should be re-evaluated
in 6 months.
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Burns: Pediatric Primary Care, 6th Edition
Chapter 30: Ear Disorders
Test Bank
Multiple Choice
1. A child who has otitis externa has severe swelling of the external auditory canal that
persists after 2 days of therapy with ototopical antibiotic/corticosteroid drops. What is
the next step in treatment for this child?
a. Insert a wick into the external auditory canal.
b. Irrigate the external auditory canal with saline.
c. Order systemic corticosteroids.
d. Prescribe an oral antibiotic medication.
ANS: A
If significant swelling is present, inserting a wick into the EAC is helpful and should be
impregnated with antibiotics as long as it is in place. Irrigation is contraindicated during
an acute infection. Systemic steroids and antibiotics are not indicated.
2. A 7-month-old infant has had two prior acute ear infections and is currently on the
10th day of therapy with amoxicillin-clavulanate after a failed course of amoxicillin.
The primary care pediatric nurse practitioner notes marked middle ear effusion and
erythema of the TM. The child is irritable and has a temperature of 99.8°F. What is
the next step in management of this child’s ear infection?
a. Order a second course of amoxicillin-clavulanate.
b. Perform tympanocentesis for culture.
c. Prescribe clindamycin twice daily.
d. Refer the child to an otolaryngologist.
ANS: D
Children who have persistent infection who have failed appropriate therapy and those
who have had three or more episodes of AOM in 6 months should be referred to an
otolaryngologist. Ceftriaxone is ordered when Augmentin fails. The PNP does not
perform tympanocentesis. Clindamycin is used for ceftriaxone failure but only if the
susceptibilities are known.
3. A school-age child has a history of chronic otitis media and is seen in the clinic with
vertigo. The primary care pediatric nurse practitioner notes profuse purulent otorrhea
from both pressure-equalizing tubes and a pearly-white lesion on one tympanic
membrane. Which condition is most likely?
a. Cholesteatoma
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Test Bank
2
b. Mastoiditis
c. Otitis externa
d. Otitis media with effusion
ANS: A
This child has symptoms of cholesteatoma, especially with a pearly white lesion on the
TM. Mastoiditis involves the mastoid bone behind the ear.
4. A child who was treated with amoxicillin and then amoxicillin-clavulanate for acute
otitis media is seen for follow-up. The primary care pediatric nurse practitioner notes
dull-gray tympanic membranes with a visible air-fluid level. The child is afebrile and
without pain. What is the next course of action?
a. Administering ceftriaxone IM
b. Giving clindamycin orally
c. Monitoring ear fluid levels for 3 months
d. Watchful waiting for 48 to 72 hours
ANS: C
Children with AOM may have effusion up to 3 months after the acute infection. The child
should be monitored to ensure that this resolves. Antibiotics are not indicated. There is no
acute infection, so watchful waiting for worsening of symptoms is not indicated.
5. The primary care pediatric nurse practitioner diagnoses acute otitis media in a 2-yearold child who has a history of three ear infections in the first 6 months of life. The
child’s tympanic membrane is intact and the child has a temperature of 101.5°F. What
will the nurse practitioner prescribe for this child?
a. Amoxicillin twice daily for 10 days
b. An analgesic medication and watchful waiting
c. Antibiotic ear drops and ibuprofen
d. Ceftriaxone given once intramuscularly
ANS: B
This child has no recent history, is over 24 months, and has relatively mild symptoms, so
can be treated by watchful waiting with adequate follow-up and analgesic medication.
Antibiotics are not indicated unless the child worsens or does not improve in 48 to 72
hours.
6. An 18-month-old child with no previous history of otitis media awoke during the
night with right ear pain. The primary care pediatric nurse practitioner notes an
axillary temperature of 100.5°F and an erythematous, bulging tympanic membrane. A
tympanogram reveals of peak of +150 mm H2O. What is the recommended treatment
for this child?
a. Amoxicillin 80 to 90 mg/kg/day in two divided doses
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Test Bank
3
b. An analgesic medication and watchful waiting
c. Ceftriaxone 50 to 75 mg/kg/dose IM given once
d. Ototopical antibiotic drops twice daily for 5 days
ANS: B
This child has no previous history and only has a mild fever and can be managed by
watchful waiting, with parents given instructions about when and why to notify the
provider. Analgesia is essential so that the child can be comfortable. If antibiotics are
indicated as a result of no improvement after 48 to 72 hours, amoxicillin is the first-line
drug. Ceftriaxone is given if the child is vomiting. Topical antibiotics are given when
there is a perforation in the tympanic membrane.
7. What will the primary care pediatric nurse practitioner teach the parents of a child
who has new pressure-equalizing tubes (PET) in both ears?
a. Parents should notice improved hearing in their child.
b. PET will help by reducing the number of ear infections the child has.
c. The child should use earplugs when showering or bathing.
d. The tubes will most likely remain in place for 3 to 4 years.
ANS: A
By reducing middle ear fluid, the child with hearing loss from this condition should show
improvement in hearing. Children may still have infections but without persistent
effusion. Earplugs are not necessary unless the child’s head is submerged. PETs usually
fall out on their own; if they are still in place 2 to 3 years after placement, they should be
removed by the otolaryngology surgeon.
8. The parent of a 4-month-old infant is concerned that the infant cannot hear. Which
test will the primary care pediatric nurse practitioner order to evaluate potential
hearing loss in this infant?
a. Acoustic reflectometry
b. Audiometry
c. Auditory brainstem response (ABR)
d. Evoked otooacoustic emission (EOAE) testing
ANS: C
ABR is not a direct measure of hearing but allows for inferences to be made about
hearing thresholds and is useful for identifying hearing loss in a young infant. Although
sedation is occasionally required, this test is useful in infants and young children unable
to cooperate with EOAE or audiometry. Acoustic reflectometry is used to detect middle
ear effusion. Audiometry requires a cooperative child. EOAE is used for universal
screening in newborns. The American Academy of Pediatrics (AAP) Bright Futures
guidelines (AAP, 2014) recommends pure-tone audiometry at 3, 4, 5, 6, 8, 10, 12, 15, and
18 years of age.
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Test Bank
4
9. A child with a history of otitis externa asks about ways to prevent this condition.
What will the primary care pediatric nurse practitioner recommend?
a. Cleaning ear canals well after swimming
b. Drying the ear canal with a hair dryer
c. Swimming only in chlorinated pools
d. Using cerumenolytic agents daily
ANS: B
Otitis externa is most frequently caused by retained moisture in the ear canal after
swimming and when the protective barriers on the skin break down. Drying the ear canals
with a hair dryer on a low setting helps to remove the moisture. Cleaning the ear canals,
swimming in chlorinated water, and using a cerumenolytic remove the wax that protects
the ear canal from superficial infection.
10. A 3-year-old child has had one episode of acute otitis media 3 weeks prior with a
normal tympanogram just after treatment with amoxicillin. In the clinic today, the
child has a type B tympanogram, a temperature of 102.5°F, and a bulging tympanic
membrane. What will the primary care pediatric nurse practitioner order?
a. A referral for tympanocentesis
b. Amoxicillin twice daily
c. Amoxicillin-clavulanate twice daily
d. Intramuscular ceftriaxone
ANS: C
Amoxicillin-clavulanate should be given for failed therapy with amoxicillin or when the
child has had AOM treated with amoxicillin within the past month.
11. A 3-year-old child with pressure-equalizing tubes (PET) in both ears has otalgia in
one ear. The primary care pediatric nurse practitioner is able to visualize the tube and
does not see exudate in the ear canal and obtains a type A tympanogram. What will
the nurse practitioner do?
a. Order ototopical antibiotic/corticosteroid drops.
b. Prescribe a prophylactic antibiotic medication.
c. Reassure the parent that this is a normal exam.
d. Refer the child to an otolaryngologist for follow-up
ANS: A
A normal, or type A, tympanogram in a child with PET may indicate a clogged tube.
Ototopical antibiotic/corticosteroid drops can occasionally clear a clogged PET.
Prophylactic antibiotics are not recommended to prevent otitis media. It is not necessary
to refer unless the pain continues in spite of standard measures.
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Test Bank
5
12. The primary care pediatric nurse practitioner obtains a tympanogram on a child that
reveals a sharp peak of -180 mm H2O. What does this value indicate?
a. A normal tympanic membrane
b. Middle ear effusion
c. Negative ear pressure
d. Tympanic membrane perforation
ANS: C
The type C tympanogram has a sharp peak between -100 and -200 mm H2O and reflects
negative ear pressure. A normal tympanogram has a sharp positive peak or a type A
tympanogram. Middle ear effusion and a TM perforation both cause a type B
tympanogram with either no peak or a flattened wave.
13. A child complains of itching in both ears and is having trouble hearing. The primary
care pediatric nurse practitioner notes periauricular edema and marked swelling of the
external auditory canal and elicits severe pain when manipulating the external ear
structures. Which is an appropriate intervention?
a. Obtain a culture of the external auditory canal.
b. Order ototopical antibiotic/corticosteroid drops.
c. Prescribe oral amoxicillin-clavulanate.
d. Refer the child to an otolaryngologist.
ANS: B
Ototopical antibiotic/corticosteroid drops are the mainstay of therapy for OE. It is not
necessary to obtain a culture unless the infection does not respond to treatment. Oral
antibiotics are not indicated unless impetigo occurs and is severe. A referral to a
specialist is not recommended.
14. The primary care pediatric nurse practitioner notes a small, round object in a child’s
external auditory canal, near the tympanic membrane. The child’s parent thinks it is
probably a dried pea. What will the nurse practitioner do to remove this object?
a. Irrigate the external auditory canal to flush out the object.
b. Refer the child to an otolaryngologist for removal.
c. Remove the object with a wire loop curette.
d. Use a bayonet forceps to grasp and remove the object.
ANS: B
Spherical objects are the most difficult to remove and should be referred. Irrigation is not
recommended for objects made of organic material and also increases the risk of pushing
the object farther down.
Copyright © 2017, Elsevier Limited. All rights reserved.
Burns: Pediatric Primary Care, 6th Edition
Chapter 36: Gynecologic Disorders
Test Bank
Multiple Choice
1. A 15-year-old female has a positive pregnancy test and asks the primary care
pediatric nurse practitioner not to tell her parents. She is tearful and says she isn’t sure
she wants to keep the baby. What will the nurse practitioner do first?
a. Determine the state-mandated reporting laws.
b. Encourage the adolescent to talk to her parents.
c. Obtain a social work consult to discuss adoption options.
d. Refer her to a prenatal care specialist for follow-up.
ANS: A
The PNP should first determine what the state’s reporting laws are in case there are
mandatory provisions for reporting statutory rape. The other options may be correct,
depending on the laws and on the decisions of the adolescent.
2. An adolescent female has heavy periods that are also irregular. The physical exam is
normal. A complete blood count reveals a hemoglobin of 8.9 g/dL. What test will the
primary care pediatric nurse practitioner order next?
a. Coagulation studies
b. C-reactive protein
c. Thyroid function
d. Ultrasound of pelvis
ANS: A
If the patient’s hemoglobin is low, coagulation studies should be ordered. CRP is ordered
if infection is suspected. Thyroid function is indicated if systemic disease is suspected. A
pelvic ultrasound is ordered if a mass is palpated, anomaly is suspected, bimanual exam
cannot be completed, or if the condition is unresponsive to treatment.
3. A 16-year-old female reports dull, achy cramping pain in her lower abdomen lasting 2
or 3 hours that occurs between her menstrual periods each month. The adolescent is
not sexually active. What is the treatment for this condition?
a. Abdominal ultrasound to rule out ovarian cyst
b. Oral contraceptives to suppress ovulation
c. Prostaglandin inhibitor analgesics and a heating pad
d. Referral to a pediatric gynecologist
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Test Bank
2
ANS: C
The adolescent is experiencing mittelschmerz pain, which is thought to occur when the
follicle ruptures at the time of ovulation. Unless the pain is severe, the adolescent should
be reassured and offered strategies to relieve discomfort, such as a heating pad and
NSAIDs. The pain is intermittent and occurs between periods; if it were persistent and
severe, abdominal US would be indicated. Oral contraceptives are rarely used to suppress
ovulation when symptoms are severe. Referral to a pediatric gynecologist is not
indicated.
4. An adolescent female tells the primary care pediatric nurse practitioner that she had
unprotected sexual intercourse 4 days prior and is worried she might become
pregnant. What will the nurse practitioner do?
a. Prescribe ulipristal acetate (Ella).
b. Recommend levonorgestrel (Plan B One Step).
c. Start a combination OCP at regular doses.
d. Suggest using the less expensive After Pill preparation.
ANS: A
The prescription medication ulipristal can be used up to 5 days after unprotected
intercourse. Levonorgestrel, which is the active ingredient in Plan B and the After Pill,
should be taken within 72 hours of unprotected intercourse. The After Pill must be
purchased online. A combination OCP may be used, but it is an alternative approach.
5. A 17-year-old sexually active female who began having periods at age 14 reports
having moderate to severe dull lower abdominal pain associated predominantly with
periods but that occurs at other times as well. The history reveals a recent onset of
these symptoms. A pregnancy test is negative. Which course of action is most
important?
a. Perform a full diagnostic workup to evaluate potential causes.
b. Prescribe a prostaglandin synthetase inhibitor.
c. Start a 3- to 6-month trial of oral contraceptive pills.
d. Suggest using transcutaneous electrical nerve stimulation.
ANS: A
This adolescent has symptoms consistent with secondary dysmenorrhea and should have
a full diagnostic workup to evaluate potential causes. Prostaglandin synthetase inhibitors,
OCPs, and TENS are useful to treat discomfort, but determining the cause is more
important.
6. A 16-year-old female reports breast tenderness and a “lump.” The primary care
pediatric nurse practitioner palpates a small fluid-filled mass in her right breast. A
pregnancy test is negative. Which action is correct?
a. Obtain a CBC to rule out infection.
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Test Bank
3
b. Order an ultrasound of the mass.
c. Prescribe NSAIDs to treat her discomfort.
d. Reassure her that the findings are normal.
ANS: B
A cyst is usually a fluid-filled mass and should be evaluated by ultrasound to confirm
this. The mass is not warm or consistent with mastitis, so a CBC is not indicated.
NSAIDs may be offered once the diagnosis is confirmed. If the US reveals a cyst,
reassurance can be given.
7. The primary care pediatric nurse practitioner is prescribing contraception for an
adolescent who has not used birth control previously. The adolescent has a normal
exam and has no family history of cardiovascular and peripheral vascular disease or
diabetes. Which preparation is used initially?
a. A combination oral contraceptive pills (OCP) with 30 to 35 mcg of estrogen and
low progestin
b. A combination OCP with low androgenic potency, such as Ortho-Cyclen
c. A progestin-only mini-pill oral contraceptive
d. A subdermal implant contraception, such as Implanon or Nexplanon
ANS: A
The usual initial OCP is a combination with 30 to 35 mcg of estrogen and low progestin
potency. The combination OCP with low androgenic potency is used for adolescents with
hirsutism or PCOS. The progestin-only mini-pill is used in patients for whom progestin is
contraindicated, such as for lactating women, and is not generally used in adolescents
because of irregular bleeding and higher failure rates. The subdermal implants are used in
older adolescents who are committed to long-term contraception.
8. An adolescent female has periods every 30 days that are consistently heavy and last
from 5 to 8 days. What is her diagnosis?
a. Menometrorrhagia
b. Menorrhagia
c. Metrorrhagia
d. Polymenorrhea
ANS: B
Menorrhagia is characterized by normal period intervals with excessive flow or duration
of menses. Menometrorrhagia involves both excessive bleeding and irregular cycles.
Metrorrhagia is irregular frequency with bleeding between cycles. Polymenorrhea is
when there are fewer than 21 days between cycles.
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Test Bank
4
9. A 4-year-old female who has had two urinary tract infections has persistent dysuria
and genital redness. The physical exam reveals a thin, flat membrane from the
posterior fourchette almost to the clitoris. Which treatment is indicated?
a. Application of A&D ointment
b. Counseling about hygiene
c. Reassurance and observation
d. Use of estrogen-containing cream
ANS: D
Estrogen-containing 1% cream should be used when children are symptomatic, especially
when UTI and pain occur. A&D ointment is used for milder symptoms and when the
opening allows drainage. Reassurance, observation, and counseling about hygiene are
indicated when UTI and obstruction do not occur.
10. The primary care pediatric nurse practitioner needs to assess a potential hymenal tear
in a prepubertal female who is apprehensive about the exam. Which approach will the
nurse practitioner use?
a. Have the child sit frog-legged on the parent’s lap.
b. Place the child in the knee-chest position on the exam table.
c. Put the child supine on the exam table with her feet in the stirrups.
d. Refer the child for a speculum exam under sedation.
ANS: B
The knee-chest position is the best position for noninvasive, internal examination of the
vulva and vagina. The frog-leg position does not allow for internal visualization. Putting
the child on the exam table with her feet in the stirrups will increase her anxiety. If an
exam cannot be performed in the office because of the child’s anxiety, sedation may be
indicated, but it is not the first choice.
11. A sexually active adolescent female tests positive for N. gonorrhoeae and C.
trachomatis. She tells the primary care pediatric nurse practitioner that she wants to
be treated today since she is moving out of town the next day. What will the nurse
practitioner order?
a. Azithromycin 1 g PO in a single dose
b. Ceftriaxone 250 mg IM and azithromycin 1 g PO one time each
c. Doxycycline 100 mg PO bid for 7 days
d. Erythromycin base 500 mg PO qid for 7 days
ANS: B
Follow-up cultures for gonorrhea are required unless ceftriaxone is used. Azithromycin is
used to treat both gonorrhea and chlamydia. The other options involve twice daily and
four times daily dosing, which present difficulties with compliance.
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Test Bank
5
12. A 16-year-old sexually active female has a fever, bilateral lower abdominal pain, and
malaise. A speculum and bimanual exam reveals adnexal tenderness. The urinalysis is
normal and cervical cultures are pending. What medications will the primary care
pediatric nurse practitioner prescribe for this patient?
a. Azithromycin, doxycycline, and penicillin
b. Cefotaxime, azithromycin, and penicillin
c. Ceftriaxone, doxycycline, and metronidazole
d. Doxycycline, penicillin, and metronidazole
ANS: C
Patients with suspected PID may be given ceftriaxone 250 mg IM once, doxycycline 100
mg PO bid for 14 days, and metronidazole 500 mg PO bid for 14 days. The other options
are not recommended by the CDC.
13. A 14-year-old female has menometrorrhagia with moderate increase in menstrual
flow and irregular periods. Her hemoglobin is 13.1 g/dL. How will this be managed?
a. Iron supplementation and prostaglandin inhibitors
b. One OCP twice daily for 3 to 4 days and then daily
c. Progestin every day for 10 to 14 days
d. Referral to a pediatric gynecologist for treatment
ANS: A
This patient has mild AUB and may be managed by observation and reassurance along
with iron to prevent anemia and prostaglandin inhibitors to reduce heavy bleeding.
Patients with moderate AUB may be prescribed OCPs or progestins. Referral to a
gynecologist is warranted with severe AUB.
14. A 16-year-old female has not had a menstrual period yet and is concerned. She denies
sexual activity. An exam reveals an adult sexual maturity rating. Which laboratory
test will the primary care pediatric nurse practitioner order initially?
a. Genetic test for Turner syndrome
b. Pituitary hormone tests
c. Pregnancy test
d. Thyroid function tests
ANS: C
When amenorrhea occurs, initial laboratory studies should include a pregnancy test
regardless of sexual history. Other tests are ordered after pregnancy is ruled out.
15. A school-age female has had vulvovaginitis for 2 months. All cultures and tests are
negative, but the symptoms persist after treatment with both topical antibiotics and
oral amoxicillin. What is the next course of action to treat this condition?
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Test Bank
a.
b.
c.
d.
6
Estrogen cream at bedtime for 2 to 3 weeks
Referral to a pediatric gynecologist for further evaluation
Trimethoprim-sulfamethoxazole daily for 1 to 2 months
Workup for possible sexual abuse
ANS: A
If antibiotics fail to treat prepubertal, nonspecific vulvovaginitis, the PNP should order
estrogen cream to thicken the vulvar epithelium. If treatment fails, referral to a pediatric
gynecologist should be made. TMP-SMX is used for recurrent vulvovaginitis. Sexual
abuse is considered if signs of trauma are present or if STI testing is positive.
Copyright © 2017, Elsevier Limited. All rights reserved.
Burns: Pediatric Primary Care, 6th Edition
Chapter 37: Dermatologic Disorders
Test Bank
Multiple Choice
1. A 3-year-old child has head lice. What will the initial treatment recommendation be
to treat this child?
a. Lindane
b. Permethrin
c. Pyrethrin
d. Spinosad
ANS: B
Permethrin is the treatment of choice for head lice because of its safety and efficacy.
Pyrethrin has more treatment failures and is not the first-line treatment. Lindane has
neurotoxic side effects and is only recommended when treatment failure occurs. Spinosad
is used in children 4 years and older.
2. An adolescent has acne with lesions on the cheeks and under the chin. Which
distribution is this?
a. Athletic
b. Frictional
c. Hormonal
d. Pomadal
ANS: C
Hormonal acne has a beard distribution. Athletic acne occurs on the forehead, chin, and
shoulders, caused by helmets and pads. Frictional occurs where bras, tight clothes, and
headbands rub. A pomadal distribution occurs along the temple and forehead, as a result
of pomades or oil-based cosmetics.
3. An infant is brought to clinic with bright erythema in the neck and flexural folds after
recent treatment with antibiotics for otitis media. What is the treatment for this
condition?
a. 1% hydrocortisone cream to affected areas for 1 to 2 days
b. Oral fluconazole 6 mg/kg on day 1, then 3 mg/kg/dose for 14 days
c. Topical keratolytics and topical antibiotics for 7 to 10 days
d. Topical nystatin cream applied several times daily
ANS: D
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Test Bank
2
Candida skin infections can occur in intertriginous areas in the neck, axilla, and groin,
and appear as a bright erythematous rash. Topical nystatin is first-line therapy. Fifteen
percent hydrocortisone is used if inflammation is severe but not instead of topical
antifungal therapy. Oral fluconazole is used if resistant to treatment. Keratolytics and
antibiotics are used to treat superficial folliculitis.
4. A child who has been taking antibiotics is brought to the clinic with a rash. The
parent reports that the child had a fever associated with what looked like sunburn and
now has “blisters” all over. A physical examination shows coalescent target lesions
and widespread bullae and areas of peeled skin revealing moist, red surfaces. What
will the primary care pediatric nurse practitioner do?
a. Consult with a pediatric intensivist for admission to a pediatric intensive care unit.
b. Order oral acyclovir 20 mg/kg/day in two doses for 6 to 12 months.
c. Prescribe systemic antihistamines and antimicrobial medications as prophylaxis.
d. Recommend analgesics, cool compresses, and oral antihistamines for comfort.
ANS: A
This child has symptoms consistent with toxic epidermal necrolysis, which is potentially
life-threatening. Children with symptoms should be admitted to the PICU for
management. The other options are treatments for erythema multiforme, a more benign,
viral-induced rash. Oral acyclovir is given when herpes simplex infection is possible.
5. An adolescent has acne characterized by papules and pustules mostly on the forehead
and chin. What will the primary care pediatric nurse practitioner prescribe?
a. Azelaic acid applied daily at nighttime
b. Benzoyl peroxide applied twice daily
c. Topical erythromycin with benzoyl peroxide
d. Tretinoin applied nightly after washing the face
ANS: C
Topical antibiotics combined with BPO are more effective than either drug alone and are
especially effective in mild to moderate inflammatory acne or as adjunctive therapy with
oral antibiotics. Azelaic acid is useful in persons with sensitive or dark skin and used for
non-inflammatory acne. Topical antibiotics are best used in conjunction with BPO.
Tretinoin is a keratolytic, useful for non-inflammatory acne.
6. During a well child examination of an infant, the primary care pediatric nurse
practitioner notes 10 café au lait spots on the infant’s trunk. What is the potential
concern associated with this finding?
a. Endocrine disorders
b. Malignancy
c. Neurofibromatosis
d. Sturge-Weber syndrome
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Test Bank
3
ANS: C
Café au lait spots are significant for neurofibromatosis and should be referred if more
than 5 lesions are present. Atypical nevi are concerning for malignancy. Port-wine stains
are concerning for Sturge-Weber syndrome. Acanthosis is a sign of diabetes.
7. A child is diagnosed with tinea versicolor. What is the correct management of this
disorder?
a. Application of selenium sulfide 2.5% lotion twice weekly for 2 to 4 weeks
b. Oral antifungal treatment with fluconazole once weekly for 2 to 3 weeks
c. Sun exposure for up to an hour every day for 2 to 4 weeks
d. Using ketoconazole 2% shampoo on lesions twice daily for 2 to 4 weeks
ANS: A
Selenium sulfide lotion or 1% shampoo is first-line treatment for children and younger
adolescents. Oral antifungal medications are used in resistant cases in older adolescents.
Sun exposure only intensifies lesions. Ketoconazole shampoo is used on older
adolescents.
8. An African-American child has recurrent tinea capitis and has just developed a new
area of alopecia after successful treatment several months prior. When prescribing
treatment with griseofulvin and selenium shampoo, what else will the primary care
pediatric nurse practitioner do?
a. Monitor CBC, LFT, and renal function during therapy.
b. Order oral prednisone daily for 5 to 14 days.
c. Perform fungal cultures on family members and pets.
d. Prescribe oral itraconazole or terbinafine.
ANS: C
Because asymptomatic carriers may be present in the household, family members and
pets should be cultured. It is not necessary to monitor lab work with griseofulvin unless
there is a change in clinical status, due to the favorable safety profile of griseofulvin.
Prednisone is used when severe inflammation is present. Oral itraconazole or terbinafine
is used if resistance to griseofulvin occurs; this child has responded to griseofulvin.
9. A 4-year-old child has clusters of small, clear, tense vesicles with an erythematous
base on one side of the mouth along the vermillion border, which are causing
discomfort and difficulty eating. What will the primary care pediatric nurse
practitioner recommend as treatment?
a. Mupirocin ointment applied to lesions 3 times daily
b. Oral acyclovir 20 to 40 mg/kg/dose for 7 to 10 days
c. Topical acyclovir applied to lesions 4 times daily
d. Topical diphenhydramine and magnesium hydroxide
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Test Bank
4
ANS: D
This child has lesions consistent with HSV-1. Topical anesthetics may be used for
comfort and may be applied with cotton-tipped swabs. Mupirocin ointment is used for
secondary bacterial infection. Oral acyclovir is used in more severe cases and most often
with HSV-2. Topical acyclovir is useful for initial genital herpes infections.
10. A school-age child has several annular lesions on the abdomen characterized by
central clearing with scaly, red borders. What is the first step in managing this
condition?
a. Fluoresce the lesions with a Wood’s lamp.
b. Obtain fungal cultures of the lesions.
c. Perform KOH-treated scrapings of the lesion borders.
d. Treat empirically with antifungal cream.
ANS: D
Unless the diagnosis is questionable, or if treatment failure occurs, tinea corporis is
treated empirically with topical antifungal creams; therefore, it is not necessary to
fluoresce the lesions, culture the lesions, or complete KOH testing of scrapings as an
initial management step.
11. A child is brought to clinic with several bright red lesions on the buttocks. The
primary care pediatric nurse practitioner examines the lesions and notes sharp
margins and an “orange peel” look and feel. The child is afebrile and does not appear
toxic. What is the course of treatment for these lesions?
a. Hospitalize the child for intravenous antibiotics and possible I&D of the lesions.
b. Initiate empiric antibiotic therapy and follow up in 24 hours to assess response.
c. Obtain blood cultures prior to beginning antibiotic treatment.
d. Perform gram stain and culture of the lesions before initiating antibiotics.
ANS: B
The child has clinical signs of erysipelas, which is a superficial variant of cellulitis.
Because the child is afebrile and doesn’t appear toxic, outpatient antibiotics with 24-hour
follow-up can be initiated. If the child does not respond or becomes toxic, hospitalization
and IV antibiotics are indicated. Blood cultures rarely are positive. Gram stain and
cultures are performed if unusual organisms are suspected or if pus is present.
12. A child who has psoriasis, who has been using a moderate-potency topical steroid on
thick plaques on the extremities and a high-potency topical steroid on more severe
plaques on the elbows and knees, continues to have worsening of plaques. In
consultation with a dermatologist, which treatment will be added?
a. Anthralin ointment in high strength applied for 10 to 30 minutes daily
b. Calcipotriol cream applied liberally each day to the entire body
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Test Bank
5
c. Oral steroids and methotrexate therapy until plaques resolve
d. Wideband ultraviolet therapy for 15 minutes twice daily
ANS: A
Anthralin ointment is useful for plaques that are resistant to steroids. Calcipotriol cream
is effective for mild to moderate plaques, but when applied in excessive quantities over
large areas can cause hypercalcemia. Oral steroids are not indicated and may worsen
symptoms by causing pustular flare. Methotrexate is used for severe disease, and these
symptoms indicate that this is moderate disease. If UV light is used, narrowband UVB
light therapy is preferred in children for safety and efficacy.
13. The primary care pediatric nurse practitioner notes velvety, brown thickening of skin
in the axillae, groin, and neck folds of an adolescent Hispanic female who is
overweight. What is the initial step in managing this condition?
a. Consultation with a pediatric dermatologist
b. Performing metabolic laboratory tests
c. Prescribing topical retinoic acid cream
d. Referral to a pediatric endocrinologist
ANS: B
The initial step is to determine whether metabolic syndrome is the underlying cause for
these lesions, which, according to the other physical findings, is most likely. If
hyperinsulinemia is present, referral to a pediatric endocrinologist is the next step. A
dermatology referral is not indicated. Unless the lesions are thick or cause discomfort,
prescribing retinoic acid is not necessary.
14. A pre-school age child has honey-crusted lesions on erythematous, eroded skin
around the nose and mouth, with satellite lesions on the arms and legs. The child’s
parent has several similar lesions and reports that other children in the day care have a
similar rash. How will this be treated?
a. Amoxicillin 40 to 5 mg/kg/day for 7 to 10 days
b. Amoxicillin-clavulanate 90 mg/kg/day for 10 days
c. Bacitracin cream applied to lesions for 10 to 14 days
d. Mupirocin ointment applied to lesions until clear
ANS: B
When children have multiple impetigo lesions or non-bullous impetigo with infection in
multiple family members or child care groups, oral antibiotics are indicated. Amoxicillinclavulanate is a first-line drug for this indication. Amoxicillin is not used for skin
infections. Bacitracin is bacteriostatic and may be used when only a few lesions are
present and if bacterial resistance is not an issue. Mupirocin is used for mild impetigo
when the case is isolated.
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Test Bank
6
15. The primary care pediatric nurse practitioner is teaching a parent of a child with dry
skin about hydrating the skin with bathing. What will the nurse practitioner include in
teaching?
a. Apply lubricating agents at least 1 hour after the bath.
b. Have the child soak in a lukewarm water bath.
c. Keep the child in the bath until the skin begins to “prune.”
d. Soaping should be done at the beginning of the bath.
ANS: B
When using bathing to hydrate dry skin, lukewarm water should be used. Lubricating
agents should be applied immediately after patting the skin dry. The bath should last long
enough to allow the skin to become moisturized without becoming supersaturated or
“pruned.” Soaping and shampooing should be performed at the end of the bath followed
by thorough rinsing.
16. A 9-month-old infant has vesiculopustular lesions on the palms and soles, on the face
and neck, and in skin folds of the extremities. The primary care pediatric nurse
practitioner notes linear and S-shaped burrow lesions on the parent’s hands and
wrists. What is the treatment for this rash for this infant?
a. Ivermectin 200 mcg/kg for 7 to 14 days, along with symptomatic treatment for
itching
b. Permethrin 5% cream applied to face, neck, and body and rinsed off in 8 to 14
hours
c. Treatment of all family members except the infant with permethrin 5% cream and
ivermectin
d. Treatment with permethrin 5% cream for 7 days in conjunction with ivermectin
200 mcg/kg
ANS: B
Permethrin 5% cream is the drug of choice for treating scabies and is intended for use in
infants as young as 2 months of age. Infants will get lesions on the face and neck, and
permethrin may be applied to the face, avoiding the eyes. Ivermectin is not recommended
for children under 5 years old. Treatment must include the infant as well as all family
members whether symptomatic or not.
17. An adolescent female has grouped vesicles on her oral mucosa. To determine whether
these are caused by HSV-1 or HSV-2, the primary care pediatric nurse practitioner
will order which test?
a. Direct fluorescent antibody test
b. Enzyme-linked immunosorbent assay
c. Tzanck smear
d. Viral culture
ANS: D
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Test Bank
7
Oral lesions are possible with both forms of herpesvirus. Viral culture is the gold
standard for distinguishing HSV-1 from HSV-2. DFA and ELISA are usually used only
with severe forms of infection. Tzanck smear dose not distinguish HSV-1 from HSV-2.
18. A school-age child has a rash without fever or preceding symptoms. Physical
examination reveals a 3-cm ovoid, erythematous lesion on the trunk with a finely
scaled elevated border, along with generalized macular, ovoid lesions appearing in a
“Christmas tree” pattern on the child’s back. What is the initial action?
a. Obtain a KOH preparation of a skin scraping to verify the diagnosis.
b. Prescribe topical steroid creams to shorten the course of the disease.
c. Reassure the child’s parents that the rash is benign and self-limited.
d. Recommend topical antihistamines and emollients to control the spread.
ANS: C
This rash is typical of pityriasis rosea, a benign, self-limited papulosquamous disease that
is not contagious. Patients may be reassured that this is the case. Because the herald
lesion is characteristic, it is not necessary to obtain a KOH scraping to look for tinea
corporis. Topical steroids do not alter the course of the disease. Topical antihistamines
and emollients may be used if itching occurs, but this is not the initial management
action.
19. An adolescent who recently spent time in a hot tub while on vacation has discrete,
erythematous 1- to 2-mm papules that are centered around hair follicles on the thighs,
upper arms, and buttocks. How will the primary care pediatric nurse practitioner
manage this condition?
a. Culture the lesions and treat with appropriate IM antibiotics.
b. Hospitalize for incision and drainage and intravenous antibiotics.
c. Order an antistaphylococcal beta-lactamase-resistant antibiotic.
d. Prescribe topical keratolytics and topical antibiotics.
ANS: D
This adolescent has hot-tub folliculitis that is superficial at this point and may be treated
with topical keratolytics and topical antibiotics. Culture is indicated if the lesions are
resistant to treatment. IV and oral antibiotics and I&D are indicated for more severe
episodes.
20. When prescribing topical glucocorticoids to treat inflammatory skin conditions, the
primary care pediatric nurse practitioner will
a. initiate therapy with a high-potency glucocorticoid.
b. order lotions when higher potency is necessary.
c. prescribe brand-name preparations for consistent effects.
d. use fluorinated steroids to minimize adverse effects.
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Test Bank
8
ANS: C
Brand-name preparations often have a more consistent base and potency. PNPs should be
familiar with a few high-, medium-, and low-potency products and use those consistently.
Therapy should be initiated with the lowest possible potency. Lotions have a lower
potency than ointments and creams. Fluorinated steroids have the highest potency and a
higher risk of side effects
21. A child has several circular, scaly lesions on the arms and abdomen, some of which
have central clearing. The primary care pediatric nurse practitioner notes a smaller,
scaly lesion on the child’s scalp. How will the nurse practitioner treat this child?
a. Obtain scrapings of the lesions for fungal cultures.
b. Order prescription-strength antifungal creams.
c. Prescribe oral griseofulvin for 2 to 4 weeks.
d. Recommend OTC antifungal creams and shampoos.
ANS: C
Whenever tinea lesions occur on the scalp or nails, oral griseofulvin must be given for 2
to 4 weeks. Unless the infection is resistant to treatment, fungal cultures are not
necessary. Topical medications alone are not effective for tinea capitus.
22. A child will need an occlusive dressing to treat lichen simplex chronicus. What will
the primary care pediatric nurse practitioner tell the parents about applying this
treatment?
a. Apply ointment before the dressing.
b. Plastic wrap should not be used.
c. The dressing should be applied to dry skin.
d. Change the dressing twice daily.
ANS: A
Occlusive dressings are placed over creams and ointments to enhance hydration and
absorption of topical medications. Plastic wrap is often used. The medications and
dressings should be applied to damp skin. The dressing should not be left on more than 8
hours.
23. A previously healthy school-age child develops herpes zoster on the lower back.
What will the primary care pediatric nurse practitioner do to manage this condition?
a. Order Burow solution and warm soothing baths as comfort measures.
b. Prescribe oral acyclovir 30 mg/kg/day in 4 doses/day for 5 days.
c. Recommend topical antihistamines to control itching.
d. Stress the need to remain home from school until the lesions are gone.
ANS: A
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Test Bank
9
Children with herpes zoster should be treated with comfort measures (symptomatic
treatment). Oral acyclovir is not recommended for all children but may be useful in
children who are immunosuppressed or have more severe forms. Topical antihistamines
are used with caution in children because of the risk of toxicity. If the lesions can be
covered, children do not need to be kept home from school.
24. A child has small, firm, flesh-colored papules in both axillae which are mildly
pruritic. What is an acceptable initial approach to managing this condition?
a. Application of trichloroacetic acid 25% to 50% using a dropper
b. Applying liquid nitrogen for 2 to 3 seconds to each lesion
c. Reassuring the parents that these are benign and may disappear spontaneously
d. Referral to a dermatologist for manual removal of lesions with curettage
ANS: C
Molluscum contagiosum is a benign viral skin infection; most lesions disappear within 6
months to 2 years. An initial “wait and see” approach is acceptable. If itching is severe,
the risk is autoinoculation and spread of lesions, along with increased discomfort and
then other treatment measures may be attempted, depending on the severity. Topical
medications, such as trichloroacetic acid or liquid nitrogen may be used if the lesions
become uncomfortable or persist and should be used with caution. More severe outbreaks
may require removal with curettage.
25. A child is brought to the clinic with a generalized, annular rash characterized by
raised wheals with pale centers. On physical examination, the child’s lungs are clear
and there is no peripheral edema. A history reveals ingestion of strawberries earlier in
the day. What is the initial treatment?
a. Aqueous epinephrine 1:1000 subcutaneously
b. Cetirizine once in clinic and then once daily for 2 weeks
c. Diphenhydramine 0.5 to 1 mg/kg/dose every 4 to 6 hours
d. Prednisone 1 to 2 mg/kg/day for 1 week with rapid taper
ANS: C
Diphenhydramine is given initially as long as anaphylaxis and angioedema are not
present. Aqueous epinephrine is used for anaphylaxis and angioedema. Cetirizine is less
effective than diphenhydramine. Prednisone is used for refractory episodes.
26. A child has an area of inflammation on the neck that began after wearing a hand-knot
woolen sweater. On examination, the skin appears chafed with mild erythematous
patches. The lesions are not pruritic. What is an appropriate initial treatment?
a. Application of a lanolin-based emollient
b. Burow solution soaks and cool compresses
c. Oral antihistamines given 4 times daily
d. Topical corticosteroids applied 2 to 3 times daily
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Test Bank
10
ANS: D
Topical corticosteroids are useful for contact dermatitis. Lanolin-based emollients are
contraindicated when inflammation is present. Burow solution soaks are useful for
vesicular rashes. Oral antihistamines are not indicated unless itching and scratching
occur.
27. An adolescent who had cradle cap as an infant is in the clinic with thick crusts of
yellow, greasy scales on the forehead and behind the ears. What will the primary care
pediatric nurse practitioner recommend?
a. Daily application of ketoconazole 2% topical cream
b. High-potency topical corticosteroids applied daily
c. Mineral oil and shampoo on the affected areas
d. Selenium sulfide shampoo twice weekly to the face
ANS: A
For facial dermatitis, daily ketoconazole 2% topical cream may be used. If steroids are
prescribed, only low-dose steroids should be used on the face. Mineral oil and shampoo
are recommended for cradle cap in infants. Selenium sulfide shampoo is used for scalp
dermatitis.
28. A school-age child is brought to clinic after a pediculosis capitis infestation is
reported at the child’s school. If this child is positive, what will the primary care
pediatric nurse practitioner expect to find on physical examination, along with live
lice near the scalp?
a. Excoriated macules along the child’s collar and underwear lines
b. Inflammation and pustules on the face and neck
c. Itching of the scalp, with skin excoriation on the back of the head
d. Linear or S-shaped lesions in webs of fingers and sides of hands
ANS: C
Head lice commonly cause itching of the scalp, especially on the back of the head and
neck, along with skin excoriation, and may be the only initial sign. Excoriated lesions
along underwear lines are typical of body lice. Inflammation and pustules occur with
acne. Linear or S-shaped lesions occur with scabies infestations.
Copyright © 2017, Elsevier Limited. All rights reserved.
Burns: Pediatric Primary Care, 6th Edition
Chapter 13: Physical Activity and Sports for Children and Adolescents
Test Bank
Multiple Choice
1. The primary care pediatric nurse practitioner is performing a pre-participation sports
physical examination on a 14-year-old male who will be on the wrestling team at
school. What will the nurse practitioner include when discussing healthy practices
with this adolescent?
a. Risks associated with repeatedly losing and gaining weight
b. The need for an electrocardiogram or echocardiogram prior to participation
c. The need to consume 20 to 30 grams of protein after exercise
d. To consume water with CHO prior to activity lasting up to an hour
ANS: A
Wrestlers often try to lose weight rapidly prior to wrestling matches to put themselves
into a lower weight category. It is important to teach young athletes about the risks
associated with repeated weight loss and gain. ECG and echocardiograms are not
recommended as a requirement for all pre-participation physical exams unless there is an
indication for doing so, such as with syncope or murmurs. Athletes do not need to
consume 10 to 20 grams of protein after exercise; complex carbohydrates are
recommended to improve muscle glycogen resynthesis. Plain water is recommended
before, during, and after all activity lasting up to an hour.
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.
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.
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Test Bank
2
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
ANS: B
Fixed weights or resistance bands are recommended for pre-pubertal youth to help
prevent injury. Strength training prior to menarche helps to strengthen long bones and is
considered beneficial. Weight training should be 2 to 3 times weekly with a day in
between sessions. Initially, youth should begin with a low number of sets and low
intensity.
4. The parent of a 14-year-old child asks the primary care pediatric nurse practitioner
how to help the child prevent injuries when basketball tryouts begin later in the
school year. Which recommendation will be of most benefit?
a. Preseason conditioning
b. Proper footwear
c. Protective knee braces
d. Stretching before practices
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
ANS: C
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Test Bank
3
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 plyometrics and strength trainin
c. To consider a different sport, such as volleyball
d. To work with a dietician to improve healthy weight gain
ANS: D
Female athletes who have amenorrhea have an increased risk of stress fractures. The
adolescent should work to attain a healthy weight, which should allow normal periods to
return and reduce this risk. Even though amenorrhea in female athletes is common, it is
concerning. Plyometrics and volleyball can increase the risk of stress fractures since both
involve jumping and thus not be suggested.
7. The parent of a child who has asthma asks the primary care pediatric nurse
practitioner about whether the child may engage in strenuous exercise. What will the
nurse practitioner tell the parent?
a. Children with asthma should be excluded from vigorous exercise and most
strenuous sports.
b. Children with asthma show improved aerobic and anaerobic fitness with moderate
to vigorous/physical activity.
c. Physical activity has been shown to improve overall pulmonary function in
children with asthma.
d. Vigorous exercise helps improve symptoms in children with poorly controlled
asthma.
ANS: B
Children with mild or well-controlled asthma may participate in moderate to vigorous
sports and show benefits to aerobic and anaerobic fitness, which helps lung function and
overall health outcomes. It is not necessary to exclude children with asthma from sports
as long as symptoms are well controlled. Overall pulmonary function does not
substantially improve with exercise. Children with poor control should not engage in
sports until symptoms are under control.
8. The primary care pediatric nurse practitioner diagnoses a high school basketball
player with mononucleosis. The adolescent asks when she may resume play. What
will the nurse practitioner tell her?
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Test Bank
a.
b.
c.
d.
4
After 3 weeks, she may begin lifting weights but not full sports.
After 4 weeks, she may return to full play and practice.
At 4 weeks, she must have an exam to determine fitness for play.
She may engage in moderate exertion and practice after 3 weeks.
ANS: C
Full return to play should be determined on a case-by-case basis and is generally
considered safe at 4 weeks after symptom onset, assuming physical stamina has returned,
all symptoms have resolved, and the sport does not increase intraabdominal pressure
during play. Athletes should avoid any form of exertion, including all sports during the
first 3 weeks at a minimum and should avoid anything with a risk of chest or abdominal
contact or anything that involves increased intra-abdominal pressure. Splenic rupture can
occur spontaneously (rare), but the risk of rupture increases when participating in a
contact or collision sport or a sport in which there is an increase in intraabdominal
pressure. The nurse practitioner should recommend an exam at 4 weeks to determine
fitness for play.
9. The primary care pediatric nurse practitioner is counseling a parent about bicycle
helmet use. The parent reports having a helmet used a year previously by an older
child and wonders about using it for a younger child since they are so expensive.
What will the nurse practitioner tell the parent?
a. “As long as the helmet does not have cracks, you may use it.”
b. “If the helmet is free from marks, you may use it.”
c. “You may continue to use a helmet up to 10 years.”
d. “You should always purchase a new helmet for each child.”
ANS: B
While parents should be taught not to purchase a secondhand helmet, using a fairly new,
undamaged helmet from an older child is acceptable. Any helmet that has marks should
be discarded, even if not cracked. Helmets should be replaced every 5 years or sooner,
depending on the manufacturer’s recommendations. It is not necessary to purchase a new
helmet for each child, especially if money is an issue.
10. The primary care pediatric nurse practitioner is performing a well child examination
on a high school age adolescent who plays football who has hypercalciuria. Which
dietary supplement will the nurse practitioner question the adolescent about?
a. Protein supplements
b. Salt tablets
c. Sports drinks
d. Vitamin C
ANS: A
Protein supplements can cause hypercalciuria with calcium loss and dehydration if
protein intake is too high. Salt tablets can cause hypernatremia and delayed gastric
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5
emptying. Sports drinks are high in sugar and electrolytes, which will not affect the
calcium content of the urine. It is not necessary to take vitamin C.
11. The primary care pediatric nurse practitioner is evaluating a heart murmur during a
pre-participation examination of a high school athlete. Which finding would be a
concern requiring referral to a cardiologist?
a. A murmur that is louder when squatting and softer when standing
b. A murmur that is quieter when squatting and louder with a Valsalva maneuver
c. A murmur with narrow and variable splitting of S2
d. A systolic murmur that is grade 1 or 2
ANS: B
Normally, squatting will increase venous return to the heart and cause murmurs to be
louder, while standing or performing a Valsalva maneuver will cause murmurs to be
quieter. If the reverse is true, then hypertrophic cardiomyopathy or mitral valve prolapse
must be ruled out. A murmur with a wide or fixed splitting of S2 must be evaluated. A
split S2 that is variable, particularly in synchrony with respirations, is common, and a
narrow S2 split is of less concern but should be monitored over time. Systolic murmurs of
grade 3 or greater must be evaluated by specialists; however, murmurs of grades 1 and 2
do not need to be evaluated by a cardiologist.
12. The primary care pediatric nurse practitioner is discussing lifestyle changes with an
adolescent who has hypertension. What will the nurse practitioner recommend about
exercise for this client?
a. Regular to vigorous activity initially with a combination of resistance and aerobic
exercise to maintain lower blood pressure
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
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
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6
b. Interactive play
c. Martial arts
d. Organized sports
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.
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?
a. Creatine
b. Dehydroepiandrosterone (DHEA)
c. Ephedra
d. Growth hormone
ANS: B
DHEA is a prohormone that is converted to either testosterone or estrone and will cause
adverse changes similar to anabolic steroids, such as increased weight, gynecomastia, and
acne. Creatine is taken because athletes believe it enhances endurance. Side effects
include weight gain but not androgenic effects such as gynecomastia or acne. Ephedra is
similar to amphetamine, with most side effects related to the heart, such as tachycardia
and arrhythmias. Growth hormone will cause increased weight and has side effects
associated with diabetes, cardiomyopathy, hepatitis, and renal failure.
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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.
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
ANS: B
Both physical and cognitive rest is indicated after diagnosis of concussion in youth,
particularly if symptoms continue following injury. Cognitive recovery may lag behind
physical recovery and is a key factor in return-to-play decisions. Only after all symptoms
resolve may athletes progress through steps to gradually return to play.
18. A 12-year-old child who plays soccer is diagnosed with vocal cord dysfunction. What
will the primary care nurse practitioner say when the child’s parents ask about
continued sports participation?
a. The child may continue to participate in soccer.
b. The child should limit activity to non-aerobic sports.
c. This condition is a contraindication for all sports.
d. This condition predisposes the child to sudden cardiac death.
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.
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8
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.
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.
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Burns: Pediatric Primary Care, 6th Edition
Chapter 32: Respiratory Disorders
Test Bank
Multiple Choice
1. In a respiratory disorder causing a check-valve obstruction, which symptoms will be
present?
a. Air entry on inspiration with expiratory occlusion
b. Complete obstruction on inspiration and expiration
c. Narrowing of the lumen with increased air flow resistance
d. Obstruction of air entry with unimpeded expiratory air flow
ANS: A
With check-valve or ball-valve obstruction, air entry is possible, but the lumen is
completely occluded during expiration so that air escape is impossible. A complete
obstruction does not allow inspiratory or expiratory air flow. A bypass valve obstruction
allows air flow but with increased resistance. There is no obstruction that impedes
inspiration while allowing expiratory air flow.
2. A previously healthy school-age child develops a cough and a low-grade fever. The
primary care pediatric nurse practitioner auscultates wheezes in all lung fields. Which
diagnosis will the nurse practitioner suspect?
a. Atypical pneumonia
b. Bacterial pneumonia
c. Bronchiolitis
d. Bronchitis
ANS: A
Wheezing in a child over 5 years of age without a history of wheezing may point to an
atypical pneumonia. Bacterial pneumonia is characterized by diminished breath sounds or
crackles along with high fever. Bronchiolitis causes coarse wheezing. Bronchitis is
characterized by cough without adventitious lung sounds.
3. A child is diagnosed with community-acquired pneumonia and will be treated as an
outpatient. Which antibiotic will the primary care pediatric nurse practitioner
prescribe?
a. Amoxicillin
b. Azithromycin
c. Ceftriaxone
d. Oseltamivir
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ANS: A
Amoxicillin is given to children with community-acquired pneumonia. Azithromycin is
used to treat atypical pneumonia. Ceftriaxone is used for inpatient treatment. Oseltamivir
is used for viral pneumonia.
4. After 14 days of treatment with amoxicillin 45 mg/kg/day for acute rhinosinusitis, a
child continues to have mucopurulent nasal discharge along with induration, swelling,
and erythema of both eyelids. What is the next course of treatment?
a. Amoxicillin 80 mg/kg/day for 14 days
b. Amoxicillin-clavulanate for 10 to 14 days
c. Antibiotic ophthalmic drops for 5 to 7 days
d. Referral to a pediatric otolaryngologist
ANS: D
The child has symptoms consistent with periorbital or preseptal inflammation and needs a
referral to an otolaryngologist or infectious disease specialist. For uncomplicated
persistent rhinosinusitis, amoxicillin-clavulanate should be prescribed. These symptoms
are not consistent with conjunctivitis, so antibiotic eyedrops are not indicated. Although
increasing the dose of amoxicillin may be part of the treatment, referral to a pediatric
otolaryngologist is a priority.
5. An adolescent has suspected infectious mononucleosis after exposure to the virus in
the past week. The primary care pediatric nurse practitioner examines the adolescent
and notes exudate on the tonsils, soft palate petechiae, and diffuse adenopathy. Which
test will the primary care pediatric nurse practitioner perform to confirm the
diagnosis?
a. Complete blood count
b. EBV-specific antibody testing
c. Heterophile antibody testing
d. Throat culture
ANS: B
EBV-specific IgG antibody testing is the specific serologic test for EBV infection.
Heterophile antibody testing can be helpful in school-age children and adolescents after
the first week of infection. A CBC can identify lymphocytosis with atypical lymphocytes
but is non-specific. A throat culture is performed to identify bacterial causes; however, in
this case of known exposure to EBV this would not be the appropriate confirmatory test.
6. A 4-year-old child with an upper respiratory tract infection has cloudy nasal discharge
and moderate nasal congestion interfering with sleep. The parent asks what product to
use to help with symptoms. What will the primary care pediatric nurse practitioner
recommend?
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Test Bank
a.
b.
c.
d.
3
Antihistamines
Decongestant sprays
Saline rinses
Zinc supplements
ANS: C
Normal saline nose drops, nasal rinses, or sprays are helpful for all ages of children to
clear nasal passages. The use of decongestants, antihistamines, and cough medicine does
not shorten the course of a disease. While their use may help with relieving nasal
symptoms, their use is not recommended for children younger than 6 years old. Zinc is
not recommended in children because of potential side effects and questionable efficacy.
7. A child is in the clinic because of symptoms of purulent, foul-smelling nasal
discharge from the right nostril. Nasal visualization reveals something shiny in a mass
of mucous in the nasal cavity. What will the primary care pediatric nurse practitioner
do?
a. Attempt to remove the mass gently using alligator forceps.
b. Perform a saline nasal rinse using a water jet device.
c. Refer the child to a pediatric otolaryngologist.
d. Suction the mucoid mass using a bulb syringe.
ANS: A
Children often insert foreign bodies into their nasal cavities and, if undetected for any
period of time, will develop foul-smelling, unilateral, purulent nasal discharge. The
foreign body may become embedded in granulation tissue or mucosa. If possible, the
PNP should attempt removal if the FB is visible and can be easily removed without
causing trauma. Saline nasal rinses with pressure may push the FB farther into the cavity.
Referral to ENT may be necessary if attempts to remove the FB are not successful.
Suction is not indicated.
8. A 5-year-old child has enlarged tonsils and a history of four throat infections in the
previous year with fever, cervical lymphadenopathy, and positive Group A
Streptococcus pyogenes (GABHS) cultures. The parent reports that the child snores at
night and expresses concerns about the child’s quality of sleep. The next step in
managing this child’s condition is to :
a. continue to observe the child for two or more GABHS infections.
b. prescribe prophylactic antibiotics to prevent recurrent infection.
c. refer to a pulmonologist for polysomnography evaluation.
d. refer to an otolaryngologist for possible tonsillectomy.
ANS: C
The potential for sleep apnea should be evaluated since the parent reports snoring and
concerns with sleep in a child with frequent throat infections. This child has not had a
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4
high enough number of GABHS throat infections to warrant tonsillectomy and should be
watched. Prophylactic antibiotics are not indicated.
9. A 5-month-old infant who has a 3-day history of cough and rhinorrhea has developed
symptoms of respiratory distress with audible expiratory wheezes and increased
coughing. The infant’s immunizations are up-to-date. The physical exam reveals a
respiratory rate of 50 breaths per minute, coarse expiratory wheezing, and prolonged
expiration. An oxygen saturation is 96% on room air. What is the recommended
treatment for this infant?
a. Administer a trial of bronchodilators.
b. Obtain a viral culture of nasal washings.
c. Order an oral corticosteroid medication.
d. Recommend increased fluids and close follow-up.
ANS: D
The infant has bronchiolitis and is stable. Increasing fluids and following up closely are
indicated as long as oxygen saturations and hydration are normal. Bronchodilator trials
are not recommended because of the risk of adverse effects and questionable efficacy.
Viral cultures are performed if hospitalization is necessary or when symptoms are severe.
Corticosteroid medications are not indicated.
10. A school-age child has frequent nosebleeds. Nasal visualization reveals fresh clots
and excoriated nasal mucosa but no visible site of bleeding. Coagulation studies are
normal. In spite of symptomatic measures, the child continues to have nosebleeds.
What is the next course of action?
a. Cauterize the mucosa with silver nitrate sticks.
b. Order a topical vasoconstrictor medication.
c. Prescribe a barrier agent such as petrolatum jelly.
d. Refer to an otolaryngologist for further evaluation.
ANS: D
Children with persistent epistaxis should be referred for evaluation and treatment after
usual symptomatic measures are ineffective. Cautery works well for exposed vessels, but
the site must be easily accessible, visible, and not bleeding briskly. Topical
vasoconstrictors are occasionally used. Petrolatum jelly has not been shown to be
effective.
11. The parent of a toddler and a 4-week-old infant tells the primary care pediatric nurse
practitioner that the toddler has just been diagnosed with pertussis. What will the
nurse practitioner do to prevent disease transmission to the infant?
a. Administer the initial diphtheria, pertussis, and tetanus vaccine.
b. Instruct the parent to limit contact between the toddler and the infant.
c. Order azithromycin 10 mg/kg/day in a single dose daily for 5 days.
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5
d. Prescribe erythromycin 10 mg/kg/dose four times daily for 14 days.
ANS: C
Chemoprophylaxis for pertussis exposure is recommended for all household and close
contacts of infected persons regardless of immunization status. Azithromycin is the drug
of choice for infants from 1 month to 6 months of age. Administering the vaccine is not
indicated since there isn’t sufficient time to develop immunity. Infants under 1 month of
age should not receive erythromycin because of the increased risk for pyloric stenosis
associated with this drug
12. A school-age child has an abrupt onset of sore throat, nausea, headache, and a
temperature of 102.3°F. An examination reveals petechiae on the soft palate, beefyred tonsils with yellow exudate, and a scarlatiniform rash. A Rapid Antigen Detection
Test (RADT) is negative. What is the next step in management for this child?
a. Consider a sexual abuse diagnosis.
b. Obtain an anti-streptococcal antibody titer.
c. Perform a follow-up throat culture.
d. Prescribe amoxicillin for 10 days.
ANS: C
While an RADT has a high specificity, it has variable sensitivity, and a negative test does
not mean that streptococcal infection is not present. A culture should be performed to
confirm the diagnosis. If the throat culture is negative for GABHS, other causes, such as
gonococcal infection, may be considered but are less likely. The RADT does not assess
for sexual abuse. An ASO titer is not useful in the diagnosis of acute pharyngitis, since
the titers remain elevated for months after an acute infection. Amoxicillin is not indicated
unless infection is confirmed.
13. A child has an acute infection causing lower airway obstruction. Which initial
symptom is expected in this child?
a. Atelectasis
b. Barrel chest
c. Over-inflation
d. Wheezing
ANS: D
Wheezing is the principal sound patients make if the obstruction allows enough air to
pass through the narrowed lumen when lower airway obstruction occurs. Eventually,
over-inflation and atelectasis occur. Barrel chest is the result of chronic over-inflation.
14. A school-age child has had nasal discharge and daytime cough but no fever for 12
days without improvement in symptoms. The child has not had antibiotics recently
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6
and there is no significant antibiotic resistance in the local community. What is the
appropriate treatment for this child?
a. Amoxicillin 45 mg/kg/day
b. Amoxicillin 80-90 mg/kg/day
c. Amoxicillin-clavulanate 80-90 mg/kg/day
d. Saline irrigation for symptomatic relief
ANS: A
This child meets criteria for treatment of acute rhinosinusitis (ARS) based on duration of
symptoms without clinical improvement. The initial treatment is amoxicillin 45
mg/kg/day. The higher dose is used to treat ARS in communities with resistant S.
pneumonia. If antibiotics have been used previously, amoxicillin-clavulanate is used. The
use of buffered isotonic saline into the nasal cavity by squeeze bottle or neti pot (in late
childhood and adolescence) may be helpful, but the clinical guidelines do not support or
negate the use of saline.
15. The primary care pediatric nurse practitioner manages care in conjunction with a
pediatric pulmonologist for a child with cystic fibrosis. Which medication regimen is
used to facilitate airway clearance for this child?
a. Ibuprofen and azithromycin
b. Inhaled dornase alfa
c. Ivacaftor
d. Prophylactic clindamycin
ANS: B
Inhaled dornase alfa is given to promote airway clearance by reducing mucus viscosity.
Ibuprofen and azithromycin is given to reduce chronic airway inflammation. Ivacaftor is
given to patients with specific gene mutations. Antibiotic therapy is based on regular
sputum cultures.
16. A 2-year-old child is brought to the clinic after developing a hoarse, bark-like cough
during the night with “trouble catching his breath” according to the parent. The
history reveals a 2 day history of low-grade fever and upper respiratory symptoms.
On exam, the child has a respiratory rate of 40 breaths per minute, occasional stridor
when crying, and a temperature of 101.3°F. What is the next step in treatment for this
child?
a. Administer intramuscular dexamethasone.
b. Admit the child for inpatient hospitalization.
c. Give the child a racemic epinephrine treatment in the office.
d. Prescribe oral dexamethasone for 2 days.
ANS: D
This child has croup with milder symptoms and may be managed at home with oral
steroids. IM steroids are given to children who are vomiting. Inpatient admission is
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7
considered for children with respiratory distress (rates between 70 and 90 breaths per
minute, severe retractions, and stridor at rest). Racemic epinephrine is useful for more
severe symptoms, especially for stridor, but is done in the ED or hospital and should
always be combined with a steroid.
17. The primary care pediatric nurse practitioner evaluates a child who awoke with a sore
throat and high fever after a nap. The child appears anxious and is sitting on the
parent’s lap with the neck hyperextended. The physical exam reveals stridor,
drooling, nasal flaring, and retractions. What will the nurse practitioner do next?
a. Administer a broad-spectrum intravenous antibiotic.
b. Obtain blood and throat cultures and start antibiotic therapy.
c. Send the child to radiology for a lateral neck radiograph.
d. Transport the child to the hospital via emergency medical services.
ANS: D
The child has symptoms of epiglottitis and should be transported immediately for
emergency treatment via ambulance. All of the other options may be initiated at the
hospital once the diagnosis is more certain. If the possibility of epiglottitis is thought to
be remote, a lateral neck radiograph may be obtained prior to visualizing the throat. If
epiglottitis is suspected, visualizing the throat is contraindicated.
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Burns: Pediatric Primary Care, 6th Edition
Chapter 33: Gastrointestinal Disorders
Test Bank
Multiple Choice
1. A child is in the clinic after swallowing a metal bead. A radiograph of the GI tract
shows a 6 mm cylindrical object in the child’s stomach. The child is able to swallow
without difficulty and is not experiencing pain. What is the correct course of
treatment?
a. Administer ipecac to induce vomiting.
b. Have the parents watch for the object in the child’s stool.
c. Insert a nasogastric tube to flush out the object.
d. Refer the child for endoscopic removal of the object.
ANS: B
A small foreign body that is not corrosive or sharp and that has reached the stomach is
most likely to continue to pass through the GI tract and no intervention is necessary.
Inducing vomiting increases the risk of aspiration of the FB. NG tube removal and
endoscopy are not indicated unless the object has the potential to damage the GI tract;
most objects that are not sharp or corrosive that have reached the abdomen will pass
through without causing damage.
2. A toddler who was born prematurely refuses most solid foods and has poor weight
gain. A barium swallow study reveals a normal esophagus. What will the primary
care pediatric nurse practitioner consider next to manage this child’s nutritional
needs?
a. Consultation with a dietician
b. Fiberoptic endoscopy evaluation
c. Magnetic resonance imaging
d. Videofluoroscopy swallowing study
ANS: D
A videofluoroscopy swallowing study will evaluate other structural defects that may
interfere with swallowing and is relatively non-invasive. A dietician consult may be a
part of the overall plan, but the toddler first needs a thorough evaluation of potential
problems. Fiberoptic endoscopy is invasive. MRI may be performed if videofluoroscopy
is inconclusive, but this is an expensive test.
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2
3. A school-age child has a 3-month history of dull, aching epigastric pain that worsens
with eating and awakens the child from sleep. A complete blood count shows a
hemoglobin of 8 mg/dL. What is the next step in management?
a. Administration of H2RA or PPI medications
b. Empiric therapy for H. pylori (HP)
c. Ordering an upper GI series
d. Referral for esophagogastroduodenoscopy (EGD)
ANS: D
EGD is the procedure of choice in children for detecting PUD because it allows direct
visualization of mucosa, localization of the source of bleeding, and collection of tissue
specimens. Empiric therapy for HP is not recommended due to increased antibiotic
resistance. An upper GI series may have false negative findings. Once peptic ulcer
disease is diagnosed, H2RA or PPI medications are first-line drugs.
4. A 2-year-old child has an acute diarrheal illness. The child is afebrile and, with oral
rehydration measures, has remained well hydrated. The parent asks what can be done
to help shorten the course of this illness. What will the primary care pediatric nurse
practitioner recommend?
a. Clear liquids only
b. Lactobacillus
c. Loperamide
d. Peppermint oil
ANS: B
Lactobacillus, given early in a viral diarrheal illness, can decrease the duration of
diarrhea by about 25 hours and is safe to use in children. Parents should begin refeeding
early to stimulate enterocyte growth and help facilitate mucosal repair. Loperamide may
be given to children over the age of 3 years. Peppermint oil may help reduce cramping,
but its efficacy is not certain.
5. A school-age child has recurrent diarrhea with foul-smelling stools, excessive flatus,
abdominal distension, and failure-to-thrive. A 2-week lactose-free trial failed to
reduce symptoms. What is the next step in diagnosing this condition?
a. Lactose hydrogen breath test
b. Serologic testing for celiac disease
c. Stool for ova and parasites
d. Sweat chloride test for cystic fibrosis
ANS: B
This child has symptoms consistent with celiac disease, especially FTT and foul-smelling
stools. Since the lactose-free trial did not reduce symptoms, the likelihood of lactose
intolerance is less and thus testing is not likely to be helpful. The symptoms are recurrent,
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3
so giardiasis is less likely. CF is still possible, but most children with CF are diagnosed as
infants and have accompanying respiratory symptoms of some type.
6. A 12-month-old infant exhibits poor weight gain after previously normal growth
patterns. There is no history of vomiting, diarrhea, or irregular bowel movements, and
the physical exam is normal. What is the next step in evaluating these findings?
a. Complete blood count and electrolytes
b. Feeding and stooling history and 3-day diet history
c. Stool cultures for ova and parasites
d. Swallow study with videofluoroscopy
ANS: B
Vomiting, diarrhea, and bowel irregularities are more predictive of organic causes of
FTT, which are not present in this infant. A careful history and physical examination and
limited laboratory evaluation are the first steps unless there is reason to think that an
organic cause is present. The fact that the infant was previously gaining weight
appropriately makes a swallowing disorder less likely.
7. The parent of an infant asks about using a probiotic medication. What will the
primary care pediatric nurse practitioner tell this parent?
a. Probiotic medications have demonstrated efficacy in treating colic.
b. Probiotics are not safe to use to treat infants who have colic.
c. There are no studies showing usefulness of probiotics to manage colic.
d. There is no conclusive evidence about using probiotics to treat colic.
ANS: D
While small studies have shown promise in treating colic in infants, the research is
contradictory and there is no conclusive evidence about effectiveness. There is no
evidence that probiotics are not safe.
8. A child is diagnosed with Crohn disease. What are likely complications for this child?
a. Cancer of the colon and possible colectomy
b. Intestinal obstruction with scarring and strictures
c. Intestinal perforation and hemorrhage
d. Liver disease and sepsis
ANS: B
Intestinal obstruction with scarring and strictures are the major complications of CD. The
other answers describe complications of ulcerative colitis.
9. A toddler is seen in the clinic after a 2-day history of intermittent vomiting and
diarrhea. An assessment reveals an irritable child with dry mucous membranes, 3-
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4
second capillary refill, 2- second recoil of skin, mild tachycardia and tachypnea, and
cool hands and feet. The child has had two wet diapers in the past 24 hours. What will
the primary care pediatric nurse practitioner recommend?
a. Anti-diarrheal medication and clear fluids for 24 hours
b. Bolus of IV normal saline in the clinic until improvement
c. Hospital admission for IV rehydration and oral fluids
d. Oral rehydration solution with follow-up in 24 hours
ANS: D
This child has mild to moderate dehydration, according to vital signs and symptoms, and
may be managed with oral rehydration solution with good follow-up. Anti-diarrheal
medications are generally not useful, but antiemetics may be used. It is not necessary to
administer IV fluids or to hospitalize unless more severe dehydration occurs.
10. A 2-month-old infant cries up to 4 hours each day and, according to the parents, is
inconsolable during crying episodes with fists and legs noted to be tense and stiff.
The infant is breastfeeding frequently but is often fussy during feedings. The physical
exam is normal and the infant is gaining weight normally. What will the primary care
pediatric nurse practitioner recommend?
a. A complete work-up, including laboratory and radiologic tests
b. Eliminating certain foods from the mother’s diet
c. Empiric treatment with a proton pump inhibitor medication
d. Stopping breastfeeding and beginning a hydrolyzed formula
ANS: B
A first step in a breastfeeding infant with symptoms of colic should be to try eliminating
certain foods such as cow’s milk products, nuts, eggs, and fish from the mother’s diet to
see if improvement occurs. It is not necessary to stop breastfeeding; hydrolyzed formulas
may be tried in formula-fed infants. An infant with a normal exam and normal weight
gain does not need further diagnostic studies. PPIs are not indicated as first-line therapy.
11. A school-age child has had abdominal pain for 3 months that occurs once or twice
weekly and is associated with a headache and occasional difficulty sleeping, often
causing the child to stay home from school. The child does not have vomiting or
diarrhea and is gaining weight normally. The physical exam is normal. According to
Bishop, what is included in the initial diagnostic work-up for this child?
a. CBC, ESR, amylase, lipase, UA, and abdominal ultrasound
b. CBC, ESR, CRP, and fecal calprotectin
c. CBC, ESR, CRP, UA, stool for ova, parasites, and culture
d. Stool for H. pylori antigen and serum IgA, IgG, tTg
ANS: A
Bishop suggests these labs as an initial approach in children suspected of having
functional abdominal pain, along with a 3-day trial of a lactose-free diet. Fecal
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5
calprotectin is added if the child has changes in stool habits suggestive of inflammatory
changes in the intestinal tract. Answer C is correct according to Rasquin’s
recommendations as is stool for H. pylori antigen.
12. An 18-month-old child has a 1-day history of intermittent, cramping abdominal pain
with non-bilious vomiting. The child is observed to scream and draw up his legs
during pain episodes and becomes lethargic in between. The primary care pediatric
nurse practitioner notes a small amount of bloody, mucous stool in the diaper. What is
the most likely diagnosis?
a. Appendicitis
b. Gastroenteritis
c. Intussusception
d. Testicular torsion
ANS: C
Intussusception is characterized by intermittent pain associated with drawing up the legs,
“currant jelly” stools, and lethargy in between episodes. Appendicitis is characterized by
pain localizing to the RLQ and is not intermittent. Gastroenteritis is likely when vomiting
precedes symptoms of pain or discomfort. Testicular torsion involves the testicles and
thus has different physical findings and would not be accompanied with bloody stools.
13. A 9-year-old girl has a history of frequent vomiting and her mother has frequent
migraine headaches. The child has recently begun having more frequent and
prolonged episodes accompanied by headaches. An exam reveals abnormal eye
movements and mild ataxia. What is the correct action?
a. Begin using an anti-migraine medication to prevent headaches.
b. Prescribe ondansetron and lorazepam to help manage symptoms.
c. Reassure the parent that this is expected with cyclic vomiting syndrome.
d. Refer to a pediatric gastroenterologist for further workup.
ANS: D
This child has an abnormal neurologic examination, which is a red flag warranting
referral for further workup for children with cyclic vomiting syndrome. Anti-migraine
medications are used in children over age 12 years and therefore should not be used for
this patient. Ondansetron and lorazepam may be useful for unrelenting nausea and poor
sleep, but this child needs to be referred to evaluate neurologic symptoms. These signs
are not expected.
14. A 10-year-old child has had abdominal pain for 2 days, which began in the
periumbilical area and then localized to the right lower quadrant. The child vomited
once today and then experienced relief from pain followed by an increased fever.
What is the likely diagnosis?
a. Appendicitis with perforation
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6
b. Gastroenteritis
c. Pelvic inflammatory disease (PID)
d. Urinary tract infection (UTI)
ANS: A
The child has the progression of symptoms typical of appendicitis with perforation – pain
before vomiting that localizes to the RLQ and then relief of pain with onset of fever upon
perforation. With gastroenteritis, vomiting precedes pain. PID symptomology includes
increasing pain over time. The symptoms of an UTI include fever, chills, and urinary
symptoms.
15. The parent of a 3-month-old reports that the infant arches and gags while feeding and
spits up undigested formula frequently. The infant’s weight gain has dropped to the
5th percentile from the 12th percentile. What is the best course of treatment for this
infant?
a. Begin a trial of extensively hydrolyzed protein formula for 2 to 4 weeks.
b. Institute an empiric trial of acid suppression with a proton pump inhibitor (PPI).
c. Perform esophageal pH monitoring to determine the degree of reflux.
d. Reassure the parent that these symptoms will likely resolve by 12 to 24 months.
ANS: A
Formula-fed infants may be given a trial of a hydrolyzed protein formula to see if
improvement occurs. An empiric trial of a PPI may be used in children and adolescents
but is not recommended in infants. Esophageal pH monitoring may be performed in
consultation with a specialist but not as first-line evaluation. The infant has warning signs
of GERD that require further investigation and not just reassurance.
16. An adolescent is diagnosed with functional abdominal pain (FAP). The child’s
symptoms worsen during stressful events, especially with school anxiety. What will
be an important part of treatment for this child?
a. Informing the parents that the pain is most likely not real
b. Instituting a lactose-free diet along with lactobacillus supplements
c. Teaching about the brain-gut interaction causing symptoms
d. Using histamine2-blockers to help alleviate symptoms
ANS: C
This child has symptoms associated with stress, and treatment should be aimed at
biobehavioral methods, beginning with teaching about the brain-gut interaction. Even
though the pain is functional, it is real. Lactose-free diets and lactobacillus supplements
may be used with documented lactose intolerance, although there is a lack of high-quality
evidence of their effectiveness. H2-blockers should not be used unless dyspepsia is
present.
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Burns: Pediatric Primary Care, 6th Edition
Chapter 35: Genitourinary Disorders
Test Bank
Multiple Choice
1. A child who had GABHS 2 weeks prior is in the clinic with periorbital edema,
dyspnea, and elevated blood pressure. A urinalysis reveals tea-colored urine with
hematuria and mild proteinuria. What will the primary care pediatric nurse
practitioner do to manage this condition?
a. Prescribe a 10- to 14-day course of high-dose amoxicillin.
b. Prescribe high-dose steroids in consultation with a nephrologist.
c. Reassure the parents that this condition will resolve spontaneously.
d. Refer the child to a pediatric nephrologist for hospitalization.
ANS: D
This child has symptoms of post-streptococcal glomerulonephritis and signs indicating a
need for hospitalization: elevated BP, edema, and dyspnea. The PNP should refer the
child to a nephrologist for hospital admission and care. Amoxicillin is not indicated; this
condition is an immunologic response to GABHS and not an infection. Steroids are not
effective in treating this disease. Although the condition usually does self-resolve, the
child needs hospitalization for close monitoring and follow-up.
2. An adolescent has right-sided flank pain without fever. A dipstick urinalysis reveals
gross hematuria without signs of infection or bacteriuria, and the primary care
pediatric nurse practitioner diagnoses possible nephrolithiasis. What is the initial
treatment for this condition?
a. Extracorporeal shockwave lithotripsy (ESWL)
b. Increasing fluid intake up to 2 L daily
c. Percutaneous removal of renal calculi
d. Referral to a pediatric nephrologist
ANS: B
The first line of therapy for all stone types is increasing fluids. ESWL may be indicated if
symptoms worsen and stones are not passed. Percutaneous removal of renal calculi and
referral to nephrology may be indicated with worsening symptoms.
3. A 9-month-old infant with a history of three urinary tract infections is diagnosed with
grade II vesicoureteral reflux. Which medication will be prescribed?
a. Amoxicillin 10 mg/kg as a single daily dose
b. Ceftriaxone IM 50 mg/kg as a single daily dose
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c. Nitrofurantoin 1-2 mg/kg as a single daily dose
d. TMP-SMX; TMP 2 mg/kg as a single daily dose
ANS: D
TMP-SMX is a first-line medication for grade II VUR prophylaxis. TMP-SMX: TMP 2
mg/kg as a single daily dose or 5 mg/kg twice/wk (based on TMP component) if older
than 1 month.Amoxicillin is a first-line treatment in infants younger than 2 months. It is
not necessary to give IM medications. Nitrofurantoin is expensive and poorly tolerated.
4. A healthy 14-year-old female has a dipstick urinalysis that is positive for 5-6 RBCs
per hpf but otherwise normal. What is the first question the primary care pediatric
nurse practitioner will ask this patient?
a. “Are you sexually active?”
b. “Are you taking any medications?”
c. “Have you had a recent fever?”
d. “When was your last menstrual period (LMP)?”
ANS: D
Menstrual blood may appear in urine and is a common cause of urine with RBCs present,
so this would be an appropriate first question of an adolescent. Asking about sexual
activity or recent fevers may be part of the diagnostic reasoning if common causes are not
present. Medications may discolor the urine but do not cause RBCs to be present.
5. A dipstick urinalysis is positive for leukocyte esterase and nitrites in a school-age
child with dysuria and foul-smelling urine but no fever who has not had previous
urinary tract infections. A culture is pending. What will the pediatric nurse
practitioner do to treat this child?
a. Order ciprofloxacin ER once daily for 3 days if the culture is positive.
b. Prescribe trimethoprim-sulfamethoxazole (TMP) twice daily for 3 to 5 days.
c. Reassure the child’s parents that this is likely an asymptomatic bacteriuria.
d. Wait for urine culture results to determine the correct course of treatment.
ANS: B
Short-term antibiotics of 3 to 5 days may be as effective for treating UTI in non-febrile
bladder infections and TMP is generally a first-line drug in children without history of
UTI. Ciprofloxacin is used in adolescents older than 18 years and this child is
symptomatic with positive leukocyte esterase and nitrites and will need treatment.
Asymptomatic bacteriuria occurs when bacteria are in the urine of a child who is
asymptomatic (without symptoms).
6. During a well child examination of a 2-year-old child, the primary care pediatric
nurse practitioner palpates a unilateral, smooth, firm abdominal mass which does not
cross the midline. What is the next course of action that?
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a.
b.
c.
d.
3
Order a CT scan of the chest, abdomen, and pelvis.
Perform urinalysis, CBC, and renal function tests.
Reevaluate the mass in 1 to 2 weeks.
Refer the child to an oncologist immediately.
ANS: D
The finding is consistent with Wilms tumor, and referral, diagnosis, and treatment are
urgent. Palpating a mass too vigorously could lead to the rupture of a large tumor into the
peritoneal cavity so care should be taking in conducting the physical examination. The
other tests may be ordered by the oncology team. Treatment and diagnosis must occur
immediately.
7. An adolescent has 2+ proteinuria in a random dipstick urinalysis. A subsequent firstmorning voided specimen is negative. What will the primary care pediatric nurse
practitioner do to manage this condition?
a. Monitor for proteinuria at each annual well child examination.
b. Order a 24-hour timed urine collection for creatinine and protein excretion.
c. Reassure the parents that this is a benign condition with no follow-up needed.
d. Refer the child to a pediatric nephrologist for further evaluation.
ANS: A
Orthostatic proteinuria, demonstrated by proteinuria of greater than 1+ with activity and
low-protein to normal urine on a first-morning void, is common in adolescents. If the
first-morning void is negative, the adolescent should be monitored annually. A 24-hour
urine collection is not indicated unless the first-morning void is elevated. Although the
orthostatic proteinuria is mostly benign, annual monitoring is recommended and patient
education should stress the importance of follow-up to evaluate the cause of proteinuria.
Children with mild asymptomatic proteinuria who have a normal first-morning specimen
do not require extensive testing for kidney disease but should be monitored annually.
Unless proteinuria is severe or persistent, referral to a nephrologist is not indicated.
8. The mother of a 12-month-old uncircumcised male infant reports that the child seems
to have pain associated with voiding. A physical examination reveals a tight, pinpoint
opening of the foreskin, which thickened and inflamed. What will the primary care
pediatric nurse practitioner do?
a. Attempt to retract the foreskin to visualize the penis.
b. Order corticosteroid cream 3 times daily for 4 weeks.
c. Refer the child to a pediatric urologist.
d. Teach the mother to gently stretch the foreskin with cleaning.
ANS: C
The child has symptoms consistent with pathologic phimosis and should be referred for
possible circumcision. The foreskin should never be forcefully retracted. Non-pathologic
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4
phimosis can usually be managed by normal cleansing and gentle stretching.
Corticosteroid cream is used for persistent, non-pathologic phimosis.
9. A 6-month-old infant has a retractile testis that was noted at the 2-month well baby
exam. What will the primary care pediatric nurse practitioner do to manage this
condition?
a. Reassure the parent that the testis will most likely descend into place on its own.
b. Refer the infant to a pediatric urologist or surgeon for possible orchiopexy.
c. Teach the parent to manipulate the testis into the scrotum during diaper changes.
d. Tell the parent that hormonal therapy may be needed to correct the condition.
ANS: B
A retractile testis that does not retain scrotal residence should be referred to a pediatric
urologist or surgeon by 6 months of age. By that age, the child should be seen by a
specialist to rule out orchiopexy, in which the testis does not descend on its own (parental
reassurance would not be appropriate). Teaching the parent to manipulate the testis is not
indicated. Hormonal therapy has not demonstrated efficacy in stimulating testicular
descent.
10. A 9-month-old infant is brought to the clinic with scrotal swelling and fussiness. The
primary care pediatric nurse practitioner notes a tender mass in the affected scrotum
that is difficult to reduce. What is the correct action?
a. Obtain an abdominal radiograph.
b. Refer immediately to a pediatric surgeon.
c. Schedule an appointment with a pediatric urologist.
d. Teach the parents signs of incarceration.
ANS: B
A scrotal mass that is difficult to reduce or is painful is likely to be a hernia. Immediate
referral is indicated to rule out incarceration, which is a medical emergency with
potentially severe consequences if not promptly treated. The PNP may order radiographs
to distinguish a hernia from a hydrocele, but not when these symptoms occur. The
referral must be immediate, since surgery is required. A child with a non-tender,
reducible hernia will require referral, but parents can be taught signs of incarceration until
an appointment can be scheduled and the specialist seen.
11. A child is diagnosed with nephrotic syndrome, and the pediatric nurse practitioner
provides primary care in consultation with a pediatric nephrologist. The child was
treated with steroids and responded well to this treatment. What will the nurse
practitioner tell the child’s parents about this disease?
a. “Future episodes are likely to have worse outcomes.”
b. “Steroids will be used when relapses occur.”
c. “This represents a cure from this disease.”
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5
d. “Your child will need to take steroids indefinitely.”
ANS: B
In situations in which a child responds well to steroids, this shows promise of a good
prognosis, indicating that the child may be treated successfully with steroids during
future anticipated relapses. The fact that a child is a “steroid responder” indicates that
future episodes of treatment will be successful and have positive outcomes. This disease
is chronic and not curable. Steroid use with children who respond positively is
intermittent during episodes of relapse. Steroids are not given continuously and are not
seen as prophylactic.
12. An adolescent male comes to the clinic reporting unilateral scrotal pain, nausea, and
vomiting that began that morning. The primary care pediatric nurse practitioner
palpates a painful, swollen testis and elicits increased pain with slight elevation of the
testis (a negative Phren’s sign). What will the nurse practitioner do?
a. Administer IM ceftriaxone and prescribe doxycycline twice daily for 10 days.
b. Encourage bed rest, scrotal support, and ice packs to the scrotum as tolerated.
c. Prescribe NSAIDs, limited activities, and warm compresses to the scrotum.
d. Refer the adolescent immediately to a pediatric urologist or surgeon.
ANS: D
These symptoms are indicative of testicular torsion. Testicular torsion causes a sudden
onset of unilateral pain and is distinguished from epididymitis when elevation of the
scrotum causes an increase in pain (Phren’s sign). It is a surgical emergency and should
warrant immediate referral. Epididymitis is caused by infection and requires antibiotics,
bed rest, scrotal support, and ice packs. Testicular appendix torsion is self-limited and can
be managed with NSAIDs, bed rest or limited activities, and warm compresses.
13. A 30-month-old girl who has been toilet trained for 6 months has daytime enuresis
and dysuria and a low-grade fever. A dipstick urinalysis is negative for leukocyte
esterase and nitrites. What is the next step?
a. Begin empiric treatment with trimethoprim-sulfamethoxazole.
b. Discuss behavioral interventions for toilet training.
c. Reassure the child’s parents that the child does not have a urinary tract infection.
d. Send the urine to the lab for culture.
ANS: D
Girls over age 24 months have a higher risk than boys for UTI. This child is
symptomatic, so her urine should be cultured even though the leukocyte esterase and
nitrites are negative; urine in the bladder less than 4 hours may be tested as negative for
leukocyte esterase. Empiric treatment may be initiated if the child had signs of sepsis.
Behavioral interventions are not indicated – the child has dysuria and fever along with
enuresis. Until the culture is found to be negative, it is not certain that the child does not
have an UTI, and thus reassurance is not the correct action.
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14. A child who has nephrotic syndrome is on a steroids and a salt-restricted diet for a
relapse of symptoms. A dipstick urinalysis shows 1+ protein, down from 3+ at the
beginning of the episode. In consultation with the child’s nephrologist, what is the
correct course of treatment considering this finding?
a. Begin a taper of the steroid medication while continuing salt restrictions.
b. Continue with steroids and salt restrictions until the urine is negative for protein.
c. Discontinue the steroids and salt restrictions now that improvement has occurred.
d. Relax salt restrictions and continue administration of steroids until proteinuria is
gone.
ANS: B
Steroid medications and salt restrictions are continued until proteinuria resolves
15. The parent of a toddler diagnosed with grade V vesicoureteral reflux asks the primary
care pediatric nurse practitioner how the disease will be treated. What will the nurse
practitioner tell this parent?
a. That long-term antibiotic prophylaxis will prevent scarring
b. That surgery to correct the condition is possible
c. that the child will most likely require kidney transplant
d. that the condition will probably resolve spontaneously
ANS: B
Children with grade V VUR generally do not experience spontaneous resolution and will
likely have to have surgery to correct the condition. Antibiotic prophylaxis will not
necessarily prevent scarring. Unless scarring occurs and is severe, kidney transplantation
is not likely.
16. The clean catch urine specimen of a child with dysuria, frequency, and fever has a
colony count between 50,000 and 100,000 of E. coli. What is the treatment for this
child?
a. Obtain a complete blood count and C-reactive protein.
b. Perform sensitivity testing before treating with antibiotics.
c. Repeat the culture if symptoms persist or worsen.
d. Treat with antibiotics for urinary tract infection.
ANS: D
If children are symptomatic and have more than 10,000 colonies of a single pathogen,
they are considered to have a UTI and are treated. If pyelonephritis symptoms such as
flank pain and sepsis are present, CBC and CRP are useful tests. Sensitivity testing is
done for patients who appear toxic, have pyelonephritis, or are non-responsive to
antibiotics.
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17. A 3-year-old child has just completed a 7-day course of amoxicillin for a second
febrile urinary tract infection and currently has a negative urine culture. What is the
next course of action?
a. Obtain a renal and bladder ultrasound.
b. Prescribe prophylactic antibiotics to prevent recurrence.
c. Refer the child for a voiding cystourethrogram.
d. Screen urine regularly for leukocyte esterase and nitrites.
ANS: A
Children with recurrent UTI should have a renal and bladder US to assess for
hydronephrosis, scarring, or other atypical findings. If the US is concerning, VCUG
and/or DMSA screen may be performed. Screening regularly is not indicated.
18. A child has gross hematuria, abdominal pain, and arthralgia as well as a rash. What
diagnosis is most likely?
a. Henoch-Schönlein purpura
b. Rhabdomyosarcoma
c. Sickle cell disease
d. Systemic lupus erythematosus
ANS: A
HSP may presents with gross hematuria in the presence of abdominal pain with or
without bloody stools, arthralgias, and a purpuric rash. Rhabdomyosarcoma is
characterized by gross hematuria and voiding dysfunction. Sickle cell disease can cause
gross hematuria but not always.
19. A preschool-age child with no previous history has mild flank pain and fever but no
abdominal pain or vomiting. A urinalysis is positive for leukocyte esterase and
nitrites. A culture is pending. Which is the correct course of treatment for this child?
a. Hospitalize for intravenous antibiotics.
b. Order amoxicillin clavulanate.
c. Prescribe trimethoprim-sulfamethoxazole.
d. Refer for a voiding cystourethrogram.
ANS: B
These symptoms suggest this young child may have pyelonephritis. Amoxicillin
clavulanate may be given to young children with uncomplicated pyelonephritis who are
well hydrated with no abdominal pain or vomiting. Hospitalization is not necessary for
uncomplicated pyelonephritis in this age child. TMP is not a first-line drug for
pyelonephritis. Voiding cystourethrogram is not indicated for a first febrile UTI.
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Burns: Pediatric Primary Care, 6th Edition
Chapter 38: Musculoskeletal Disorders
Test Bank
Multiple Choice
1. A parent is concerned that a 12-month-old child is “bow-legged.” A physical
examination reveals internal tibial torsion bilaterally. A radiograph reveals
asymmetric bowing of the legs with an angle greater than 15 degrees. What is the
correct action for the primary care pediatric nurse practitioner?
a. Observe the child’s condition over time to assess progression.
b. Order physical therapy to prevent progression of symptoms.
c. Reassure the parent that the child will outgrow this deformity.
d. Refer to a pediatric orthopedic specialist for treatment.
ANS: D
In Blount disease, the bowing is asymmetrical; children with this disorder need
immediate referral to an orthopedist. Physiologic bowing may self-resolve and may be
managed with observation, physical therapy, and reassurance.
2. A school-age child has a fractured wrist with a Salter-Harris Type II fracture,
according to the radiologist. What is true about this type of fracture?
a. Growth disturbance of the long bones of the arm is likely.
b. There is a metaphyseal fragment on the compression side of fracture.
c. There is usually a compression or crushing injury to the physis.
d. This will require anatomic reduction using an open approach.
ANS: B
With a Salter-Harris Type II fracture, a metaphyseal is present on the compression side of
the fracture. Types I and II Salter-Harris fractures rarely show growth disturbances. Type
V fractures have a compression or crushing injury to the physis. Anatomic reduction with
an open approach is usually necessary for a Type III fracture.
3. A child who plays soccer is in the clinic reporting pain and swelling in both knees. A
physical examination reveals swelling and focal tenderness at the tibial tuberosities,
with pain worsening when asked to extend the knees against resistance. What is the
treatment for this condition?
a. Apply ice packs to both knees and avoid activities that cause pain.
b. Begin quadriceps-stretching exercises now to prevent further injury.
c. Obtain radiographic studies to rule out fractures or ligament tears.
d. Refer to a pediatric orthopedic specialist to evaluate the need for surgery.
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2
ANS: A
The history of sports involving kicking a ball and the location and type of pain and
swelling are consistent with Osgood-Schlatter disease (OSD). Management involves rest
and ice and sometimes NSAIDs. Quadriceps-stretching exercises are not encouraged until
the acute symptoms pass. Radiographic studies are not necessary. Referral is not
indicated for OSD.
4. A 3-year-old child is brought to the clinic by a parent who reports that the child
refuses to use the right arm after being swung by both arms while playing. The child
is sitting with the right arm held slightly flexed and close to the body. There is no
swelling or ecchymosis present. What will the primary care pediatric nurse
practitioner do?
a. Consider maltreatment as a possible cause of injury.
b. Gently attempt a supination and flexion technique.
c. Immobilize the arm with a sling and refer to orthopedics.
d. Obtain a radiograph of the child’s right arm and elbow.
ANS: B
This is most likely an annular ligament displacement injury, or “nursemaid’s elbow.” The
primary provider can attempt to reduce the elbow using either a supination/flexion
technique or a pronation technique. Consider maltreatment if recurrent dislocations or
other symptoms or signs are present. If this fails after three attempts, immobilization and
referral are indicated. Radiologic studies are rarely necessary.
5. During a well baby examination of a newborn, the primary care pediatric nurse
practitioner notes adduction of the right forefoot, with normal position of the midand hind-foot, along with a convex-shaped lateral border of the foot. What will the
nurse practitioner do to evaluate this deformity?
a. Grasp the heel with one hand and abduct the forefoot with the other hand.
b. Observe both legs for medial and lateral rotations.
c. Order anterior-posterior and lateral radiographs of both feet.
d. Refer the infant immediately to a pediatric orthopedic specialist.
ANS: A
The foot position is characteristic of metatarsus adductus. The PNP should evaluate
whether the deformity is rigid, requiring treatment by an orthopedist, or not. If the
forefoot can be brought past the midline with the heel held in place, it is not considered to
be a rigid deformity. Assessing legs for medial and lateral rotations is part of the exam
for in-toeing. Radiographs are not routinely performed. Referral to an orthopedic
specialist, if this is found to be rigid deformity, is not urgent.
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3
6. A school-age child falls off a swing and suffers a closed fracture of the right clavicle.
How will this be managed?
a. Application of a figure-eight clavicle brace for 6 to 8 weeks
b. Hospitalization for traction of the affected extremity and shoulder
c. Immobilization with a sling to support the affected extremity
d. Referral to an orthopedic specialist for possible surgical reduction
ANS: C
Most children with fractured clavicle can be treated with sling immobilization for 3 to 4
weeks. Figure-eight clavicle braces are uncomfortable and have questionable
effectiveness; they are used if displacement leads to decreased shaft length.
Hospitalization for traction is not indicated. Surgical reduction is uncommon and used for
open fractures, neurovascular compromise, multiple trauma, rib cage fractures, and
severe displacement.
7. A young adolescent female is observed to have mild unequal scapula prominences on
gross examination while standing. In the Adams forward bending position, this
inequality disappears. What will the primary care pediatric nurse practitioner do?
a. Discuss posture and exercise and ask about backpacks and books.
b. Obtain radiographic studies of the entire spine and neck.
c. Reassure the child’s parent that functional scoliosis will self-resolve.
d. Refer to an orthopedic specialist for evaluation and possible bracing.
ANS: A
Unequal scapulas noted on standing can denote scoliosis and deserves a more thorough
physical assessment. Functional scoliosis can be diagnosed by assessing curves in the
spine in the Adams forward bending position. Although it is relatively benign, functional
scoliosis can progress to structural scoliosis if not treated, which can be done with
physical therapy or other means, such as exercises or removing external forces (carrying
heavy loads, heavy one-sided backpacks) that place unequal pressures on the spine, to
prevent progression. Radiographs may be necessary if this worsens. This will not selfresolve but must be managed to prevent progression. Orthopedic referral is not necessary
at this early, modifiable stage.
8. The primary care pediatric nurse practitioner elicits positive Ortolani and Barlow
signs in a 6-month-old infant not previously noted in the medical record. What is the
correct treatment?
a. Pavlik harness
b. Spica cast
c. Surgical intervention
d. Triple diapering
ANS: C
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4
The 6- to 18-month-old infant with a dislocated hip is likely to require either closed
manipulation or open reduction. The other interventions should be used in younger
infants.
9. A young adolescent reports chest pain associated with coughing and lifting. Physical
examination reveals tenderness over several ribs, radiating to the back. Auscultation
of the heart, lungs, and abdomen are normal. There is no history of injury. What will
the primary care pediatric nurse practitioner do?
a. Obtain a chest radiograph to evaluate possible causes for these symptoms.
b. Order an electrocardiogram to rule out potential cardiovascular disease.
c. Recommend NSAIDs, stretching exercises, and ice packs to the area.
d. Refer the child to a pediatric orthopedist for evaluation and treatment.
ANS: C
The child has symptoms and a history consistent with costochondritis. Treatment is
symptomatic with analgesics, ice packs, and exercise and rest. Chest radiographs offer no
diagnostic value, except to rule out other causes. Unless heart sounds are abnormal, or
there are other signs of cardiovascular disease, an ECG is not indicated. Referral is not
necessary unless symptoms persist.
10. What will the primary care pediatric nurse practitioner elicit when obtaining a
positive Barlow maneuver when screening for developmental dysplasia of the hip?
a. Dislocation of an unstable hip
b. Dropping of the iliac crest with a raised leg
c. Reduction of a dislocated hip
d. Unequal knee heights in a supine child
ANS: A
The Barlow maneuver dislocates an unstable or dislocatable hip posteriorly. Having the
child raise a leg and watching for dropping of the iliac crest on that side is the
Trendelenberg sign. The Ortolani maneuver reduces a posteriorly dislocated hip. Unequal
knee heights in a supine child occur with a positive Galeazzi maneuver.
11. A 14-year-old boy who is overweight develops a unilateral limp with pain in the hip
and knee on the affected side. An exam reveals external rotation of the hip when
flexed and pain associated with attempts to internally rotate the hip. What is most
important initially when managing this child’s condition?
a. Place the child on crutches or in a wheelchair to prevent weight-bearing.
b. Provide information about weight loss to minimize further injury.
c. Recommend seeing an orthopedic specialist as soon as possible.
d. Refer the child to physical therapy to improve range of motion.
ANS: A
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Test Bank
5
This child’s age, history, and symptoms are consistent with slipped capital femoral
epiphysis. The child should be placed on crutches or in a wheelchair to prevent weight
bearing. Obesity is often part of the history and should be managed, but the immediate
need is to prevent further damage to the hip. Referral to orthopedics should immediately
follow prevention of weight bearing. Physical therapy may be part of treatment after the
epiphysis is stabilized.
Copyright © 2017, Elsevier Limited. All rights reserved.
Burns: Pediatric Primary Care, 6th Edition
Chapter 40: Common Injuries
Test Bank
Multiple Choice
1. 1. A child has a 1-cm laceration on the forehead proximal to the hairline after running into a
pole while playing sports. To minimize the risk of infection, the primary care pediatric nurse
practitioner will irrigate the wound and
a. a.
allow the wound to heal by secondary intention.
b. b.
delay closure of the wound for several days.
c. c.
refer the child to a plastic surgeon for wound closure.
d. d.
suture the wound within 6 hours.
ANS: D
Children are less likely than adults to get wound infections, with an infection rate from sutured
lacerations at 2%. The PNP should clean and suture the wound. Wounds from animal bites are
often left to heal by secondary intention to prevent infection. Referral to a plastic surgeon is
necessary for cosmetic reasons. Delaying closure for several days is recommended for heavily
contaminated wounds and those caused by high-velocity missile injuries, crush injuries, and
explosion injuries.
1. 2. A school-age child steps on a nail while wearing tennis shoes and develops cellulitis in
that foot. The child’s immunizations are up-to-date. What antibiotic will the pediatric nurse
practitioner empirically prescribe?
a. a.
Amoxicillin-clavulanate
b. b.
Ciprofloxacin
c. c.
Clindamycin
d. d.
Trimethoprim-sulfamethoxazole
ANS: B
Plantar puncture wounds, particularly those wounds that occur following puncture of
sneakers/shoes, require ciprofloxacin to cover potential Pseudomonas infection and to protect
against an osteomyelitis. Amoxicillin-clavulanate is used in other puncture wounds with signs of
infection. Clindamycin is used for similarly wounded children allergic to penicillins. TMP-SMX
is used if MRSA is cultured.
1. 3. A toddler is brought to the clinic after grabbing the hot end of his mother’s curling iron.
An examination reveals a pale, yellow burned area to the palm of one hand. What is true
about this burn?
a. a.
It may take up to 3 weeks to heal with scarring likely.
b. b.
c. c.
d. d.
Scarring is unlikely, with healing expected in 3 to 7 days.
Surgical intervention and skin grafting are usually required.
This type of burn usually heals without scarring in 7 to 14 days.
ANS: A
A deep partial-thickness burn appears pale and yellow and scarring is more likely to occur, with
complete healing taking up to 3 weeks. A superficial burn is erythematous without blisters and
heals in 3 to 7 days without scarring. A full-thickness burn involves extensive destruction of
underlying tissues and requires surgical intervention and skin grafts. A superficial
partial-thickness burn is red, mottled, moist, and painful and may scar, with healing in 7 to 14
days.
1. 4. A child is brought to the clinic immediately after being stung by a wasp while playing in
the yard. The physical examination reveals localized redness and edema at the site, along
with abdominal tenderness, watery eyes, and generalized hives. What is the initial treatment?
a. a.
Administer intramuscular epinephrine.
b. b.
Apply a topical glucocorticoid cream.
c. c.
Give oral diphenhydramine.
d. d.
Order a bronchodilator treatment.
ANS: A
This child has signs of a severe reaction to the sting and should receive epinephrine first,
followed by oral diphenhydramine and bronchodilators if wheezing. Topical glucocorticoids are
used for mild, localized reactions.
1. 5. A school-age child sustained a contusion on the front of one thigh while playing football
and reports some difficulty flexing his foot on the affected side. What will the primary care
pediatric nurse practitioner do to treat this injury?
a. a.
Place the child on crutches and limit weight-bearing until symptoms subside.
b. b.
Prescribe acetaminophen with hydrocodone along with NSAIDs.
c. c.
Recommend rest, ice packs, compression, and elevation of the extremity.
d. d.
Refer the child to an orthopedic specialist for immediate evaluation and treatment.
ANS: D
Children with contusions that restrict movement or sensation and those affecting the quadriceps
muscle may include compartment syndrome. These children should be referred to orthopedic
specialists immediately so that the compartment pressure does not result in irreplaceable damage.
The other options may be performed in consultation with a specialist.
1. 6. The primary care pediatric nurse practitioner is preparing to close a laceration on a
child’s forehead using topical skin adhesive. What is the correct way to apply this product?
a. a.
Apply the adhesive between the wound margins and then hold the edges together.
b. b.
Apply the adhesive to the wound and then secure the edges with surgical tape.
c. c.
d. d.
Have the child remain still for 15 to 20 minutes after the adhesive is applied.
Hold the wound edges together and apply the adhesive on top of the skin.
ANS: D
Topical adhesive is applied by holding the wound edges together (approximating the wound
edges) and then applying the adhesive on top, often requiring two or three applications of the
adhesive but allowing skin cooling between applications. The adhesive should not be applied
between the wound margins or in the wound. Surgical tape and bandages are not used with
topical adhesive. It is not necessary for the child to remain still after the adhesive is applied,
since it dries quickly.
1. 7. A child is bitten on one arm by a neighbor’s dog. The dog is immunized against rabies
and the child’s last tetanus immunization was 4 years prior. The wound edges are gaping and
avulsed. What is an important initial intervention when treating this injury?
a. a.
Administration of rabies prophylaxis and a tetanus booster
b. b.
Debriding and suturing the wound to prevent infection
c. c.
Irrigation of the wounds with high-pressure normal saline
d. d.
Reporting the animal bite to the local animal control authority
ANS: C
Animal and human bites need to be irrigated with normal saline using >5 psi of pressure. The
animal has been vaccinated for rabies and the child’s tetanus is current, so prophylaxis for both
of these is not indicated. There is controversy about whether primary closure is appropriate.
Reporting the animal is not a primary action.
1. 8. A child is bitten by a snake near a swimming pool in an area where copperhead snakes
are known to inhabit, although the parents cannot describe the snake. An examination of the
bite reveals a severe local reaction at the site with edema and intense pain. What will the
primary care pediatric nurse practitioner do first?
a. a.
Administer narcotic analgesics to provide comfort.
b. b.
Begin treatment with oral amoxicillin-clavulanate for 5 days.
c. c.
Clean the wound and administer tetanus prophylaxis.
d. d.
Transport the child by ambulance to a medical center.
ANS: D
If a venomous snakebite is suspected, rapid transportation to a medical center with referral to
appropriate specialists and antivenin therapy is indicated. Narcotics may impair clinical
evaluation. Non-venomous snakebites are treated with oral antibiotics if signs of infection are
present after the wound is cleaned and tetanus prophylaxis is given.
1. 9. A child is brought to the clinic after falling from a swing and scraping both knees and
hands. An examination reveals abraded skin with oozing serous fluid and blood, along with
dirt and grime from the playground surface. What will the primary care pediatric nurse
practitioner do to minimize the risk of infection?
a. a.
Apply povidone-iodine to all areas.
b. b.
Irrigate gently with normal saline.
c. c.
Rinse with hydrogen peroxide.
d. d.
Scrub the abraded areas with alcohol.
ANS: B
Gentle irrigation with water or normal saline is the preferred method for cleaning a wound.
Povidone-iodine, alcohol, and hydrogen peroxide should not be used on open wounds.
Burns: Pediatric Primary Care, 6th Edition
Chapter 15: Sexuality
Test Bank
Multiple Choice
1. The primary care pediatric nurse practitioner is performing a well child exam on an 8year-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
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.
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?
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Test Bank
2
a. Ask the adolescent whether she wishes to discuss these matters since she is
becoming an adult.
b. Separate the parent from the adolescent to discuss the adolescent’s concerns in
private.
c. Spend private time with the parent to discuss how sexuality education reduces the
risk of early sexual intercourse and risky sexual behaviors.
d. Tell the parent that this information is a routine part of adolescent well child
examinations and must be included.
ANS: C
Research has shown that sexuality education leads to a reduction in early onset of sexual
intercourse and risky sexual behaviors. It is important for the PNP to be sensitive to the
values of the family but also to advocate for the child. The child should be told,
especially when she shows an interest in sexual relationships, that she may seek care
independently of her parent and that it will remain confidential. When possible, the
parent’s wishes should be taken into account and both the adolescent and the parent
should be encouraged to begin an open dialogue about these matters.
4. The primary care pediatric nurse practitioner is counseling the parents of a 13-yearold female who has Down syndrome about sexual maturation. What will the nurse
practitioner tell these parents?
a. It is important to discuss and support healthy sexuality.
b. Providing too much information about sexuality may be confusing given the
child’s cognitive level of understanding.
c. Suppressing periods with contraceptives will lessen their daughter’s distress.
d. They should give her information about periods but not about sexuality.
ANS: A
Persons with disabilities have the same desires to make decisions and foster fulfilling
relationships with others as other people have. Unless healthy sexuality is taught and
supported, unhealthy and abusive sexuality is more likely to occur. Parents should give
information when it is desired and delivered in a manner appropriate to the child’s level
of understanding. Suppressing periods only ignores the issue but does not change the
increased feelings that accompany puberty.
5. During a well child examination of a 6-year-old girl, the primary care pediatric nurse
practitioner notes that the child becomes embarrassed and resists taking off her
underwear for the exam. What should the nurse practitioner infer from this
observation?
a. The child has been sexually molested.
b. The child is feeling violated by the examiner.
c. The parent is exhibiting regressive behavior.
d. This is a normal reaction in a child of this age.
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Test Bank
3
ANS: D
Young school-age children can be extremely modest and embarrassed and resist taking
off their clothes for an examiner. Since this is normal, it does not indicate a history of
sexual abuse unless other signs are present. Older school-age children more commonly
feel violated during an exam, not younger children. This response of increased modesty is
age-appropriate and not regressive.
6. The primary care pediatric nurse practitioner is providing anticipatory guidance to the
parent of a school-age boy. The parent expresses concerns that the child prefers to
play with dolls, is worried that the child will be a homosexual, and asks what can be
done to prevent this from happening. What will the nurse practitioner tell this parent?
a. Homosexual identity formation cannot be predicted by early childhood behavior.
b. Masculinizing boys from an early age helps to determine heterosexual orientation.
c. Sexual orientation identification begins late in adolescence and not in childhood.
d. The development of sexual orientation is generally a multifaceted process.
ANS: D
The etiology and age of preferred sexual orientation is unknown, and the sequential
developmental signs are debated. The development of sexual orientation is most likely
multifaceted and cannot be predicted by one phenomenon, such as playing with dolls
alone. Early childhood behavior can predict homosexual orientation as girls may feel
“unfeminine” and boys may exhibit feminine tendencies. It is clear that psychosocial
components and parenting do not cause or prevent homosexuality.
7. The primary care pediatric nurse practitioner is performing a well child examination
on a 3-year-old. The child’s parent reports that the child has recently begun
masturbating. What will the nurse practitioner counsel this parent?
a. To allow the behavior whenever it occurs, since it is normal
b. To discuss sexuality with the child
c. To explore whether the child is being abused
d. To teach the child about privacy and hand hygiene
ANS: D
Masturbation is normal at this age and children do this because it is pleasurable. Parents
should be taught to discuss privacy and hygiene with the child and to encourage the child
to limit the activity to a private place. At this age, the behavior is not associated with
sexual fantasies, so a discussion of sexuality is not warranted. Masturbation at this age is
common and is not usually an indication of abuse.
8. The parent of an 8-year-old child tells the primary care pediatric nurse practitioner
that the child has begun to ask questions about why a schoolmate has “2 daddies” and
wonders how to talk to the child about this. What will the nurse practitioner
recommend?
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Test Bank
4
a. Beginning a discussion about different types of sexual relationships and same-sex
partners
b. Discussing the issue with the child in terms of the parent’s religious values and
norms
c. Explaining that not all families are the same and what is most important is that
they love and care for their children
d. Telling the child that some adult relationships are complicated and will be
understood when the child is older
ANS: C
School age is a good time for parents to reinforce the notion that there is diversity in
families within which parents and adults love and care for their children. It is not
necessary to be explicit but to establish a good history of communication and to explain
complex issues to children at a level of the child’s understanding. In this way, the child
will know that parents are accessible and open to discussion of complex and/or puzzling
issues.
9. During a well child examination, a 15-year-old female tells the primary care pediatric
nurse practitioner that some of her friends have begun having sex. She has a
boyfriend but denies engaging in sex with him. What will the nurse practitioner do
initially?
a. Ask her for her definitions of “sex.”
b. Discuss the risks of sexually transmitted diseases.
c. Find out if she is considering sexual relations.
d. Give her information about contraception.
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.
Copyright © 2017, Elsevier Limited. All rights reserved.
Burns: Pediatric Primary Care, 6th Edition
Chapter 20: Cognitive-Perceptual Disorders
Test Bank
Multiple Choice
1. The parent of a 4-year-old child reports that the child gets upset when the hall light is
left on at night and won’t leave the house unless both shoes are tied equally tight. The
primary care pediatric nurse practitioner recognizes that this child likely has which
type of sensory processing disorder?
a. Dyspraxia
b. Over-responder
c. Sensory seeker
d. Under-responder
ANS: B
Children who are over-responders have difficulties with clothing, physical contact, light,
sounds, and food. Dyspraxia refers to difficulty recognizing and distinguishing shapes
and textures. Sensory seekers are on perpetual overdrive and often in trouble. Underresponders have little or no reaction to stimulation, pain, and extreme hot or cold.
2. The primary care pediatric nurse practitioner is considering medication options for a
school-age child recently diagnosed with ADHD who has a primarily hyperactive
presentation. Which medication will the nurse practitioner select initially?
a. Low-dose stimulant
b. Moderate-dose stimulant
c. Low-dose non-stimulant
d. Moderate-dose non-stimulant
ANS: B
Stimulants are generally the first-line medication for ADHD, with non-stimulants
recommended for non-responders. Moderate- to high-dose stimulants are recommended
for children with primarily hyperactive presentations.
3. The parent of a preschool-age child who is diagnosed with a sensory processing
disorder (SPD) asks the primary care pediatric nurse practitioner how to help the
child manage the symptoms. What will the nurse practitioner recommend?
a. Establishing a reward system for acceptable behaviors
b. Introducing the child to a variety of new experiences
c. Maintaining predictable routines as much as possible
d. Providing frequent contact, such as hugs and cuddling
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Test Bank
2
ANS: C
Children with SPD do best with an environment that is predictable and routine and the
same from day to day. Discipline and/or a reward system is not effective. Children with
SPD can become overwhelmed by new experiences or frequent touch.
4. The primary care pediatric nurse practitioner is examining a 3-year-old child who
speaks loudly, in a monotone, does not make eye contact, and prefers to sit on the
exam room floor moving a toy truck back and forth in a repetitive manner. Which
disorder does the nurse practitioner suspect?
a. Attention-deficit/hyperactivity disorder
b. Autism spectrum disorder
c. Executive function disorder
d. Sensory processing disorder
ANS: B
Autism spectrum disorder manifests in toddlers by alterations in socialization and speech
as described above, along with repetitive behaviors. ADHD manifests with a lack of
focus on activities and distractibility. Executive function disorders can manifest in a
variety of ways but not with repetitive behaviors. Children with sensory processing
disorders have altered responses to sensations.
5. The primary care pediatric nurse practitioner cares for a preschool-age child who was
exposed to drugs prenatally. The child bites other children and has tantrums when
asked to stop but is able to state later why this behavior is wrong. This child most
likely has a disorder of
a. executive function.
b. information processing.
c. sensory processing.
d. social cognition.
ANS: A
Children with prenatal drug or alcohol exposure often have executive function disorders,
characterized by an inability to stop or delay a response or interrupt an inappropriate
behavior and an inability to modify emotional expression appropriately. Information
processing refers to thinking and problem-solving ability. Sensory processing has to do
with the ability to take in information through senses and to process it appropriately.
Social cognition refers to the ability to interpret behavior and emotions of the self and
others.
6. A child who has attention-deficit/hyperactivity disorder (ADHD) has difficulty
stopping activities to begin other activities at school. The primary care pediatric nurse
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Test Bank
3
practitioner understands that this is due to difficulty with the self-regulation
component of
a. emotional control.
b. flexibility.
c. inhibition.
d. problem-solving.
ANS: B
Flexibility is a component of self-regulation, which is under the control of executive
functions in the cerebral cortex and is the ability to shift or transition between activities
or thoughts. Emotional control is the ability to modify emotional expression to the most
adaptive expression. Inhibition refers to the ability to stop or delay an initial response.
Problem solving is a component of metacognition.
7. The primary care pediatric nurse practitioner is selecting a medication for a 12-yearold child who is newly diagnosed with ADHD. The child is overweight, has a history
of an atrial septal defect at birth, and reports mild shortness of breath during exercise.
What will the nurse practitioner prescribe?
a. A low-dose stimulant medication
b. A non-stimulant medication
c. Behavioral therapy only
d. Cardiovascular pre-screening
ANS: D
Children with potential heart problems with symptoms such as previously detected
cardiac abnormalities and shortness of breath with exercise should have a cardiovascular
evaluation by a cardiologist prior to initiating treatment. If the screening and assessment
are normal, a stimulant medication may be prescribed.
8. The primary care pediatric nurse practitioner is evaluating a school-age child who has
been diagnosed with ADHD. Which plan will the nurse practitioner recommend
asking the child’s school about to help with academic performance?
a. 504
b. FAPE
c. IDEA
d. IEP
ANS: A
The Section 504 plan specifies “reasonable accommodations” to help children with
disabilities, such as physical or mental conditions, to benefit from their education. Many
children with ADHD with learning disabilities but not cognitive deficits are eligible for
this plan. FAPE, or free and appropriate public education, is a part of the special
education system and lays out regulations for providing special education. IDEA is the
Individuals with Disabilities Education Act, which provides mandates for providing
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Test Bank
4
education for children with disabilities. An IEP, or Individualized Education Plan, is a
written plan defining disabilities, educational needs, and specific annual goals for
meeting these needs. It is not generally used for children who do not have cognitive
deficits, such as those with ADHD.
9. The primary care pediatric nurse practitioner is conducting a follow-up examination
on a child who has recently begun taking a low-dose stimulant medication to treat
ADHD. The child’s school performance and home behaviors have improved. The
child’s parent reports noticing a few tics, such a twitching of the eyelids, but the child
is unaware of them and isn’t bothered by them. What will the nurse practitioner
recommend?
a. Adding an alpha-agonist medication
b. Changing to a non-stimulant medication
c. Continuing the medication as prescribed
d. Stopping the medication immediately
ANS: C
Tics may occur as a side effect of stimulant medications but do not need to be
discontinued if there is a net benefit and the symptoms are not disturbing to the child. It is
not necessary to add an alpha-agonist, change to a non-stimulant medication, or stop the
medication.
10. The primary care pediatric nurse practitioner uses the Neurodevelopmental Learning
Framework to assess cognition and learning in an adolescent. When evaluating social
cognition, the nurse practitioner will ask the adolescent
a. about friends and activities at school.
b. if balancing sports and homework is difficult.
c. to interpret material from a pie chart.
d. to restate the content of something just read.
ANS: A
Social cognition is one construct of the Neurodevelopmental Learning Framework and is
the ability to know what to discuss when, with whom, and for how long as well as the
ability to work and play with others in a cooperative manner. Asking about friends will
tell the PNP something about this ability. Determining the ability to manage a schedule
assesses temporal-sequential ordering ability. Evaluating interpretation of material
presented in a chart format assesses spatial ordering skills or visual thinking. Asking the
adolescent to restate something in his or her own words assesses language and verbal
skills.
11. The parent of a child diagnosed with ADHD tells the primary care pediatric nurse
practitioner that the child gets overwhelmed by homework assignments, doesn’t seem
to know which ones to do first, and then doesn’t do any assignments. The nurse
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Test Bank
5
practitioner tells the parent that this represents impairment in which executive
function?
a. Activation
b. Effort
c. Emotion
d. Focus
ANS: A
Activation is an executive function that helps individuals organize, prioritize, and begin
activities. This child cannot prioritize a group of assignments and winds up not doing any
of them, showing an inability to prioritize and begin activities. Effort is the function
associated with sustaining effort and regulating awareness. Emotion is the function of
managing frustration. Focus is associated with sustaining and shifting attention to a task.
12. The primary care pediatric nurse practitioner is performing an examination on a 5year-old child who exhibits ritualistic behaviors, avoids contact with other children,
and has limited speech. The parent reports having had concerns more than 2 years ago
about autism, but was told that it was too early to diagnose. What will the nurse
practitioner do first?
a. Administer an M-CHAT screen to screen the child for communication and
socialization delays.
b. Ask the parent to describe the child’s earlier behaviors from infancy through
preschool.
c. Reassure the parent that if symptoms weren’t present earlier, the likelihood of
autism is low.
d. Refer the child to a pediatric behavioral specialist to develop a plan of treatment
and management.
ANS: B
The DSM-5 criteria state that a patient must show symptoms from early childhood even if
the symptoms are not recognized until later in life. The parent had noticed symptoms
prior but was told not to worry; these symptoms should be evaluated in light of the
current symptoms. The M-CHAT is used for infants and toddlers and not for school-age
children. Autism symptoms are generally evident by age 3 years. The PNP should
complete the assessment before making a referral.
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Burns: Pediatric Primary Care, 6th Edition
Chapter 26: Endocrine and Metabolic Disorders
Test Bank
Multiple Choice
1. An initial key part of management of a child suspected of having an inborn error of
metabolism is
a. consulting a metabolic specialist.
b. obtaining a complete family history.
c. ordering metabolic screening tests.
d. referring the family to a dietician.
ANS: A
A metabolic specialist should be consulted as soon as an IEM is suspected and common
etiologies for symptoms have been ruled out. A complete family history and metabolic
screening tests will be part of the ongoing diagnostic process, but these should not delay
referral since many of these disorders can have life-threatening or devastating outcomes.
Once the diagnosis is known, a dietician may be consulted.
2. The primary care pediatric nurse practitioner performs a physical examination on a 9month-old infant with congenital hypothyroidism who takes daily levothyroxine
sodium and notes a recent slowing of the infant’s growth rate. What will the nurse
practitioner order?
a. Free serum T4 and TSH levels
b. Serum levothyroxine level
c. Total T4 and free T4 levels
d. TSH and total T4 levels
ANS: A
The infant is showing signs of hypothyroidism. Free serum T4 will be low and TSH will
be high in central hypothyroidism; these are monitored to determine whether doses of
levothyroxine are adequate. Serum levothyroxine levels are not used. Total T4 is used to
diagnose TBG deficiency.
3. The primary care pediatric nurse practitioner is performing a well child examination
on a 12-year-old child who was diagnosed with type 1 diabetes at age 9. The child
had a lipid screen at age 10 with an LDL cholesterol <100 mg/dL. What will the
nurse practitioner recommend as part of ongoing management for this child?
a. Annual lipid profile evaluation
b. Annual screening for microalbuminuria
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Test Bank
2
c. Comprehensive ophthalmologic exam
d. Hypothyroidism screening every 5 years
ANS: C
Children who have been diagnosed for 3 to 5 years and who are over age 10 should be
referred for annual comprehensive ophthalmologic exams. This child had a previous
normal lipid profile and needs to be evaluated every 5 years and not annually. Annual
screening for microalbuminuria begins at 5 years after onset. Hypothyroidism screening
should be done annually.
4. The primary care pediatric nurse practitioner is evaluating a child who has short
stature. Although bone age studies reveal a delay in bone age, the child’s growth is
consistent with bone age. Which diagnosis is most likely?
a. Constitutional growth delay
b. Growth hormone deficiency
c. Idiopathic short stature
d. Klinefelter syndrome
ANS: A
Children with constitutional growth delay have a delay in bone age but growth patterns
consistent with bone age. Children with growth hormone deficiency have a delay in both
bone age and growth. Children with idiopathic short stature will have a bone age
consistent with chronological age. Klinefelter syndrome is an overgrowth syndrome.
5. A 16-year-old adolescent female whose BMI is at the 90th percentile reports irregular
periods. The primary care pediatric nurse practitioner notes widespread acne on her
face and back and an abnormal distribution of facial hair. The nurse practitioner will
evaluate her further based on a suspicion of which diagnosis?
a. Dyslipidemia
b. Hypothyroidism
c. Nonalcoholic steatohepatitis
d. Polycystic ovary syndrome
ANS: D
PCOS has symptoms of irregular menses, acne, and hirsutism and is associated with
obesity. Dyslipidemia, hypothyroidism, and nonalcoholic steatohepatitis are all possible
conditions associated with obesity but do not have the symptoms described in the
scenario.
6. A 13-year-old Native American female has a BMI at the 90th percentile for age. The
primary care pediatric nurse practitioner notes the presence of a hyperpigmented
velvet-like rash in skin folds. The child denies polydipsia, polyphagia, and polyuria.
The nurse practitioner will
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Test Bank
a.
b.
c.
d.
3
counsel the child to lose weight to prevent type 2 diabetes.
diagnose type 2 diabetes if the child has a random glucose of 180 mg/dL.
order a fasting blood sample for a metabolic screen for type 2 diabetes.
refer the child to a pediatric endocrinologist.
ANS: C
This child has three risk factors for type 2 diabetes: Native American ethnicity,
overweight, and acanthosis nigricans. The PNP should perform metabolic screening on a
fasting blood sample to diagnose this. Lifestyle changes may be necessary to control the
disease if diagnosed, but this child may already have the disease, and management
options aren’t clear until the diagnosis is made. Diagnosis is based on a random glucose
>200 mg/dL. It is not necessary to refer this child until a diagnosis is made.
7. A 12-year-old child has a recent history of increased thirst and frequent urination. The
child’s weight has been in the 95th percentile for several years. A dipstick UA is
positive for glucose, and random plasma glucose is 350 mg/dL. Which test will the
primary care pediatric nurse practitioner order to determine the type of diabetes in
this child?
a. Fasting plasma glucose
b. Hemoglobin A1C levels
c. Pancreatic antibodies
d. Thyroid function tests
ANS: C
If the type of diabetes is uncertain, screening for pancreatic antibodies should be
considered to confirm the diagnosis of type 1 diabetes. Fasting plasma glucose may be
elevated in both types. Hemoglobin A1C does not distinguish among types. Thyroid
function tests are not indicated unless there is a suspicion of concomitant associated
autoimmune conditions.
8. A 6-year-old female has had a recent growth spurt and an exam reveals breast and
pubic hair development. Her bone age is determined to be 8 years. What will the
primary care pediatric nurse practitioner do next?
a. Order LH and FSH levels and a long-acting GnRH agonist.
b. Order thyroid function tests to exclude primary hypothyroidism.
c. Reassure the parent that this is most likely idiopathic.
d. Refer the child to a pediatric endocrinologist for management.
ANS: D
Children with early puberty should always be referred to a pediatric endocrinologist for
evaluation and management. The PNP may order lab work in consultation with an
endocrinologist but should refer when this condition is suspected. Thyroid function tests
are performed for isolated menarche. Reassuring the parent without completely
diagnosing the condition is not indicated.
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Test Bank
4
9. The primary care pediatric nurse practitioner evaluates children’s growth to screen for
endocrine and metabolic disorders. Which is a critical component of this screening?
a. Measuring supine length in children over the age of 2 years
b. Obtaining serial measurements to assess patterns over time
c. Using the CDC growth chart for children under age 2 years
d. Using the WHO growth chart for children over age 2 years
ANS: B
Measuring stature is an important part of a physical examination to screen for endocrine
and metabolic disorders. Serial measurements are critical to assess growth patterns over
time. Supine length is measured in children under the age of 2 years. CDC growth charts
should be used in children older than 2 years and WHO charts in children under age 2
years.
10. The primary care pediatric nurse practitioner diagnoses an 8-year-old child with type
1 diabetes after a routine urine screen is positive for glucose and negative for ketones
and plasma glucose is 350 mg/dL. The child’s weight is normal and the parents report
a mild increase in thirst and urine output in the past few days. Which course of action
is correct?
a. Admit the child to the hospital for initial insulin management.
b. Begin insulin and refer the child to a children’s diabetes center.
c. Order a fasting serum glucose and a dipstick UA in the morning.
d. Send the child to the emergency department for fluids and IV insulin.
ANS: B
Children without diabetic ketoacidosis may be managed as outpatients, but newly
diagnosed patients should be referred to a children’s diabetes center for insulin therapy
and diabetes education. Unless the child is ketoacidotic, hospitalization or ED referral is
not indicated. It is not necessary to order further testing.
11. The primary care pediatric nurse practitioner is performing a well child examination
on a 5-year-old girl. The parents ask if the child s adult height can be predicted. The
nurse practitioner learns that the mother is 5'8" tall and the father is 5'11" tall. The
nurse practitioner will estimate which expected adult height for this child?
a. 5'11" tall
b. 5'7" tall
c. 5'8" tall
d. 6' tall
ANS: B
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Test Bank
5
Calculation of expected adult height for a girl is: [(Father s height - 5 in.) + (Mother s
height)]/2, so [(71" - 5") + 68"]/2 = 134/2 = 67" or 5'7". A calculation of boy s expected
height: [(Mother s height + 5 in.) + (Father s height)]/2 would be 6' tall.
12. A 7-year-old female has recently developed pubic and axillary hair without breast
development. Her bone age is consistent with her chronological age, and a pediatric
endocrinologist has diagnosed idiopathic premature adrenarche. The primary care
pediatric nurse practitioner will monitor this child for which condition?
a. Adrenal tumor
b. Congenital adrenal hyperplasia
c. Polycystic ovary syndrome
d. Type 1 diabetes mellitus
ANS: C
Children with idiopathic premature adrenarche are at increased risk for PCOS and
metabolic syndrome. Adrenal tumor and CAH are both possible causes of premature
adrenarche, but these have been ruled out to make a diagnosis of idiopathic premature
adrenarche. Type 2 diabetes is related to metabolic syndrome, not type 1.
13. The primary care pediatric nurse practitioner is reviewing lab work and diabetes
management with a school-age child whose HbA1C is 7.6% who reports usual blood
sugars before meals as being 80 to 90 mg/dL. The nurse practitioner will consult with
the child’s endocrinologist to consider which therapy?
a. Continuous glucose monitoring
b. Continuous subcutaneous insulin infusion
c. Self-monitoring of blood glucose
d. Use of a long-acting insulin analogue
ANS: A
This child has an elevated HbA1C and signs of hypoglycemia before meals. Continuous
glucose monitoring reports both real time interstitial glucose levels and directional
trending graphs every few minutes with alarms that warn of low and high blood glucose
levels. Recent research has indicated that use of the CGM is effective in lowering HbA1C
and decreasing hypoglycemic episodes. CSII allows flexibility with timing of meals and
adjustment of insulin doses. Self-monitoring of blood glucose does not lower HbA1C or
decrease hypoglycemic episodes.
14. The primary care pediatric nurse practitioner is performing a well child examination
on a 2-year-old child with a history of intrauterine growth retardation (IUGR) whose
height remains less than the 3rd percentile on a WHO growth chart. What will the
nurse practitioner do?
a. Consider prescribing growth hormone therapy.
b. Reassure the parent that this is normal for this child.
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Test Bank
6
c. Refer the child to a dietician for dietary supplementation.
d. Refer the child to a pediatric endocrinologist.
ANS: D
Children with IUGR who fail to catch up by age 2 may be candidates for GH therapy and
should be referred to a pediatric endocrinologist. The PNP does not prescribe GH; this
must be done by a pediatric endocrinologist. Although this is common for these children,
parents should be offered options for treatment. Dietary supplementation may be part of
therapy, but the need for GH therapy should be evaluated.
15. The primary care pediatric nurse practitioner notes a musty odor when examining a
newborn at a 2-week checkup. What will the nurse practitioner suspect?
a. Galactosemia
b. Glucose-6-phosphatase deficiency
c. Phenylketonuria
d. Urea cycle disorder
ANS: C
Children with phenylketonuria have a musty or mousy odor. Galactosemia causes poor
weight gain, lethargy, and jaundice after milk feeding has begun. Glucose-6-phosphatase
deficiency causes cardiomegaly and seizure. Urea cycle disorders are characterized by
vomiting and lethargy.
16. An infant has congenital adrenal hyperplasia. At a routine well baby checkup, the
primary care pediatric nurse practitioner notes vomiting, poor feeding, lethargy, and
mild dehydration. Which action is correct?
a. Administer an intramuscular stress dose of hydrocortisone succinate.
b. Administer intravenous fluids in the clinic and reassess hydration status.
c. Prescribe an oral hydrocortisone in a replacement dose of 8 to 10 mg/M2.
d. Refer the infant to the emergency department for fluids, dextrose, and steroids.
ANS: D
The infant is showing signs of adrenal crisis and will need ED management for IV
dextrose, normal saline, and stress doses of hydrocortisone succinate. Because of the
presence of dehydration, the infant will need IV fluids but must be sent to the ED because
of the risk of a worsening crisis. Oral hydrocortisone in replacement doses is given as
part of routine management, not as treatment for adrenal crisis.
17. The mother of a female infant is concerned that her daughter is developing breasts.
The primary care pediatric nurse practitioner notes mild breast development but no
pubic or axillary hair. What is the likely diagnosis?
a. Congenital adrenal hyperplasia causing breast development
b. Precocious puberty needing endocrinology management
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Test Bank
7
c. Premature adrenarche which will lead to pubic hair onset
d. Premature thelarche which will resolve over time
ANS: D
Infant and toddler girls may have isolated breast development, or premature thelarche,
which usually resolves over time and rarely progresses to true precocious puberty. CAD
will have other symptoms and is associated with premature adrenarche, which is the early
development of pubic and axillary hair. Precocious puberty involves the early onset of
multiple features of puberty and not just breast development.
18. The primary care pediatric nurse practitioner is providing nutritional counseling for a
9-year-old female whose weight is at the 95th percentile for her age. What is the goal
for this patient?
a. A loss of 10 to 15 pounds in 6 months
b. An average weight loss of 2 pounds per month
c. Maintenance of her current weight
d. Weight loss of 5% of her current body weight
ANS: C
The goal for weight management in obese children is weight maintenance and not weight
loss, allowing the child to grow into her weight to achieve a BMI less than the 85th
percentile.
19. The primary care pediatric nurse practitioner prescribes metformin for a 15-year-old
adolescent newly diagnosed with type 2 diabetes. What will the nurse practitioner
include when teaching the adolescent about this drug?
a. That insulin therapy will be necessary in the future
b. The importance of checking blood glucose 3 or 4 times daily
c. To consume a diet with foods that are high in vitamin B12
d. To use a stool softener to prevent gastrointestinal side effects
ANS: B
The PNP should counsel youth taking metformin to increase foods high in vitamin B12.
Insulin therapy is necessary only for those with ketonuria or diabetic ketoacidosis or later,
when the body becomes unable to produce sufficient insulin. Metformin does not cause
hypoglycemia, so patients only need to check blood glucose twice daily: once before
breakfast and again 2 hours after dinner. GI side effects are mild and self-limiting.
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Burns: Pediatric Primary Care, 6th Edition
Chapter 31: Cardiovascular Disorders
Test Bank
Multiple Choice
1. A 5-year-old child who had a repair for transposition of the great arteries shortly after
birth is growing normally and has been asymptomatic since the surgery. The primary
care nurse practitioner notes mild shortness of breath with exertion and, upon
questioning, learns that the child has recently complained of dizziness. What will the
nurse practitioner do?
a. Order an echocardiogram and chest radiograph.
b. Perform pulmonary function testing.
c. Reassure the parent that these symptoms are common.
d. Refer the child to the cardiologist immediately.
ANS: D
Children with a history of d-TGA who have a history of palpitations, syncope, or
shortness of breath should be referred to a cardiologist. Echocardiograms should be
performed annually under the supervision of the cardiologist. Pulmonary function testing
is not indicated. These symptoms may represent problems in patency with the coronary
arteries and are not common.
2. A 12-year-old child whose weight and BMI are in the 75th percentile has a diastolic
blood pressure that is between the 95th and 99th percentiles for age, sex, and height
on three separate occasions. Initial tests for this child will include
a. complete blood count.
b. erythrocyte sedimentation rate.
c. renal function and plasma renin tests.
d. urinalysis and electrolytes.
ANS: C
Since the majority of children with stage 1 or 2 hypertension have renal or renovascular
causes for elevated BP, renal function and plasma renin tests should be performed.
Children under 10 years of age with stage 2 hypertension should have more aggressive
laboratory evaluation, including CBC, ESR, UA, and electrolytes.
3. During a well baby examination of a 6-week-old infant, the primary care pediatric
nurse practitioner notes poor weight gain, acrocyanosis of the hands and feet, and a
respiratory rate of 60 breaths per minute. Oxygen saturation on room air is 93%. The
remainder of the exam is unremarkable. Which action is correct?
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Test Bank
a.
b.
c.
d.
2
Follow-up in 1 week to assess the infant’s weight.
Order a chest radiograph and an electrocardiogram.
Reassure the parents that the exam is within normal limits.
Refer the infant to a pediatric cardiologist.
ANS: D
Infants with oxygen saturation less than 95% and those with poor feeding should be
referred emergently to a cardiologist. The infant may have CHF and will need to be
evaluated.
4. The primary care pediatric nurse practitioner is performing a well child examination
on a school-age child who had complete repair of a tetralogy of Fallot defect in
infancy. What is important in this child’s health maintenance regime?
a. Cardiology clearance for sports participation
b. Restriction of physical activity to avoid pulmonary complications
c. Sub-acute bacterial endocarditis prophylaxis precautions
d. Teaching about management of hypercyanotic episodes
ANS: A
Children who have had TOF repair must be cleared by cardiology before participation in
sports, but there is no need to restrict all physical activity. SBE prophylaxis is given prior
to surgery and for 6 months afterward. Hypercyanotic episodes occur before repair.
5. The primary care pediatric nurse practitioner performs a well child examination on a
12-month-old child who had repair of a congenital heart defect at 8 months of age.
The child has a normal exam. The parent reports that the child is not taking any
medications. The nurse practitioner will contact the child’s cardiologist to discuss
whether the child needs which medication?
a. Amoxicillin
b. Capoten
c. Digoxin
d. Furosemide
ANS: A
Children who have had complete repair of CHD should have SBE prophylaxis with
amoxicillin for 6 months after the procedure. Capoten, an antihypertensive, digoxin, an
inotropic medication, and furosemide, a diuretic, are given for specific symptoms as
indicated.
6. An infant with trisomy 21 has a complete AV canal defect. Which finding, associated
with having both of these conditions, will the primary care pediatric nurse practitioner
expect?
a. Crackles in both lungs
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Test Bank
3
b. Hepatomegaly
c. Oxygen desaturation
d. Peripheral edema
ANS: C
Because infants with trisomy 21 maintain neonatal high pulmonary vascular resistance,
they often do not show signs of CHF but instead will have signs of pulmonary
hypertension with loud single S2 and desaturation with agitation or effort. Crackles,
hepatomegaly, and edema are signs of CHF.
7. A 3-month-old infant who was previously healthy now has a persistent cough,
bilateral lung crackles, and poor appetite. The primary care pediatric nurse
practitioner auscultates a grade III/VI, low-pitched, holosystolic murmur over the left
lower sternal border and palpates the liver at one centimeter below the ribs. What
diagnosis is likely?
a. Atrial septal defect
b. Coarctation of the aorta
c. Patent ductus arteriosis
d. Ventricular septal defect
ANS: D
The symptoms above are characteristic of a VSD and may not present at birth but appear
later as CHF becomes more pronounced. An ASD typically does not have a murmur until
the child is 2 or 3 years old, but the provider can often hear a split S2 sound. Coarctation
of the aorta may cause a systolic ejection murmur. A PDA has a characteristic
machinery-like murmur.
8. The primary care pediatric nurse practitioner provides primary care for a 4-month-old
infant who has a ventricular septal defect. The infant has been breastfeeding well but
in the past month has dropped from the 20th percentile to the 5th for weight. What
will the nurse practitioner recommend?
a. Adding solid foods to the infant’s diet to increase caloric intake
b. Fortifying breast milk to increase the number of calories per ounce
c. Stopping breastfeeding and giving 30 kcal/ounce formula
d. Supplementing breastfeeding with 24 kcal/ounce formula
ANS: B
Infants with heart defects who have CHF may need modification of formula or breast
milk to increase calories. This infant is nursing well, so fortifying the breast milk to
increase calories is the first and best option. Adding solids does not significantly increase
caloric intake.
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Test Bank
4
9. During a well child assessment, the primary care pediatric nurse practitioner
auscultates a harsh, blowing grade IV/VI murmur in a 6-month-old infant. What will
the nurse practitioner do next?
a. Get a complete blood count to rule out severe anemia.
b. Obtain an electrocardiogram to assess for arrhythmia.
c. Order a chest radiograph to evaluate for cardiomegaly.
d. Refer to a pediatric cardiologist for further evaluation.
ANS: D
A harsh, blowing murmur is suspicious for pathology, so a cardiology referral is
warranted. The cardiologist will determine which tests and procedures should be
performed.
10. A 6-year-old child has a systolic blood pressure between the 95th and 99th percentile
for age, sex, and height and a diastolic blood pressure between the 90th and the 95th
percentile on three separate clinic visits. This child’s blood pressure is classified as
a. normotensive.
b. pre-hypertensive.
c. stage 1 hypertensive.
d. stage 2 hypertensive.
ANS: C
Stage 1 hypertensive pressure ranges from the 95th percentile or from 120/80 mm Hg to
5 mm Hg above the 99th percentile for age, sex, and height for either systolic or diastolic
pressure. Normotensive pressure is below the 90th percentile. Pre-hypertensive pressure
is between the 90th and 95th percentiles. Stage 2 hypertensive pressure is greater than the
99th percentile.
11. A 15-year-old female reports fainting at school in class on two occasions. The
adolescent’s orthostatic blood pressures are normal. The primary care pediatric nurse
practitioner suspects a cardiac cause for these episodes and will order which tests
before referring her to a pediatric cardiologist?
a. 12-lead electrocardiogram
b. Echocardiogram
c. Tilt table testing
d. Treadmill exercise testing
ANS: A
A 12-lead ECG is useful for initial evaluation. Echocardiogram may be performed if the
ECG shows potential cardiomyopathy. Tilt table testing is not recommended for use in
primary care due to poor reliability. Treadmill exercise testing may be used in cases of
exercise-related syncope.
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Test Bank
5
12. During a routine well child exam on a 5-year-old child, the primary care pediatric
nurse practitioner auscultates a grade II/VI, harsh, late systolic ejection murmur at the
upper left sternal border that transmits to both lung fields. The child has normal
growth and development. What will the nurse practitioner suspect?
a. Aortic stenosis
b. Patent ductus arteriosus
c. Pulmonic stenosis
d. Tricuspid atresia
ANS: C
Pulmonic stenosis may be asymptomatic with a murmur as described above. Aortic
stenosis is characterized by a louder, harsh systolic crescendo-decrescendo murmur at the
upper right sternal border with radiation to the neck, LLSB, and apex. PDA has a
machinery-like murmur. Tricuspid atresia is characterized by cyanosis.
13. A 12-year-old child whose BMI is greater than the 95th percentile has a blood
pressure at the 98th percentile for age, sex, and height. After lifestyle changes that
include diet and exercise, the child’s BMI drops to the 90th percentile, but the blood
pressure remains the same. What is the primary care pediatric nurse practitioner’s
next step in treating this child?
a. Continued close monitoring of blood pressure
b. Ordering an echocardiogram or MRI
c. Prescribing an ACE inhibitor medication
d. Referral to a nephrologist or cardiologist
ANS: D
Children who have persistent BP elevation after lifestyle changes are made should be
referred to a nephrologist or cardiologist who has experience using antihypertensive
agents in children. The specialist orders necessary tests and medications, not the primary
care provider.
14. A 12-month-old infant who had cardiopulmonary bypass with RBC and plasma
infusions during surgery at 8 months is seen for a well child examination. Which
vaccine may be administered at this visit?
a. MMR
b. OPV
c. PCV-13
d. Varivax
ANS: C
Live vaccines should be delayed until 6 months after cardiopulmonary bypass and
exposure to RBCs and plasma. The PCV-13 is not a live-virus vaccine and the others are.
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Test Bank
6
15. The primary care pediatric nurse practitioner is performing a sports physical on an
adolescent whose history reveals mild aortic stenosis. What will the nurse practitioner
recommend?
a. Avoidance of all sports to prevent sudden death
b. Clearance for any sports since this is mild
c. Evaluation by a cardiologist prior to participation
d. Low-intensity sports, such as golf or bowling
ANS: C
Children with mild AS may participate in any sport but must have annual cardiac
evaluations. Children with severe AS should avoid sports to prevent sudden death. The
PNP should not clear the child for sports without a cardiology evaluation. Low-intensity
sports are recommended for children with moderate AS.
16. The primary care pediatric nurse practitioner is examining a 2-week-old infant and
auscultates a wide splitting of S2 during expiration. What condition may this finding
represent?
a. Atrial septal defect
b. Coarctation of the aorta
c. Patent ductus arteriosis
d. Ventricular septal defect
ANS: A
A wide splitting of S2 without becoming a single sound on expiration may indicate
increased pulmonary flow, typical of atrial septal defect. Coarctation of the aorta may
cause a systolic ejection murmur. A patent ductus arteriosus has a characteristic
machinery-like murmur. A ventricular septal defect has a harsh, high-pitched, grade II to
IV/VI holosystolic murmur.
17. A 5-year-old child has an elevated blood pressure during a well child exam. The
primary care pediatric nurse practitioner notes mottling and pallor of the child’s feet
and lower legs and auscultates a systolic ejection murmur in the left infraclavicular
region radiating to the child’s back. The nurse practitioner will suspect which
condition?
a. Aortic stenosis
b. Coarctation of the aorta
c. Patent ductus arteriosus
d. Pulmonic stenosis
ANS: B
Coarctation of the aorta may not have symptoms until later childhood and may present as
high blood pressure in the upper extremities and poor perfusion in the lower extremities.
A systolic ejection murmur at the left infraclavicular region with transmission to the back
is characteristic. Aortic stenosis is characterized by a louder, harsh systolic crescendo-
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Test Bank
7
decrescendo murmur at the upper right sternal border with radiation to the neck, LLSB,
and apex. PDA has a machinery-like murmur. Pulmonic stenosis may be asymptomatic or
may have a harsh, late systolic ejection murmur at the upper left sternal border that
transmits to both lung fields.
18. A 7-year-old child who has a history of a repaired congenital heart defect has many
dental caries along with gingival erythema and irritation and a temperature of
102.5°F. What will the primary care pediatric nurse practitioner do next?
a. Admit to the hospital with a pediatric cardiology consult.
b. Obtain blood cultures and a CBC and consult a pediatric cardiologist.
c. Refer the child to a pediatric dental surgeon immediately.
d. Start prophylactic antibiotics such as penicillin twice daily for 2 weeks.
ANS: A
Children who are suspected of having SBE should be admitted to the hospital and
referred to pediatric cardiology. The child should begin treatment as soon as SBE is
suspected, so getting labs and then consulting a cardiologist is not correct. The SBE is the
priority treatment, not the gingivitis or caries. Treatment should include IV antibiotics in
the hospital.
19. An adolescent female has a history of repaired tetralogy of Fallot. Which long-term
complication is a concern for this patient?
a. Aortic stenosis
b. Chronic cyanosis
c. Mitral valve prolapse
d. Ventricular failure
ANS: C
Patients with repaired TOF, especially adolescent females, are at risk for mitral valve
prolapse. Aortic aneurysm is a long-term risk for those with a history of left-sided
lesions. Chronic cyanosis is a concern for lesions causing Eisenmenger syndrome or
defects causing right ventricular outflow obstruction. Ventricular failure can occur with
prolonged aortic or pulmonic valvar stenosis.
20. The primary care pediatric nurse practitioner auscultates a new grade II vibratory,
mid-systolic murmur at the mid sternal border in a 4-year-old child that is louder
when the child is supine. What type of murmur is most likely?
a. Pathologic murmur
b. Pulmonary flow murmur
c. Still’s murmur
d. Venous hum
ANS: C
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Test Bank
8
A Still’s murmur is characterized by a vibratory or musical low-grade sound, along the
sternal border, which is louder when the child is supine or during inspiration. It is usually
heard in children between the ages of 2 and 6 years old. Pathologic murmurs are usually
harsh, not vibratory. A pulmonary flow murmur has a soft, blowing sound and radiates to
the lung fields. A venous hum has a soft, high-pitched swishing sound.
21. A 9-month-old infant has a grade III/VI, harsh, rumbling, continuous murmur in the
left infraclavicular fossa and pulmonic area. A chest radiograph reveals cardiac
enlargement. The primary care pediatric nurse practitioner will refer the infant to a
pediatric cardiologist and prepare the parents for which intervention to repair this
defect?
a. Cardiopulmonary bypass surgery
b. Coil insertion in the catheterization laboratory
c. Indomethacin administration
d. Observation for spontaneous closure
ANS: B
This murmur is characteristic of a PDA and, because of cardiac enlargement, represents a
larger shunt, requiring repair. Infants older than 8 months of age may have a coil or plug
inserted into the shunt in the cardiac catheterization laboratory. Cardiopulmonary bypass
surgery is not indicated, even with ligation of the shunt. Indomethacin is administered to
premature infants in the early post-natal period and is not useful in term or older infants.
Because this infant is symptomatic, observation for spontaneous closure is not
recommended.
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