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197 Cards in this Set
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Laboratory analysis of neonatal ocular discharge would be positive for gram-negative intracellular diplococci for which of the following organisms?
A. Chlamydia. B. Haemophilus influenzae. C. Adenovirus. D. Gonococcus. |
D. Gonococcus.
Gram-negative intracellular diplococcus are diagnostic of N. gonorrhoeae infection and will not be present with infections caused by the other organisms. |
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Ms. Smith brings her 6 month old daughter into the clinic for her well child checkup. When asked if she has any concerns regarding her daughter, she states “Her left eye tears all the time and has since birth. I went to urgent care once and the doctor gave me some antibiotic for her eye but that didn’t seem to help.” After completing your history and physical exam, you assess the infant to be healthy except for left dacryostenosis without evidence of infection. What education and counseling would you give the mother regarding your findings?
A. Referral to an ophthalmologist is recommended since this condition has continued for 6 months. B. Another course of ophthalmic antibiotics is recommended to prevent infection while we wait for the tearing to stop. C. Spontaneous resolution almost always occurs by 12 months of age. D. The blockage in the tear duct was probably the result of a minor neonatal eye infection. |
C. Spontaneous resolution almost always occurs by 12 months of age.
Dacryostenosis is the result of cellular debris blocking the normal drainage system from the eye into the nose. It is not secondary to an infection. 95% of infants with dacryostenosis will have spontaneous resolution by 12 months of age. Antibiotics are not necessary unless the eye drainage becomes purulent. |
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Justin is a 12-year-old boy brought in by his mother because of “swelling around his right eye for the past 24 hours.” When evaluating Justin to determine whether he has a periorbital cellulitis or orbital cellulitis, which of the following findings would support the diagnosis of orbital cellulitis?
A. History and evidence of a recent insect bite near the right eye. B. Proptosis of the right eye and decreased visual acuity. C. Induration, erythema, and tenderness around the right eye. D. History of being hit with a baseball in the right eye in the past 48 hours. |
B. Proptosis of the right eye and decreased visual acuity.
The diagnostic feature of orbital cellulitis is proptosis of the affected eye with visual changes. Trauma and insect bites are commonly associated with periorbital infections. Redness, swelling, and tenderness are common with both periorbital and orbital cellulitis. |
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Heather, age 18 months, is found to have a positive cover-uncover test for her right eye during her well child examination. Heather’s mother reports she has noticed her daughter’s “eye turning in when she is tired.” Which of the following management plans would be appropriate at this time?
A. Refer to ophthalmology for evaluation and treatment. B. Patch the right eye and tell mother to have the patch on 8 hours a day. C. Schedule a return appointment in 2 months to reassess the eye. D. Discuss with mother the need for surgery in the immediate future. |
A. Refer to ophthalmology for evaluation and treatment.
Strabismus is a common cause of amblyopia and needs to be treated before loss of vision occurs. It is unknown if the current strabismus is due to weak eye muscles or refractive error, so the child must be seen by an ophthalmologist to decide the appropriate treatment. Patching may be indicated but not for 8 hours at a time. |
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Alicia is 4 years old and was brought to the urgent care clinic by her mother because the school nurse called to report Alicia was complaining of left ear pain. The mother reports the child was well until last night when she started coughing and had a clear runny nose. There is no report of fever and Alicia appears in no acute distress and reports a level 4 on the Oucher Scale. Her left tympanic membrane is red without visible landmarks and movement on insufflation. Which of the following would be the most appropriate treatment plan at this time?
A. Tylenol for pain and fever and amoxicillin 250 mg orally twice a day for 10 days. B. Auralgan (antipyrine and benzocaine) orally twice a day for 10 days and Tylenol for pain and fever management. C. Amoxicillin-clavulanic acid 200 mg orally twice a day for 10 days and Tylenol for pain and fever management. D. Amoxicillin 500 mg orally twice a day for 10 days and Auralgan for ear pain. |
B. Auralgan (antipyrine and benzocaine) orally twice a day for 10 days and Tylenol for pain and fever management.
This child is not high-risk for bacterial otitis media and has only had symptoms for 24 hours. The m other should be told to manage pain with the ear drops and Tylenol and return to the clinic if symptoms persist for 2 more days or fever develops. No antibiotics are warranted at this visit. |
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Children with otitis media with effusion who are not at risk for developmental delay should:
A. Be placed on antihistamine therapy for 2 weeks to attempt to clear blocked eustachian tube. B. Have a full course of high-dose amoxicillin to clear any underlying infection. C. Have a 5-day course of prednisone to decrease inflammation. D. Return to be reevaluated in 3 months for resolution of condition. |
D. Return to be reevaluated in 3 months for resolution of condition.
Otitis media with effusion is a common residual finding after otitis media and often takes 2 to 3 months to fully resolve. Watchful waiting is the most appropriate treatment. If unresolved in 3 months, then referral to an ENT for assessment and hearing valuation is appropriate. |
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The primary diagnostic criteria for otitis media with effusion is:
A. Minimal movement of tympanic membrane with pneumatic otoscopy. B. Convex tympanic membrane with no visible bony landmarks. C. A diffuse light reflex with red tympanic membrane. D. Abnormal audiogram showing hearing loss of 15 to 30 decibels. |
A. Minimal movement of tympanic membrane with pneumatic otoscopy.
Otitis media with effusion is a noninfectious collection of fluid in the middle ear. The fluid collection interferes with normal movement of the membrane by pneumatic otoscopy. This lack of movement may or may not interfere with hearing and the tympanic membrane usually looks yellow, concave, with or without bony landmarks visible. |
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Ototoxicity due to medications results in which type of hearing loss?
A. Conductive hearing loss. B. Sensorineural hearing loss. C. Mixed conductive and sensorineural hearing loss. D. Mild transitory hearing loss. |
B. Sensorineural hearing loss.
Ototoxicity resulting from medications results in sensorineural hearing loss due to damage to the cranial nerve VIII. |
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Allergic rhinitis has both an early and late phase with distinct pathophysiology and signs and symptoms. Which of the following is true about the late phase of allergic rhinitis?
A. IgE-sensitized mast cells release prostaglandins, cytokines, and histamine. B. Leukotrienes are responsible for symptoms of sneezing and rhinorrhea. C. Nasal epithelium becomes infiltrated with inflammatory cells resulting in nasal congestion. D. Late phase symptoms of itching eyes and sneezing are the result of prostaglandin release. |
C. Nasal epithelium becomes infiltrated with inflammatory cells resulting in nasal congestion.
The early phase of allergic rhinitis has histamine, prostaglandins, and cytokines released. Histamine causes the symptoms of sneezing and rhinorrhea. The late phase is characterized by nasal congestion. |
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Jennifer and Tate Johnson, ages 5 and 7, are brought to the clinic because of a 3-4 week history of sneezing, nasal congestion, rhinorrhea, and itchy eyes. Family moved a year ago from Arizona to New York. Your diagnosis is allergic rhinitis. Mother says they “have never had allergies before so couldn’t this be a cold?” Which following info would support the diagnosis of allergic rhinitis?
A. Low-grade fever off and on for the past 2 weeks. B. Asthma or atopic dermatitis in biological family members. C. Onset of symptoms late autumn and early winter. D. A history of sinusitis in both children. |
B. Asthma or atopic dermatitis in biological family members.
They are now exposed to new allergens since they moved to NYC. Family hx of either atopic dermatitis or asthma would indicate an allergic family hx and add support for the diagnosis. Fever is more consistent with an infective process as is onset of symptoms in late autumn and winter. A hx of sinusitis is not informative b/c it could have been due to infection or allergies. |
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Mrs. Johnson returns in a month and reports that Jennifer and Tate’s allergy symptoms are limited to nasal rhinitis and congestion interfering with their activities of daily living. The most appropriate treatment would be:
A. A safe first-generation antihistamine such as diphenhydramine. B. A systemic glucocorticoid in low dose to control the inflammatory process. C. A second-generation glucocorticoid antihistamine such as fexofenadine. D. Daily intranasal glucocorticoid during allergy season. |
D. Daily intranasal glucocorticoid during allergy season.
Topical medication application, such as intranasal glucocorticoids, is preferable to systemic medication if the symptoms are limited to one system. |
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You perform a rapid strep test on Michael (age 13) and the results are positive. The most appropriate management plan would be:
A. Penicillin V 250 mg twice a day for 5 days and acetaminophen for fever and pain management. B. Azithromycin for 5 days with ibuprofen for fever and pain management. C. Penicillin V 500 mg twice a day for 10 days with either acetaminophen or ibuprofen for fever and pain management. D. Cephalexin 500 mg twice a day for 10 days. |
C. Penicillin V 500 mg twice a day for 10 days with either acetaminophen or ibuprofen for fever and pain management.
The first-line drug of choice is penicillin unless there is a known resistance. The appropriate dose for an adolescent is 500 mg twice a day for 10 days. Fever and pain can be managed with either acetaminophen or ibuprofen. |
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Matthew, age 10, is brought to urgent care clinic with a swollen cervical lymph node that the mother states has been there for a month. The lymph node is nontender and measures 2 cm in diameter. A review of his records indicates a previous positive group A beta hemolytic pharyngitis infection 1 month ago. The most appropriate management plan at this time would be:
A. Immediate referral for biopsy and treatment. B. Document size and characteristics of node and have child return in 2 weeks for reevaluation. C. Repeat 10-day course of penicillin V. D. Place PPD and obtain serology tests for toxoplasmosis and cytomegalovirus. |
B. Document size and characteristics of node and have child return in 2 weeks for reevaluation.
The LYMPHADENOPATHY post-infection may last for 4-6 WEEKS. With a documented hx of past infection, the findings are WNL but need to be reevaluated to determine their resolution. If the node does not resolve or other symptoms develop, further evaluation is necessary. |
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Which of the following statements is true about chalazions?
A. Chalazions are more common in children with eczema. B. Chalazions are caused by obstruction of the meibomian glands of the upper and lower eyelids, causing a painless nodule. C. Chalazions should be treated with either erythromycin or sulfacetamide 10% eye ointment. D. Chalazions are caused by acute localized inflammation of one or more sebaceous glands of the eyelids, causing painful furuncle. |
B. Chalazions are caused by obstruction of the meibomian glands of the upper and lower eyelids, causing a painless nodule.
Chalazions usually resolve with warm compresses and good lid hygiene. Seborrheic blepharitis is associated with eczema. Acute inflammation of the sebaceous glands of the eyelids is associated with a painful furuncle. |
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Which of the following terms describes an eye that deviates medially?
A. Exotrophia. B. Esotrophia. C. Hyperophia. D. Hypotrophia. |
B. Esotrophia.
Extrophia is an eye that deviates outward or laterally. Hypertrophia is an eye that deviates upward. Hypotrophia is an eye that deviates downward. |
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Influenza A is a seasonal infection that can cause serious illness in young children and children with chronic respiratory conditions. Antiviral prophylactic drugs can diminish the severity of the infection. These medications are:
A. Approved for infants and children of all ages. B. Are effective when given any time during the illness. C. Are dosed at 5 mg/kg/day for children less than 40 kg. D. Are effective for influenza A, B, and C. |
C. Are dosed at 5 mg/kg/day for children less than 40 kg.
Amantadine, rimantadine, and zanamivir are effective in diminishing the severity of influenza A only if given early in the course of the illness. They have not been approved by the FDA for children younger than 12 months of age and have no effect on influenza B or C. The standard dose is 5 mg/kg/day. |
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Common organisms causing pneumonia in newborn infants are:
A. Staphylococcus aureus, pseudomonas, group A beta-hemolytic streptococcus. B. Haemophilus influenzae, Staphylococcus pneumoniae, herpes simplex. C. Mycoplasma, Staphylococcus pneumoniae, Haemophilus influenzae. D. Group B streptococci, gram-negative enteric bacilli, Chlamydia trachomatis. |
D. Group B streptococci, gram-negative enteric bacilli, Chlamydia trachomatis.
Newborns are exposed to a unique set of organisms as they pass through the birth canal. These include all the organisms listed in answer D. |
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Children infected with measles are contagious:
A. As long as the rash is present. B. 3 to 5 days before the presence of a rash. C. Through respiratory droplets and secretions from the rash. D. During the febrile period of the illness. |
B. 3 to 5 days before the presence of a rash.
Children with measles are contagious during the early phase of the illness even before the rash develops. Respiratory droplet spread is the most frequent means of communication and the illness is not contagious via contact with the rash. |
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The nurses in the newborn nursery request the pediatric nurse practitioner assess a newborn infant who appears to have difficulty feeding. The nurse practitioner determines tracheoesophageal fistula (TEF) must be ruled out. Which of the following tests should be ordered?
A. CAT scan with contrast dye B. Chromosome analysis C. Chest x-ray D. Barium swallow |
C. Chest x-ray
TEF can be accurately diagnosed with a chest x-ray. A CAT scan is not necessary and nothing should be given by mouth until it is determined how the fistula is attached to the trachea. Some chromosome abnormalities are associated with TEF so chromosome analysis may be done in the future but would not be diagnostic for the condition. |
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A 6- month treatment with INH, or rifampin for INH-resistant tuberculosis is required for:
A. All children with a 10 mm induration to Mantoux skin test. B. Only children with a positive Mantoux test and positive chest x-ray for tuberculosis. C. All children with positive Mantoux and previous history of Bacille Calmette-Guerin (BCG) vaccine. D. All children with greater than 10 mm induration with Mantoux skin test and a history of positive risk factors. |
D. All children with greater than 10 mm induration with Mantoux skin test and a history of positive risk factors.
Children with a 10 mm induration and no risk factors or symptoms do not need to be treated with INH. Children with a positive PPD test of greater than 10 mm should be treated regardless of chest x-ray findings. All children who have been treated with BCG will have a positive PPD so only those with positive chest x-ray findings consistent with TB should be treated. |
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Evan is a 2 month old infant born at home and seen only once in the clinic for a newborn checkup at 3 days of age. According to his mother, he was doing well until 1 week ago when he started having difficulty feeding and “seemed to have trouble catching his breath”. Possible causes of dyspnea in a young infant previously thought to be healthy include:
A. Diaphragmatic hernia. B. Congestive heart failure due to patent ductus arteriosus. C. Tracheoesophageal fistula. D. Positive Coombs’ test due to ABO incompatibility. |
B. Congestive heart failure due to patent ductus arteriosus.
Diaphragmatic hernia and TEF would be identified at birth or shortly thereafter. Most ABO incompatibilities would also be evident early after birth. A heart defect may not be obvious at birth, but changes in blood flow with the increase in pulmonary pressure after birth may result in congestive heart failure over time. |
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Pleural effusion is often associated with pulmonary infections caused by which of the following organisms?
A. S. aureus, S. pneumoniae B. M. pneumoniae, M. catarrhalis C. H. influenzae, staph epidermis D. Pseudomonas aeruginosa, group A streptococci |
A. S. aureus, S. pneumoniae
These 2 organisms are found in pneumonia and septicemia. |
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Apnea in the newborn infant can be caused by obstruction in the airway, central nervous system abnormality, or a combination of both. Which of the following diagnoses is an example of obstructive apnea?
A. Apnea due to prematurity. B. Choanal atresia. C. CO2 toxicity. D. Increased intracranial pressure. |
B. Choanal atresia.
Apnea associated with prematurity, CO2 toxicity, and ICP are all associated with CNS problems. Only choanal atresia is obstructive and requires surgery to correct. |
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Common pharmacologic therapy for apnea of prematurity includes:
A. Albuterol. B. Budesomide. C. Amphetamines. D. Caffeine. |
D. Caffeine.
Caffeine is used to stimulate the premature infant’s nervous system to prevent apnea. |
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Breath-holding spells are:
A. Most common in children over the age of 3 years. B. Have been found to increase the risk of seizures in later life. C. Used by children to manipulate caregiver behavior. D. Involuntary events related to autonomic dysregulation. |
D. Involuntary events related to autonomic dysregulation.
Breath-holding spells are most common in ages 6-24 months. They are NOT VOLUNTARY, but are the result of autonomic dysregulation leading to prolonged expiratory apnea. No long-term seizure problems have been identified. |
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Allie, age 2, is brought to the clinic by her grandmother (Allie’s guardian). The grandmother is concerned because Allie “holds her breath until she turns pale”. What additional information would you obtain from the grandmother?
A. Does anything trigger the episode, how long does it last, and does the child sleep afterward? B. Does the child have a history of asthma and is she living in an older house? C. Does the child have a fever, problems when running, and does the mother have anemia? D. Was the child breastfed, does she has pica, and is she still taking a bottle? |
A. Does anything trigger the episode, how long does it last, and does the child sleep afterward?
“Pallid breath-holding spells” are often characterized by a trivial physical or emotional trauma that triggers a cry, pallor, and opisthotonoid posture; resolves after 1 minute, and is often followed by sleep. |
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Mark, age 12, has a blood pressure of 140/90 mmHg. The pediatric nurse practitioner should:
A. Repeat the blood pressure on two additional and separate occasions. B. Do an immediate cardiac work-up on the patient. C. Consider this a normal reading. D. Start the child on hydrochlorothiazide (HCTZ). |
A. Repeat the blood pressure on two additional and separate occasions.
A minimum of 3 readings with an average systolic BP of 140mmHg and a diastolic of 90 mmHg establishes the diagnosis of hypertension. |
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Mark (age 12) was eventually started on lisinopril daily. The PNP would monitor:
A. Electrolytes periodically B. Heart rate C. Glycohemaglobin A1C D. Potassium and creatinine |
D. Potassium and creatinine
To monitor kidney function, the PNP would check the potassium and creatinine levels. Electrolytes should be monitored on diuretics. |
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Mary (age 3, Kawasaki syndrome) is admitted to the hospital for treatment of her fever. The PNP knows that the following treatment will be started to shorten the fever and to decrease the risk of complications:
A. Aspirin therapy. B. Intravenous antibiotics. C. Intravenous heparin. D. Intravenous immunoglobulin (IVIG). |
D. Intravenous immunoglobulin (IVIG).
IVIG shortens the duration of fever and decrease the risk of coronary artery aneurysms three to five fold. |
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Mary is later diagnosed with level-two risk for coronary artery disease. You explain to the parents that this means that Mary:
A. Had a transient dilation with normalization of the echocardiogram in the past 8 weeks B. Has a small to medium aneurysm in one coronary artery C. Has never had any coronary abnormalities D. Has coronary obstruction |
A. Had a transient dilation with normalization of the echocardiogram in the past 8 weeks
Level 2 has transient dilation with normalization of measurement by 6 to 8 week echocardiogram. Level 1 has no coronary abnormalities. Level 3 has a small to medium aneurysm. Level 5 has coronary artery obstruction. |
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Rudy, age 10 months, is brought to the clinic by his parents. This mother is concerned because he is not eating well, seems to be sleeping more than usual, and is very fussy. His temp is 99.1 F rectally, respirations are 20, he is diaphoretic, and his heart rate is 210 bpm. The PNP:
A. Tells the mother that the pulse rate is normal, since the child has a fever. B. Listens to the heart rate for at least 10 seconds. C. Refers the child to a pediatric cardiologist. D. Tells the mother that a normal heart rate is an infant is 100 to 150 bpm. |
C. Refers the child to a pediatric cardiologist.
The child is afebrile and the normal HR in a 10 month old is up to 180 bpm. This child has associated sxs of SVT, along with poor feeding, pallor, and diaphoresis. The child should be referred, since the PNP would have a high suspicion of SVT. |
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Larry has a history of acute rheumatic fever (ARF). The PNP is following him for carditis. The PNP listens closely at the 5th intercostal space at the mid-clavicular line on the left side of the chest to hear closure of the:
A. Tricuspid valve. B. Pulmonic valves. C. Aortic valve. D. Mitral valve. |
D. Mitral valve.
Rheumatic fever can affect the mitral valve, so the PNP would listen for the opening and closing of the mitral valve. |
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The treatment of choice for acute rheumatic fever is:
A. Erythromycin 800 mg orally twice a day B. Cipro 500 mg orally twice a day C. Benzanthine penicillin G IM D. Depo-Medrol IV |
C. Benzanthine penicillin G IM
Erythromycin can be given if the child is allergic to penicillin. |
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Cardiac chest pain in children is:
A. Midpercodial and radiates to the left arm. B. Severe crushing pain that radiates to the back. C. Subcostal in nature. D. Often an emotional response. |
A. Midpercodial and radiates to the left arm.
Severe crushing pain radiating to the back is usually associated with aortic tears. Subcostal pain is generally chest wall related. The parents’ experience with chest pain may influence symptoms. |
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A 12 month old is seeing the PNP for the first time for a well child checkup. Historical information is obtained from the mother about the child’s weight gain trajectory and it is discovered that at birth, he weighed 7 pounds and 5 ounces and his head circumference was at the 50th percentile. Today he is 19 pounds and his head circumference is at the 15th percentile. Given what you know about normal growth in children, the best action that you should take would be:
A. Tell this mother that the child’s weight and height growth appear to be normal. B. Request the growth charts from the child’s last primary care provider’s office. C. Check the newborn screening results. D. Order a CBC with differential, lead level, a urinalysis, and a urine culture. |
D. Order a CBC with differential, lead level, a urinalysis, and a urine culture.
This infant has failed to triple his or her weight, is currently in the 3rd percentile, and has a slowing growth trajectory of the head circumference, suggesting that there is significant failure to thrive. While answers B and C are important to complete at some point, it is a greater priority to rule out anemia, lead toxicity, infection (chronic or subclinical), urinary infection, or kidney disorders as contributing causes of this child’s poor growth. |
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The best method to check for the first signs of dehydration in a child is:
A. Look for the production of tears. B. Check for capillary refill greater than 3 seconds. C. Check for a reduced blood pressure and widening pulse pressure. D. Look at the lips to see if they are cracked. |
A. Look for the production of tears.
Lack of tears is one of the first signs of those listed that suggest a child has moderate dehydration. The other options are all signs of severe dehydration. |
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The PNP is seeing an adolescent today for a follow-up on an acute but protracted episode of diarrhea. Her mother thinks that she does not look well even though her diarrhea has stopped. Her weight today is 94 pounds, down from her usual 100 pounds. Additionally, she is slightly tachycardic, mildly orthostatic, has dry mucous membranes, and has not voided for 6 hours. The best immediate action is:
A. Have her drink ½ a liter (16 oz) of rehydration fluid hourly over the next 4 hrs in the office. B. Send her to the local ER for admission. C. Have her drink 1 liter (33 oz) of rehydration fluid hourly over the next 4 hrs in the office. D. Have her mother encourage her to drink lots of fluids and see her back in the morning. |
C. Have her drink 1 liter (33 oz) of rehydration fluid hourly over the next 4 hrs in the office.
The adolescent seems to be in the convalescent stage of this illness because the diarrheal portion of gastroenteritis has ended; however, this mother’s concerns and your assessments indicate that she is suffering from a moderate level of dehydration. Her condition seems fairly stable but not enough to allow her to go home at this point. Oral rehydration is the best choice and moderate dehydration suggests that you should establish fluid replacement at 100 ml/kg of ideal body weight over 4 hours and reassess hourly. |
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An 8 year old female comes to the office with a 6 hour history of periumbilical abdominal pain that is increasing in intensity and is accompanied with anorexia, nausea, and vomiting. Additionally, this child has a low-grade fever. The physical examination reveals guarding with generalized tenderness. The best thing to order given this clinical presentation would be:
A. CBC with diff, sedimentation rate, lipase, and amylase. B. Chest x-ray C. Abdominal flat plate (KUB) D. Abdominal ultrasound |
A. CBC with diff, sedimentation rate, lipase, and amylase.
The priority differential dx should include pyelonephritis, ruptured ovarian follicle, or ovarian torsion, inflammatory bowel disease, appendicitis, peptic ulcer disease, and pancreatitis. A CBC with diff, ESR, amylase, and lipase would most efficiently guide your decision-making process through this diagnostic challenge. Some of the other tests may be indicated after the result of the serum analysis. |
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Which of the following historical elements is NOT closely linked with irritable bowel syndrome?
A. Alternating periods of constipation and diarrhea B. Abdominal pain relieved by a bowel movement C. Hematochezia D. Abdominal distention and gas |
C. Hematochezia
Patients with IBS rarely present with hematochezia or bloody bowel movements. It is also rare that patients with IBS demonstrate systematic complaints such as fever, anorexia, and weight loss; however, these are all common complaints of patients diagnosed with an inflammatory bowel disease such as Crohn’s disease or ulcerative colitis. |
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The preicteric phase of hepatitis B infection is most closely associated with:
A. Lethargy, lymphadenopathy, and nausea B. RUQ pain, fever, and vomiting C. Urticaria, fever, and RUQ pain D. Arthritis, urticaria, and fever |
This book says “D. Arthritis, urticaria, and fever” is the right answer.
The prodromal/preicteric phase (2 days to 2 weeks) follows the incubation period (of 6-24 weeks). Often sxs are lethargy, anorexia, nausea, vomiting, and RUQ abdominal pain (HOWEVER, other sources say that RUQ pain occurs in the Icteric Phase; plus, this answer contradicts itself because in choices B and C, RUQ pain is present). SOME patients experience a MILD FEVER, urticaria, and polyarthritis. Icteric Phase – bilirubinuria, pale stools, and jaundice. |
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A 4 year old presents with hx of painless bright-red rectal bleeding intermittently for the last month. The physical examination, including the rectal exam, is entirely normal. The stool obtained on the rectal examination is guiac-positive. What is the most likely cause of the bleeding?
A. Gastric ulcers B. Malignancies C. Diverticulitis D. Polyps |
D. Polyps
Juvenile gastrointestinal polyps frequently present as cases of painless rectal bleeding in otherwise well children less than 5 years of age without weight loss. The polyps are most commonly found in the rectum; although they may not be appreciated on rectal examination. A pediatric gastroenterologist will need to remove the polyps during an outpatient endoscopic procedure. These fleshly growths are most often singular, and not malignant or premalignant. Therefore, the singular polyps, to be differentiated from polypoid conditions with multiple polyps (i.e. Gardner’s syndrome), are not associated with any cancerous conditions or predisposal to the developmental of cancer. |
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A 12 month old infant comes in the office for an urgent visit. His mother has indicated that he has been very lethargic lately and there has been a 2-week history of acholic stools. He does not appear to be jaundiced or have hepatomegaly on examination; however, he does have an elevated urobilinogen. What would be the most accurate information to offer to this mother?
A. All of the testing has been normal thus far, and so I would like to have you watch your child and call with any other problems and return in 2 weeks to follow up. B. These findings all suggest that there is rapid hemolysis or red blood cell breakdown occurring in your infant. C. These findings indicate that your infant may be suffering from an intrahepatic infection or problem of the liver. D. These findings indicate that your infant has an obstruction to the hepatic system and cannot excrete bile into the intestines. |
D. These findings indicate that your infant has an obstruction to the hepatic system and cannot excrete bile into the intestines.
An increase in unconjugated bilirubin is signaled as the unconjugated bilirubin, a breakdown product of hemoglobin (i.e., heme is converted to bilirubin), which cannot attach to glucuronide (conjugated bilirubin) found in the liver. Therefore, unconjugated bilirubin increases. If there is an intrahepatic inflammation or infection, the conjugated bilirubin will increase, the bilirubin will enter the small intestines and continue to color the stools, and the additional bilirubin will spill into the bloodstream, and be filtered by the kidneys causing the urobilinogen to increase. HOWEVER, if there is an obstruction to the biliary collecting system, the serum conjugated bilirubin will INCREASE resulting in an INCREASED UROBILINOGEN but the bile will NOT move into the gut and the stools will LACK COLOR or be “ACHOLIC” stools. |
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A mother and her 4 month old infant with chronic diarrhea and poor weight gain for 2 months come to the clinic for the results of a previously obtained stool culture. Which organism, if found on the culture results, would make the PNP include HIV into the diff dx?
A. Rotavirus B. Mycobacterium avium C. Yersinia D. Salmonella |
B. Mycobacterium avium
The other 3 are common causes of gastroenteritis in children. But Mycobacterium avium is rarely found in children, and is the agent in 95% of the infections found in children with AIDS. Thus, an infant with FTT and generalized sxs with a positive stool culture with M. avium is verly likely infected with HIV. |
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A PNP is seeing a 2 week old infant male for a well child exam. The child is breastfeeding and gaining weight appropriately. This mother indicates that he frequently becomes constipated, his abdomen becomes distended, and he is very irritable. The mother reports that she relieves these sxs either by giving a glycerin suppository or providing rectal stim, just as she had been taught by the hospital. He needed to have rectal stim in the hospital because his first stool didn’t occur until 3 days of life. Following either of these techniques, he generally has an explosive stool accompanied by a large amount of gas and then seems to be fine for 3-4 more days. Given this hx, which of the following would you suggest to determine the etiology of this problem most efficiently?
A. Stool culture and ova/parasite analysis B. Refer to gastroenterologist for a rectal biopsy C. Order a barium enema D. Order a T3 and TSH |
B. Refer to gastroenterologist for a rectal biopsy
Consider Hirschprung’s disease if the infant did not pass its first stool for more than 48 hours. Hirschprung’s disease is an obstruction to the colon related to an aganglionic section of large intestines usually found within the first 3-5 cm of the rectal segment. A barium enema may provide an INITIAL screen as it may identify a transition zone, however this is NOT A RELIABLE TEST to use with an infant younger than 3 months of age. While hypothyroidism may produce constipation, it generaly does not result in failure to pass a stool in the first 48 hours. The clinical picture of an intestinal infection or presence of ova and parasites is very different and would not interfere with passing the initial bowel movement. |
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Helicobacter pylori infections in children are most frequently associated with which of the following?
A. Gastric ulcers B. Recurrent chronic abdominal pain C. Chronic otitis media D. Antral and duodenal ulcers |
D. Antral and duodenal ulcers
H. pylori is a spirochete which most commonly burrows into the antral portion of the stomach and the duodenum. However, there only is a weak association with this organism and chronic recurrent abdominal pain and gastric ulcers. |
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The most likely cause of proteinuria in a 14 year old male who presents for a physical exam and no recent illnesses is which of the following?
A. Acute nephritis syndrome. B. Orthostatic proteinuria. C. Exercise-induced proteinuria. D. Fever-induced proteinuria. |
B. Orthostatic proteinuria.
30% of cases of proteinuria are found on random urinalysis of children. The child excretes abnormal amounts of urinary protein when in the upright position, but excretes normal amounts of urinary protein when lying flat. |
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Which of the following is NOT true regarding cryptorchidism?
A. About 20% of children will respond to hormonal therapy. B. The most common type is retractile testicles. C. Surgical orchidopexy remains the standard treatment. D. It only occurs unilaterally. |
D. It only occurs unilaterally.
Cryptorchidism may be unilateral or bilateral. This condition can be due to a hyperactive cremasteric reflex (retractile testicles), tension from external musculature (canalicular testicle), hormonal abnormalities (intraabdominal testicle), or problems during fetal development (ectopic or absent testicles). |
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The overall incidence of primary dysmenorrhea is:
A. 10% B. 25% C. 50% D. 80% |
D. 80%
Primary dysmenorrhea is very prevalent, with an overall incidence of 79.6%. The peak incidence is 1 to 3 years after menarche. |
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Which of the following statements is FALSE?
A. There is an association between gynecomastia and the development of breast cancer. B. If mastitis occurs, breastfeeding can be continued. C. Mastalgia is treated with a supportive bra and analgesics. D. No treatment is required for an imperforate hymen with microperforation. |
A. There is an association between gynecomastia and the development of breast cancer.
There is no relationship to the development of breast cancer with gynecomastia. Lactating women are encouraged to continue nursing. Breast pumping can also be used with mastitis. No treatment is needed in a case where a female has an imperforate hymen with microperforation. Mastalgia may occur premenstrually or during menstruation in adolescents and is treated with a supportive bra and analgesics. |
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A mother of a 3 year old has questions about the care for her child who has just been diagnosed with molluscum contagiosum (MC). The PNP offers the following advice:
A. There is low risk for communicability and the rash is self-limiting. B. The rash is highly contagious and the child should avoid contact with others. C. Systemic involvement is common and IV antibiotics will be ordered. D. The child will not be allowed to go back to preschool until he has been treated. |
A. There is low risk for communicability and the rash is self-limiting.
MC is NOT highly contagious. It is a benign, usually asymptomatic skin disease with no systemic manifestations and the child with MC is not excluded from preschool/school. |
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Which of the following is correct regarding pityriasis rosea?
A. It is teratogenic to a fetus. B. Sunlight increases the severity of the rash. C. Duration of the rash can be 3 to 4 months. D. Keflex will increase resolution of the rash. |
C. Duration of the rash can be 3 to 4 months.
Pityriasis rosea is NOT teratogenic. Exposure to sunlight MAY RELIEVE itching and enhance resolution of the rash; the etiology is thought to be viral and antibiotics are not indicated. |
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Which of the following describes the rash of rubeola?
A. Discrete rose-pink macules approximately 2-3 mm; fade w/ pressure; most prominent on trunk; appearance after high fever falls. B. Diffuse, fine erythematous macular-papular rash; beings on face and rapidly spreads to entire body; disappears by 4th day in same order that it appeared. C. Deep red macular-papular rash; begins at hairline on forehead, behind ears, and at back of neck; spreads down from face and hairline over 3 days and later becomes confluent. D. Progresses from crop of red macules to papules to vesicles that become unbilicated and then crust. |
C. Deep red macular-papular rash; begins at hairline on forehead, behind ears, and at back of neck; spreads down from face and hairline over 3 days and later becomes confluent.
A = Roseola infantum (6th disease; human herpesvirus 6) B = Rubella D = Varicella |
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What is the primary symptom of atopic dermatitis?
A. Allergic rhinitis. B. Erythematous generalized dry skin. C. Pruritus. D. Erythematous weepy patches. |
C. Pruritus.
Atopic dermatitis is known as the “itch that rashes”; secondary changes in the skin result from the trauma of scratching. |
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Which of the following is true regarding the treatment of pediculosis?
A. Vinegar hair rinse may help loosen nits before combing. B. The AAP recommends that manual removal of nits must be complete prior to school reentry. C. Environmental disinfecting is essential as fomites have a major role in infestation. D. Malathion 0.05% is highly effective and safe for infants and neonates. |
A. Vinegar hair rinse may help loosen nits before combing.
The AAP states that manual removal is not necessary. Fomites do not have a major role in infestation, so environmental disinfecting is often unnecessary. The use of malathion is contraindicated in infants and neonates. |
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Pernicious anemia is the result of a lack of:
A. Iron in the diet. B. Exposure to sunlight. C. Vitamin B12 in the diet. D. Pancreatic enzymes. |
C. Vitamin B12 in the diet.
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A PNP is doing newborn nursery rounds. She observes mild jaundice in an infant less than 24 hours old. Which of the following would she consider as a cause for this?
A. Normal newborn hyperbilirubinemia. B. Rh-positive fetus of an Rh-negative mother. C. Rh-negative fetus of an Rh-positive mother. D. Extrahepatic biliary atresia. |
B. Rh-positive fetus of an Rh-negative mother.
Jaundice in a neonate LESS THAN 24 HOURS old is NOT NORMAL. An Rh-positive child of an Rh-negative mother would be at risk for hemolytic disease of the newborn because the MATERNAL RESPONSE to the foreign antigen results in the production of the IgG ISOTOPE that crosses the PLACENTAL BARRIER. These antibodies attach to the fetal RBCs which causes hemolysis of the fetal RBCs, resulting in jaundice in the first 24 hours of life. Jaundice caused by BILIARY ATRESIA presents in the FIRST 2-3 DAYS of life. |
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A child diagnosed with hemophilia type B (Christmas disease) would have a(n):
A. Decrease in factor VIII. B. Increase in PTT (partial thromboplastin time). C. Prolonged PT (prothrombin time). D. Decreased platelet count. |
B. Increase in PTT (partial thromboplastin time).
The defect in hemophilia type B is FACTOR IX. The PT and platelet counts are usually NORMAL, but the PTT is 2-3 TIMES NORMAL. |
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A 5 year old child presents with a warm, tender 3-4 cm epitrochlear lymph node. The mother reports that the child has had what she thinks are infected bug bites on his hand for about a week. The child lives on a farm with lots of animals and frequently plays outside. The exam is otherwise normal. Given this history, your most likely diagnosis is:
A. Cat-scratch disease. B. Lyme disease. C. Epstein-Barr virus. D. Rocky Mountain spotted fever. |
A. Cat-scratch disease.
This child has exposure to animals, so is vulnerable to possible bites. A kitten bite may often look like an infected bug bite. A SINGLE ENLARGED NODE near the site of puncture is the CLASSIC PRESENTATION OF CAT-STRACH FEVER. |
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The recommended treatment for bleeding episodes for those with von Willebrand disease is:
A. Infusion of factor VIII. B. Blood transfusion. C. DDAVP intranasal inhalation. D. Transfusion with von Willebrand factor. |
C. DDAVP intranasal inhalation.
DDAVP works by stimulating an increased release of von Willebrand factor. In severe cases of von Willebrand disease (type three), transfusions of vWf and factor VIII may be needed. |
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A 6 year old child presents to the PNP in the ER with a cutaneous purpura rash mainly on the legs and buttocks, fever, and complaints of joint pain mostly in the knees and ankles. On examination, the PNP also notes some scrotal edema. On the basis of these findings, the most likely diagnosis is:
A. Henoch-Schonlein purpura. B. Idiopathic thrombocytopenia purpura. C. Testicular torsion. D. Systemic lupus erythematosus. |
A. Henoch-Schonlein purpura.
The classic presentation of Henoch-Schonlein pupura is a purpuric rash, fever, joint pain, and scrotal edema. Testicular torsion would not have the rash or joint pain, and ITP does not normally present with fever. This is not the rash associated with SLE. |
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The treatment of a child with the Henoch-Schonlein purpura includes:
A. IVIG B. NSAIDs C. High-dose corticosteroids D. Immune system modifiers |
B. NSAIDs
NSAIDs are given to control the JOINT PAIN. Corticosteroids have NOT been shown to change the course of the disease. IVIG and immune system modifiers are NOT helpful, as most children RECOVER WITH NO TREATMENT. |
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A 13 year old girl presents for a routine physical. You elicit during your history that she has had lower back pain, on and off, for the last 3 to 4 months worse with spine hyperextension. Her mother states she knows it is caused by the gymnastics, as her older daughter also had this type of back pain at the same age and the sister is just fine. Today her back does not hurt, and she has full range of motion. You would:
A. Order an x-ray of her back. B. Prescribe ibuprofen at any and all signs of back pain. C. Have her evaluated by a physical therapist. D. Have her change sports from gymnastics. |
A. Order an x-ray of her back.
Although she is asymptomatic today, her hx of gymnastics and lower back pain that becomes more painful w/ hyperextension could be a SPONDYLITIS which can be associated with other CONGENITAL SPINAL DEFECTS. |
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Which treatments are appropriate for a male adolescent who has Osgood-Schlatter’s disease?
A. Activity modification and ice treatment as needed. B. Achilles stretching before activity and a knee brace during physical activity. C. Restriction from all sports activity until asymptomatic for 3 consecutive months. D. Ice and NSAIDs every day until full adult growth is achieved. |
A. Activity modification and ice treatment as needed.
Osgood-Schlatter’s disease is ASEPTIC NECROSIS of the TIBIAL TUBERCLE BELOW THE KNEE and is considered an overuse injury occurring in adolescents during times of rapid growth. The condition is SELF-LIMITING. The pain, usually associated with KNEE EXTENSION, can be treated with activity modification, ice, NSAIDs, and a tibial band during periods of pain and/or increased activity. A strengthening of the quadriceps can be helpful in minimizing knee pain. |
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A 4 year old boy presents with his mother who states that her son is beginning to “walk funny and seems less coordinated now.” The noticed changes have occurred over the past 6 to 7 months. You would suspect muscular dystrophy with which reported history?
A. Upper extremity weakness B. Hx of delayed gross motor development C. Persistent toe-walking with increasing reports of falling D. Weak cough and frequent URIs |
C. Persistent toe-walking with increasing reports of falling
Muscular dystrophy usually presents in the preschool years with a gradual disappearance of motor skills that originally developed on a normal sequence and time. Muscle weakness presents initially in the lower extremities with report of “walking funny”, clumsiness, persistent toe-walking, and Gower’s sign. (definition of “Gower’s sign” from Medscape: To get up from a sitting or supine position, the child must first become prone on the elbows and knees. Next, the knees and elbows are extended to raise the body. Then, the hands and feet are gradually brought together to move the body's center of gravity over the legs. At this point, the child may release one hand at a time and support it on the knee as he or she crawls up their legs to achieve an upright position.) |
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A positive bulge sign indicates:
A. Medial collateral ligament tear B. Torn meniscus C. Herniated disk D. Knee joint effusion |
D. Knee joint effusion
Bulge sign is performed by placing the ball of the hand over MEDIAL PATELLA, milk fluid distally from suprapatellar pouch, and repeating several times. Reappearance of the swelling indicates knee joint effusion. |
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A 2-week old healthy baby presents with “in-pointing of the toes.” On exam, the baby has an adduction of the forefoot that cannot be passively straightened. Your initial action would be:
A. Refer to orthopedic specialist B. Refer to physical therapy for passive stretching C. X-ray the affected foot D. Recheck the foot position at the 2-month checkup |
A. Refer to orthopedic specialist
Adduction of the forefoot with the foot plantar flexed at the ankle are common signs of clubfoot. Successful serial casting and manipulation needs to begin as early as possible, immediate referral to orthopedic specialist is indicated. |
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Included in the diff dx for a patient with a painless limp would be:
A. Juvenile rheumatoid arthritis (JRA) B. Legg-Calve-Perthes disease C. Slipped capital femoral epiphysis D. Leg length discrepancy |
D. Leg length discrepancy
The other 3 all present with a painful limp |
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Most common fractures in children occur in which area of the bone?
A. Diaphysis B. Cancellous bone C. Epiphyseal plate D. Compact bone |
C. Epiphyseal plate
Most common fractures occur in epiphyseal plate (growth plate) b/c this is the weakest part of the growing bone. |
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What is the most common site of osteosarcoma in adolescents?
A. Tibia B. Fibula C. Femur D. Humerus |
D. Humerus
Osteosarcoma is the most common malignant bone tumor in adolescents and young adults. Osteosarcoma most commonly affects the Humerus, followed by the distal femur and proximal tibia. |
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The parents of a 5-year old recently diagnosed with muscular dystrophy wish to speak to you about the hereditary nature of the disease. As you prepare to answer their questions, you review that muscular dystrophy is:
A. An X-linked recessive gene transmitted by unaffected female carriers. B. A recessive gene that requires that mother and father be carriers. C. A dominant sex-linked gene predominantly in white families from western Europe. D. A recessive gene that is known to skip a generation between transmission. |
A. An X-linked recessive gene transmitted by unaffected female carriers.
Muscular dystrophy is transmitted through the dystrophin gene. The absence of dystrophin in the muscle membrane leads to progressive skeletal and cardiac muscle damage. |
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A developmentally normal 6 month old presents with a full but not bulging fontanelle and a progressive increase in head circ. MRI shows benign enlargement of subarachnoid space in the frontal area. This is consistent with:
A. Hydrocephalus B. External hydrocephalus C. Macrocephaly D. Neurofibromatosis |
B. External hydrocephalus
This is a benign enlargement of subarachnoid space in frontal or frontoparietal regions; head size rapidly increases to 90% and then parallels the growth curve. The normal developmental status and lack of changes in the ventricles is NOT CONSISTENT WITH HYDROCEPHALUS. If the child has macrocephaly only, the MRI would not show fluid collection in subarachnoid space. Neurofibromatosis may be present, but there is nothing in the hx or physical exam consistent with this dx. |
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A 14 year old without any medical problems presents with a 1-day hx of fever and severe headache. On exam, she has a temp of 101.4 F, positive Brudzinski’s sign, and positive Kernig’s sign. She is diagnosed with presumptive meningitis. What is a possible long-term complication?
A. Brain abscess B. Encephalitis C. Hearing loss D. Subdural effusions |
C. Hearing loss
Hearing impariments are the most common neurologic sequela of meningitis, occurs in 35% of patients. Speech impairments, learning disabilities, and behavioral problems are also long-term complications of bacterial meningitis. Mortality rate is 4-10%. Seizures are a common complication affecting 1/3 of patients. Subdural effusions occur in 1/3, and are asymptomatic and resolve without treatment. Brain abscess is uncommon, more likely in newborn period. |
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What disorder is associated with positional plagiocephaly in a 2-month old?
A. Microcephaly B. Macrocephaly C. Torticollis D. Strabismus |
C. Torticollis
Deformational flattening of the occipital area will cause frontal and temporal prominence. The lambdoidal suture is not closed prematurely, but the supine infant positioning causes external pressure on the skull resulting in flattening. Congenital torticollis may occur if there is STRETCHING of the STERNOCLEIDOMASTOID muscle with a localized hematoma. There may be a mass felt in the body of the muscle due to fibrosis with shortening of the muscle on the affected side. In a 2 month old, strabismus would not cause head tilt. Microcephaly and macrocephaly do not cause positional plagiocephaly. |
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A 7 year old child presents with a 2-year hx of headaches at the end of the day associated with stress. Recently, the headaches are not relieved with acetaminophen, are located in the occipital area, and are worse when the child coughs or is active. The child’s personality has become increasingly irritable. Which is the most likely diagnosis?
A. Cluster headache B. Chronic progressive headache C. Tension headache D. Migraine headache |
B. Chronic progressive headache
Occipital headaches such as these are rare and require immediate eval & imaging…this presentation is consistent with Chronic Progressive HA. Tension HA – tightening, nonpulsating pain, w/ or w/o photophobia or phonophobia, but w/o nausea, vomiting, or exacerbation with activity. Migraine HA – recurrent HA w/ symptom-free periods, may be associated w/ visual, sensory, or motor aura, abdominal pain, nausea, vomiting, throbbing HA, unilateral location, relief after sleeping, and positive family hx. They are usually frontotemporal and bilateral in children. Cluster HA – rarely seen before age 10, characterized by 1 to several attacks recurring each 24 hours; they have headache-free periods which may last from months to years. |
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On exam, a 4 year old has large calves with lumbar lordosis, and a waddling, clumsy gait. The family hx is unremarkable. Which is the most likely diagnosis?
A. Muscular dystrophy B. A brain tumor C. Charcot-Marie-Tooth disease D. Essential hypotonia |
A. Muscular dystrophy
The clinical features of muscular dystrophy include normal milestones until walking, clumsiness, waddling gait, weakness in climbing stairs, pseudohypertrophy of calf muscles, contractures of heel cords, an early complaint of leg pain, toe walking, contractures of biceps, neck, and Achilles tendon. Charcot-Marie-Tooth disease – stork-like legs with high arches. Essential Hypotonia – waddling gait, but there would be no pseudohypertrophy of calves. Brain Tumor – may cause clumsiness, but also would not cause pseudohypertrophy of calf muscles. |
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An 18 month old patient presents with lumbar lordosis, delay in walking, and diminished reflexes. The family hx is incomplete. Which of the following lab tests is most helpful?
A. CBC B. Lactose dehydrogenase (LD) C. Creatinine kinase (CK) D. Erythrocyte sedimentation rate (ESR) |
C. Creatinine kinase (CK)
CK is very elevated in muscular dystrophy. LD and AST may be elevated, but CK is the most useful marker. CBC and ESR would be NORMAL. |
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A 6 year old complains of HA in the morning before school for 2 months. On physical exam, there is a head tilt, past pointing, and difficulty in performing rapid, alternating head movements. What is the most appropriate next step?
A. CT with contrast B. MRI with contrast C. Lumbar puncture D. Plain radiograph of the skull |
B. MRI with contrast
These are sxs of POSTERIOR FOSSA TUMOR. CT scan does NOT image the posterior fossa as well as an MRI. Lumbar puncture would NOT be done prior to scanning. Plain radiograph of skull would be done to identify depressed and linear skull fractures, but would NOT be helpful with this child. |
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An 8 week old presents with an acute onset of moving less and seemingly slipping out of the mother’s arms when held. On exam, the infant is uninterested in her environment, has significant head lag, and is quiet. The temp is normal. Which of the following tests should be ordered?
A. Neonatal metabolic screen B. Stool sample for Clostridium botulinum C. Thyroid screen D. Liver function tests |
B. Stool sample for Clostridium botulinum
Botulism is an ACUTE PROBLEM caused by toxins. Infants present with apathy listelessness, feeding poorly, decreased head control, weak cry and suck, and hypotonia with an absence of fever. Metabolic disorders and thyroid disease would NOT BE ACUTE. Liver function tests would not be helpful. |
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A 15 year old has familial essential tremors. He is embarrassed by his problem and wants to be treated. Which of the following treatments is the most appropriate?
A. Stimulant B. Beta-adrenergic blocker C. Selective serotonin reuptake inhibitor D. Anxiolytic |
B. Beta-adrenergic blocker
Essential tremor has been linked to chromosome 3q13 and 2p2-22. There are several normal forms of tremors such as physiologic tremor and enhanced physiologic tremor that occur when the child is angry or fearful. Essential tremor should only be treated when there is functional disability or social embarrassment. Two first-line drugs that can be used to treat essential tremors include propranolol and primidone. Other drugs include clonazepam, gabapentin, topiramate, or botulinum toxin. |
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A 14-year-old presents with a history of 2 months eye blinking as a 4-year-old. His parents recently divorced. Today his chief complaint is 1 month hx of intermittent twitch of the upper eyebrow. The exam is normal. What should be the next course of action?
A. Reassurance B. Clonidine C. Neurology referral D. Psychiatric referral |
A. Reassurance
Reassurance is the appropriate action. Neuro or psych referral is NOT INDICATED for a transient tic disorder. Transient tic disorder includes multiple motor and/or vocal tics with a total duration of sxs for less than 1 year. Clonidine and guanfacine have been shown to be effective in milder cases of Tourette’s syndrome (TD) with dopamine receptor antagonist, the drug used in severe TD. Children with tics NEED OBSERVATION. The diagnostic criteria for transient tic disorder is: minimum 1 month, not longer than 12 months. In contrast, in Tourette’s syndrome, there must never be a tic-free period of more than 3 consecutive months. |
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A 6 year old has a tumor compressing the brainstem. What set of sxs can be expected?
A. Word retrieval difficulties, seizures, hemiparesis B. Ocular palsies, diplopia, and nystagmus C. Intellectual changes, seizures, hearing loss D. Visual field defects, precocious puberty, seizure |
B. Ocular palsies, diplopia, and nystagmus
Brainstem tumors = nausea, vomiting, diplopia, weakness, unsteady gait, headache, & drowsiness. Hydrocephalus is a common occurrence. Downbeating nystagmus can be seen with involvement of medulla, and upbeating nystagmus is seen when cranial nerve VI is affected. Seizures are LESS COMMON with brainstem involvement. Loss of language & word retrieval problems are common in SUPRATENTORIAL tumors. Precocious puberty and visual field defects are seen with involvement of MIDLINE tumors. |
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Which of the following statements about asthma prevalence is the most accurate?
A. Prevalence is greater for boys compared to girls in all ethnic groups B. Prevalence among African American children is higher than other ethnic groups C. Overall prevalence does not differ overall by income or ethnic group D. Prevalence is lower for children of European American descent than other ethnic groups |
C. Overall prevalence does not differ overall by income or ethnic group
Prevalence is greater for boys in ALL ethnic groups EXCEPT Puerto-Rican children. Prevalence does not vary by income or ethnicity, although black children have 3 X more hospitalizations and mortality than white children. |
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Abigail, a 3 year old, presents to the clinic with a URI and wheezing. This occurred the past 2 times she had “colds”. Her father & older brother have allergies and asthma. You suspect that Abigail may also have asthma. Which of the findings would be most appropriate to confirm the dx in Abigail?
A. Wheezing improves or ceases with bronchodilator therapy B. Office spirometry shows airway obstruction C. Both inspiratory and expiratory wheezes are present D. PA and lateral CXR are normal |
A. Wheezing improves or ceases with bronchodilator therapy
Asthma is primarily a clinical dx, especially for a 3 year old who is TOO YOUNG FOR OFFICE-BASED SPIRO. Reversibility of wheezing in response to a bronchodilator is sufficient for a diagnosis. |
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Which of the following classes of meds is most effective in reducing chronic airway inflammation in asthma?
A. Methylxanthines B. Inhaled beta-agonists C. Leukotrienes D. Inhaled corticosteroids |
D. Inhaled corticosteroids
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Jennifer is a 6 year old who has mild persistent asthma. She is being seen in the clinic in early November for a well child physical. She weighs 20 kg. Her last visit was 6 months ago and her asthma has been well-controlled since then. Spirometry was performed at that time and showed an FEV1 at 80% of predicted. Her last asthma exacerbation was in April during spring allergy season and was successfully managed with yellow-zone treatment. Today, Jennifer’s physical examination is normal. Which of the following orders by the PNP would be most appropriate?
A. Obtain spirometry in the office today B. Give influenza vaccine today C. Obtain a chest x-ray today D. Give pneumococcal 23 valent vaccine today |
B. Give influenza vaccine today
Annual influenza vaccine is recommended for children with asthma. Spirometry is recommended ANNUALLY and whenever treatment is changed, and Jennifer had it done 6 months ago, with good results. There is no indication for a chest x-ray or for pneumococcal 23 valent vaccine today. |
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Which of the following best describes the correct technique for using a conventional metered dose inhaler?
A. Actuate the inhaler concurrent with a rapid inhalation and hold for 10 seconds. B. Actuate the inhaler concurrent with a rapid exhalation and hold for 10 seconds. C. Actuate the inhaler concurrent with a slow inhalation and hold it for 10 seconds. D. Actuate the inhaler concurrent with a slow exhalation and hold for 10 seconds. |
C. Actuate the inhaler concurrent with a slow inhalation and hold it for 10 seconds.
It is important to inhale SLOWLY. For young children who use a spacer with a mask, the mask eliminates the need to coordinate the breathing with actuation of the inhaler. |
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How many infants are born with cerebral palsy (CP) each year in the United States?
A. 1,000 B. 10,000 C. 5,000 D. 20,000 |
B. 10,000
According to the CDC National Center for Birth Defects and Developmental Disabilities, there are approximately 10,000 infants born each year with CP. |
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Neemo is 8 years old and has significantly involved spastic quadriparesis of unknown etiology. He has normal mentation, but has hip dislocations that will require surgical intervention. In accordance with the primary care medical home model as advocated by the AAP, Neemo’s primary care provider must be included in the perioperative process. The rationale for the assessment of Neemo’s up-to-date immunization status, particularly regarding varicella, is that:
A. Neemo’s immunity will be compromised after undergoing general anesthesia B. Neemo’s comfort would be aggravated by the presence of varicella lesions under his hip spica cast C. Live virus vaccines can be safely administered to anyone, regardless of immunity status D. Varicella vaccine, if needed, can be given orally postoperatively |
B. Neemo’s comfort would be aggravated by the presence of varicella lesions under his hip spica cast
The outbreak of varicella vesicles under a cast or brace is an entirely preventable occurrence. Unless medically contraindicated, a child’s immunization status should be documented and verified as “up to date” prior to admission to the hospital for any surgical intervention. |
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Trevor is a 5-year-old boy affected by cerebral palsy secondary to an anoxic brain injury (near-drowning incident) which occurred at 18 months. Trevor is home-schooled by his mother. He is aware of his environment, sensitive to his surroundings, and communicates through a device that answers “yes” and “no” by his pushing a button. Review of plan of care for Trevor is that Botox injections will be administered into his quadriceps and hip adductor muscles. Trevor’s preadmission planning should include:
A. Informing Trevor that he will receive several shots into his affected muscles. B. Asking him what color of cast he would like on his legs C. Assuring Trevor that he will be given a painless anesthetic prior to the procedure so that he will not feel, or remember, receiving the shots D. Telling Trevor that a side effect of Botox is excessive drooling, and this will make him feel embarrassed. |
C. Assuring Trevor that he will be given a painless anesthetic prior to the procedure so that he will not feel, or remember, receiving the shots
The child has communicated that he is fearful of experiencing pain. Addressing this fear by assuring him that he will receive a painless anesthetic prior to the procedure so that he will not feel or remember receiving the shots is meant to address his (very real) anxiety. |
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James is a 7 year old boy affected by spastic left hemiplegic cerebral palsy. His MRI reveals evidence consistent with a previous anoxic ischemic brain injury. James ambulates with a left “toe walk” due to a left equinus deformity and left inward tibial torsion. Which of the following primary care examinations should be conducted on James more frequently than annually?
A. Dental B. Hearing C. Vision D. Growth |
A. Dental
Children with cerebral palsy tend to have poor oral hygiene and dental problems. Certain medications, such as Dilantin, can cause dental problems. Children w/ cerebral palsy should be referred to a dentist w/ experience in caring for children w/ developmental delays and should have routine visits every 6 months. |
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What is the purpose for prescribing Baclofen for a child w/ CP?
A. Decrease anxiety B. Decrease spasticity C. Reduce muscle spasms D. Reduce extrapyramidal reactions |
C. Reduce muscle spasms
Baclofen – reduces muscle spasms Diazepam – reduces anxiety & muscle spasms Dantrolene sodium & botulinum A toxin – reduce spasticity Benztropene mesylate – reduces extrapyramidal reactions |
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Which embryologic germ layer tissue is responsible for the development of most childhood cancers?
A. Mesoderm B. Endoderm C. Ectoderm D. Neuroderm |
A. Mesoderm
Mesoderm develops into – muscle, connective tissue, bone, blood cells, testes |
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Which of the following disorders have a strong association with acute lymphocytic leukemia or lymphoma?
A. Ataxia-telangiectasia B. Turner’s syndrome C. Klinefelter’s syndrome D. WAGR syndrome |
A. Ataxia-telangiectasia
Ataxia-telangiectasia - a rare, childhood neurological disorder that causes degeneration in the part of the brain that controls motor movements and speech. Turner’s syndrome & WAGR syndrome – increase risk for Wilms’ tumor and ovarian cancer Klinefelter’s syndrome – increases risk for breast cancer |
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Mortality rates for childhood cancer have been on the decline since the late 1970s. Which type of childhood cancer continues to report higher mortality rates?
A. Acute lymphocytic leukemia (ALL) B. Acute myelocytic leukemia (AML) C. Retinoblastoma D. Wilms’ tumor |
B. Acute myelocytic leukemia (AML)
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Which mode of cancer treatment will have the most damaging effect on physical growth?
A. Chemotherapy B. Internal radiation C. Cranial radiation D. Biologic response modifiers |
C. Cranial radiation
Cranial radiation has been shown to most directly affect growth through damage to the endocrine glands responsible for growth-related hormone production. |
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Which of the following physical growth assessment guidelines should be followed for a child with cancer?
A. Height, weight, BMI – documented on standardized growth curves for all children every 2 months while the child is in therapy. B. Height, weight, BMI – documented on standardized growth curves for all children every 2 months while the child is in therapy and for the 1st year after therapy. C. Height, weight, BMI, head circumference – documented on standardized growth curves for all children every 2 months while the child is in therapy and for the 1st year after therapy. D. Height, weight, BMI – documented on standardized growth curves for all children every 6 months while the child is in therapy and for the 1st year after therapy. |
B. Height, weight, BMI – documented on standardized growth curves for all children every 2 months while the child is in therapy and for the 1st year after therapy.
Head circ should be documented and followed in children YOUNGER THAN 3 YEARS OF AGE. |
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Which of the following 16-year-old children will be at the greatest risk for late effects of childhood cancer treatment?
A. Undergoing induction therapy for ALL B. Entering maintenance therapy for ALL C. Completed chemotherapy for ALL 5 years ago D. Completed chemotherapy for ALL when he was 2 years old. |
D. Completed chemotherapy for ALL when he was 2 years old.
The younger the child was while undergoing childhood cancer treatment, the higher the risk for late effects. |
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Children who have been treated for Hodgkin’s disease should be given which of the following vaccinations 6 months following treatment?
A. Meningococcal B. Varicella C. MMR D. Polio |
A. Meningococcal
Patients who have had Hodgkin’s lymphoma are particularly susceptible to meningococcal disease. |
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Jane is 26 weeks pregnant with her first baby. The ultrasound of the fetus done at 16 weeks gestation revealed a unilateral cleft lip. What advice should the PNP provide to Jane regarding breastfeeding her newborn?
A. Breastfeeding will likely cause an increase of ear infections in the newborn; therefore, it is not recommended. B. Infants with cleft lip are likely to be successful at breastfeeding because the breast tissue will fill in the gap in the lip. C. Newborn infants should be in a supine position when breastfeeding to allow for a better seal. D. Breastfeeding will not be possible, as the newborn will not be able to suck at birth. |
B. Infants with cleft lip are likely to be successful at breastfeeding because the breast tissue will fill in the gap in the lip.
Breastfeeding should be encouraged in all infants, especially those infants with cleft lip and palate. The breast tissue is soft and will sometimes form the needed seal to enhance sucking. The protective immunity acquired with breastfeeding can decrease the incidence of ear infections in these infants. To prevent nasal regurgitation, these infants should be fed in a semi-upright position. |
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Common causes of classic inborn error of metabolism (IEM) are:
A. A defect in the lack of activity of a specific enzyme involved in amino acids, carbohydrates, and protein metabolism. B. A defect in the lack of activity of a specific enzyme involved in amino acid, carbohydrates, or lipid metabolism. C. A defect in the lack of activity of a specific enzyme involved in amino acids and carbohydrates metabolism. D. A defect in the lack of activity of a specific enzyme involved in amino acids, carbohydrates, or vitamin metabolism. |
B. A defect in the lack of activity of a specific enzyme involved in amino acid, carbohydrates, or lipid metabolism.
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As the PNP, you instruct the parents of a child with galactosemia that the child must be provided with dietary supplements of what type of nutrient?
A. Vitamin D B. Selenium C. Calcium D. Vitamin C |
C. Calcium
Infant’s diet will be soy formula or other lactose-free formula so calcium supplementation is important because soy products are not rich in calcium. |
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A child diagnosed with maple syrup urine disease (MSUD) has diet restrictions which require what type of modifications?
A. High in amino acids, isoleucine, valine, and lysine B. High in amino acids, lysine, isoleucine, and leucine C. Low in amino acids, leucine, isoleucine, and valine D. Low in amino acids, lysine, isoleucine, and valine |
C. Low in amino acids, leucine, isoleucine, and valine
These amino acids are THREE-BRANCHED-CHAIN amino acids. MSUD kids have to AVOID these amino acids. |
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Which statement accurately reflects the most important indicator that a child is possibly presenting with an IEM (inborn error of metabolism) disorder?
A. Loss of a developmental milestone is evident within the first 3 months of birth. B. Most symptoms of the disorder develop after a change in diet has taken place. C. Progressive deterioration of the symptoms occurs after an initial period of apparent good health. D. Symptoms of developmental delay usually occur within 1 month of birth. |
C. Progressive deterioration of the symptoms occurs after an initial period of apparent good health.
Sxs of an inborn error of metabolism become evident usually after some level of good health. In part, this is due to absence of or a build-up of an enzyme or metabolite. Symptoms may become present within the first week of life or thereafter. |
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Biotinidase deficiency may present itself with numerous clinical symptoms such as hypotonia, eczematous rash, alopecia, and seizures. Seizures for this genetic disorder can be described as:
A. Generalized tonic-clonic B. Infantile spasms C. Not responsive to conventional therapies D. Seizures in combination with other clinical symptoms of the disorder |
C. Not responsive to conventional therapies
Seizures respond rapidly to pharmacologic dosing of BIOTIN. |
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Gastrointestinal problems more commonly seen in a child with Down syndrome are Hirschsprung’s disease and _____ :
A. Pyloric stenosis B. Intussusception C. Duodenal atresia D. Gastroesophageal reflux |
C. Duodenal atresia
Hirschsprung’s and duodenal atresia are seen in 10% of Down syndrome children. |
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A 16 year old female junior in high school has been in trouble with school authorities since age 12 for petty theft. She has a history of truancy, and has most recently been expelled for smoking marijuana in the bathroom and setting fire to an abandoned house. She has been admitted to a psychiatric hospital for her behavioral problems. Her parents are unable to control her, and they state that she lies constantly, stays out all night without telling them where she is going, and is frequently angry with them when they try to intervene. You would consider which of the following diagnoses?
A. Major depressive disorder B. Conduct disorder C. Oppositional defiant disorder D. Bipolar disorder |
B. Conduct disorder
The repetitive and pervasive pattern of violating the basic rights of others and major age-appropriate social norms or rules indicates conduct disorder. Because the onset is after age 10, it would indicate adolescent onset type, which generally has a better prognosis than childhood onset type. |
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One approach to the problem of aggression in psychiatrically referred juveniles is to consider aggression as a dimensional characteristic of patients that may be continuously present but in varying degrees across many different psychiatric disorders. With this dimensional approach to aggression, psychiatric medications are prescribed to:
A. Target the primary diagnosis B. Target aggression as a symptom C. Target associated conditions, such as anxiety D. Avoid dealing with the family |
B. Target aggression as a symptom
In the dimensional approach to aggression, psych meds target aggression as a sxs of a disorder, rather than treating the disorder itself. This approach is analogous to the palliative tx of pain or fever w/ meds, regardless of the underlying medical condition. |
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The parents of a 3-year-old report that their son seems to be having difficulty with motor skills such as building blocks. Upon assessment, you find the child has more limited verbal skills than expected for his age and he has poor walking coordination. You would suspect which diagnosis?
A. Autistic disorder B. Asperger’s disorder C. Childhood disintegrative disorder D. Rett’s disorder |
D. Rett’s disorder
Rett’s disorder – child shows deterioration of developmental milestones, head circ, and overall growth. Specific characteristic hand movements are always present. Poor coordination, ataxia, and apraxia are part of Rett’s. Autism – aberrant development is usually present from early on. Hand mannerisms may or may not appear. Many people with autism have unremarkable gross motor function. |
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Peter, a 16 year old, is expelled from school for repeated violations for disruptive behavior and breaking rules. He has a hx of truancy and failing grades for several years, since the onset of these behaviors. Peter is unpopular with his peers, really doesn’t have any friends, and spends a lot of time by himself. You would expect him to carry a diagnosis of:
A. Conduct disorder, adolescent onset B. Oppositional defiant disorder C. Unsocialized conduct disorder D. Delinquent |
C. Unsocialized conduct disorder
Criteria for this dx: the general criteria for conduct disorder, but also includes a clear poor relationship with the individuals’ peer group as shown by isolation, rejection, or unpopularity, and by lacking in close reciprocal friendships. |
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Your assessment of a depressed adolescent reveals suicidal ideation, but the family support suggests that they can handle ambulatory treatment. Recommendations for management of the ambulatory suicidal patient include:
A. Medication should be withheld from the suicidal patient in all cases. B. Minimize the number of medications available in the home to reduce the opportunity for overdose. C. It is developmentally appropriate for parents to permit the teen to manage his or her medication. D. The primary care provider does not need to consult with a child and adolescent mental health provider. |
B. Minimize the number of medications available in the home to reduce the opportunity for overdose.
The plan for management of the suicidal teen outside of a hospital includes minimizing the availability of extra meds by prescribing only enough to cover until the next apt; having parents keep meds in a locked cabinet and to be involved in the meds management; removal of potentially lethal means of suicide such as firearms, knives, poisons, and pills; and developing a systematic plan for checking with the patient routinely to assess feelings and self-destructive urges. |
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A 6 month old with complete atrioventricular canal defect comes into the clinic. The PNP notes a consistent drop in weight over the last 3 months. Mom reports he drinks 1.5 – 2 oz every 4 hrs, and it takes him nearly an hour to finish feeding. What is the most appropriate action?
A. No changes at this time; this is normal growth for a cardiac baby B. Refer to cardiology immediately upon completion of your visit C. Change formula to 24 cal/oz and have them follow up with their cardiologist in the next week D. Send the family to the local hospital for placement of a feeding tube |
C. Change formula to 24 cal/oz and have them follow up with their cardiologist in the next week
This infant is likely in heart failure so increased demands will necessitate increased calorie needs. If he spends more than 30 minutes per feeding, he is likely burning the calories he is working so hard to take in. Increased-calorie formula allows for infants to eat less with more benefit. Follow-up with the cardiologist is also necessary for a cardiac child who is showing growth deceleration. |
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A 7 year old is being seen for a complaint of headaches and hypertension. An important differential for the PNP to consider is:
A. Patent ductus arteriosus B. Aortic insufficiency C. Coarctation of the aorta D. Interrupted aortic arch |
C. Coarctation of the aorta
Older children evaluated for HTN may often have cardiac disease as opposed to renal disease; to evaluate HTN, four-point blood pressures and femoral pulse examination are critical. |
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Which of the following congenital heart disease lesions is acyanotic?
A. Coarctation of the aorta B. Truncus arteriosus C. Ventricular septal defect D. Pulmonary stenosis |
C. Ventricular septal defect
Oxygenated blood recirculates in the heart because the blood crosses the defect from the left to the right side of the heart. |
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Cystic fibrosis is an autosomal recessive inheritance pattern disease also thought to be caused by a defect in the CF gene, cystic fibrosis transmembrane conductance regulator (CFTR), which:
A. Is located on the long arm of chromosome 7 B. Encodes for lipids that function as a chloride channel C. Is not regulated by cyclic adenosine monophosphate (cAMP) D. No mutations of the CF gene have been identified |
A. Is located on the long arm of chromosome 7
CFTR encodes for PROTEIN that functions as a CHLORIDE CHANNEL. More than 1400 mutations of CF gene have been identified. CFTR is regulated by cyclic adenosine monophosphate (cAMP). |
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Signs and sxs of CF vary widely by age. Approx 1/3 of patients are diagnosed by:
A. 6 years B. 12 years C. 2 months D. 12 months |
C. 2 months
Median age of diagnosis is 14 months with 1/3 of the patients diagnosed at less than 2 months by positive family hx, meconium ileus, and neonatal screening. |
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Non-CF conditions that produce elevated sweat electrolytes include all of the following EXCEPT:
A. Diabetes B. Adrenal insufficiency C. Hypothyroidism D. Malnutrition |
A. Diabetes
While diabetes may produce a diaphoresis resulting in clammy skin, the sweat chloride is not necessarily elevated, as diabetics have normal sweat glands. The function of the sweat duct cells is to absorb rather than secrete chloride, salt is not retrieved from the isotonic primary sweat as it is transported to the skin surface; chloride and sodium levels are consequently elevated. |
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Antiinflammatory medications in cystic fibrosis patients are:
A. Contraindicated B. Used as to treat bacterial infections C. Used in low doses to decrease inflammation of the airways D. Used in high doses to decrease inflammation of the airways |
D. Used in high doses to decrease inflammation of the airways
Corticosteroids are useful for the treatment of allergic bronchopulmonary reactive airway diseases by decreasing inflammation in high doses. They have no antibacterial properties, may result in growth retardation, cataracts, and abnormal glucose tolerance. |
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When ordering pancreatic enzyme replacements for cystic fibrosis patients, all of the following are true EXCEPT:
A. Enzyme dosage and product should be individualized for each patient B. Replacements fully correct stool fat and nitrogen losses C. Administration of large doses has been linked to colonic strictures requiring surgery D. Enzyme replacement should not exceed 10,000 units/kg/day |
B. Replacements fully correct stool fat and nitrogen losses
Extracts of animal pancreas given with ingested food reduce but do not fully correct stool fat and nitrogen losses. The dose of enzymes required usually increases with age, but some teenagers and young adults may later have a decrease in their requirement. |
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The average life expectancy of patients with CF is:
A. 45 B. 56 C. 36 D. 25 |
C. 36
According to the Cystic Fibrosis Foundation, as of 2004 the average life expectancy was 36.8, with 95% of patients dying of respiratory failure. |
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A 12 year old presents to your office with a 2-week hx of polyuria, polydipsia, and polyphagia. She also is complaining of weakness, vomiting, and abdominal pain. Based on the signs and symptoms, which of the following is the most appropriate first action?
A. Immediate referral to the emergency department B. HLA C. Urinalysis D. Random plasma glucose |
A. Immediate referral to the emergency department
Refer the child to the emergency department as she may have diabetic ketoacidosis (DKA), which is a medical emergency. The other tests are important in diagnosing type 1 diabetes when the child does not appear severely ill. |
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A 10 year old was recently diagnosed with type 1 diabetes. Which of the following is the most important to tell her family when giving anticipatory guidance?
A. The time after diagnosis is the “honeymoon” and can last an unpredictable amount of time B. Beta cell destruction is complete in 2 years C. The need for insulin increases after diagnosis D. The need for insulin decreases after diagnosis |
C. The need for insulin increases after diagnosis
While the “honeymoon” phase and beta cell destruction are important to discuss with the family, it is more important to discuss insulin. INSULIN NEEDS GROW after diagnosis, not decline. |
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The most important therapy in managing type 2 diabetes is:
A. Insulin B. Metformin C. Diet D. Exercise |
C. Diet
Diet is the MOST IMPORTANT management of TYPE 2 DM by eating a reduced-calorie diet regularly. Insulin may be required initially, and metformin may be necessary as maintenance therapy. Exercise is important along with diet. |
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In providing anticipatory guidance to a 16 year old newly diagnosed type 2 diabetic, which information is the most important to discuss?
A. Hyperglycemia B. Hypoglycemia C. Frequent infections D. Insulin resistance |
D. Insulin resistance
Insulin resistance is the MOST IMPORTANT COMPLICATION OF TYPE 2 diabetes. It can lead to metabolic syndrome and polycystic ovary disease. Hyperglycemia, hypoglycemia, and frequent infections are complications of type 2 diabetes as well. |
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Which of the following is the most useful in managing type 1 diabetes in a 4-year-old?
A. Positive reinforcement B. Teaching benefits of the best control C. Making diabetes schedule accommodating D. Body image concerns |
A. Positive reinforcement
Positive reinforcement is important for a PRESCHOOLER in order to help the child develop SELF-CONFIDENCE. The other answers are all important as the child grows OLDER. |
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The most common initial eating disorder diagnosis is:
A. Anorexia nervosa B. Bulimia nervosa C. Eating disorder not otherwise specified (EDNOS) D. Female athletic triad |
C. Eating disorder not otherwise specified (EDNOS)
Its estimated that 50% of children/adolescents who are discovered in peds settings do NOT meet official criteria for anorexia or bulimia. It is thought, however, that about 50% of those patients INITIALLY diagnosed with EDNOS WILL GO ON to meet criteria for anorexia nervosa or bulimia nervosa. They may have similar medical signs and sxs and will require the same types of treatment as the officially diagnosed patients. It is purported that EDNOS should be treated as aggressively anorexia nervosa or bulimia nervosa. |
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What laboratory values would you expect to find in your patient with anorexia who presents with an acute, substantial weight loss in a short time followed by weight gain?
A. Low phosphorus, low potassium, low magnesium, low glucose B. High potassium, low sodium, high glucose C. Low calcium, high sodium, low protein D. High magnesium, low glucose, high potassium |
A. Low phosphorus, low potassium, low magnesium, low glucose
Medical complications include significant metabolic abnormalities, such as hypophosphatemia, hypomagnesemia, hypokalemia, hypoglycemia, normal or low albumin, hypocalcemia, and hyponatremia. Not only can these electrolyte abnormalities be caused by anorexia or bulimia, but can also recur in the refeeding phase of nutritional therapy. |
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A 13 year old male patient with a known eating disorder presents to the clinic with stable vital signs, an ESR of 145, diarrhea, and a macular rash. What is the best action?
A. Order a C reactive protein (CRP) to evaluate acute inflammation B. Conduct other systems workups to rule out malignancies or inflammatory diseases C. Refer to infectious disease clinic D. Reassure parents this is a normal finding in teens who present with eating disorders |
B. Conduct other systems workups to rule out malignancies or inflammatory diseases
There are several disease processes that can present with the initial signs and sxs of eating disorders in addition to other illnesses. Children/adolescents w/ eating disorders can also present with other disease processes. This patient has a known eating disorder and has stable vital signs which indicate metabolic stability. An elevated ESR is NOT TYPICAL FOR PATIENTS WITH EATING DISORDERS. Usually ESR is normal or low. Although CRP may help to rule out an acute infection, the ESR merits further investigation at this point. The differential diagnosis includes inflammatory bowel disease, TB, hypo/hypothyroidism, DM, malignancies, rhematologic disease, and problems with the pituitary gland. |
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Which of the following is the best action the PNP should take for a 13 year old female pt with amenorrhea and osteopenia?
A. Start Fosamax to increase bone growth B. Order a repeat DEXA scan to verify findings C. Provide nutritional counseling to promote weight restoration, which should result in the onset of menses D. Order two Tums tablets per day to increase calcium |
C. Provide nutritional counseling to promote weight restoration, which should result in the onset of menses
Approx 40-60% of bone mass is deposited during puberty and peak mass is usually achieved by late adolescence or early adulthood. Although this area of research is very controversial, it appears that nutritional health, weight gain, and return of menses are the markers used to evaluate improved health. The biphosphanates (Foxamax) are BEING INVESTIGATED but are NOT FIRST-LINE TREATMENT. Estrogen replacement may be good for pts with very low %body fat, but are also NOT first-line tx. It is though that WEIGHT RESTORATION, ESTROGEN (from menses), and NUTRITION appears to have the BEST RESULT. |
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Which of the following statements is true regarding females/males from other countries with eating disorders?
A. Third-world countries do not recognize eating disorders B. Foreign citizens who live in the United States are more at risk for eating disorders C. Spain and Italy have more eating disorders than other countries D. Males are more likely than females to have eating disorders in foreign countries |
B. Foreign citizens who live in the United States are more at risk for eating disorders
It is NOT known that Spain and Italy have greater or fewer eating disorders than other countries. FOREIGN citizens who have exposure to western culture are MORE at risk for developing eating disorders. |
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You saw a 16 year old female, a known anorexic, 5 days ago. At that time, she had been eating only about 500 calories per day for 3 months. Today, she presents for her follow-up visit and mom states she has been eating all of her meals and 3 snacks per day (about 2000 calories/24 hrs) since she as last in your office. What is the best action to take today?
A. Provide positive encouragement and schedule a weight check in 7 days B. Counsel on obesity prevention C. Admit to the hospital D. Order and evaluate serum electrolytes |
D. Order and evaluate serum electrolytes
Someone who is taking in a small amount of calories over a set period of time will slow his/her metabolic systems down and decrease weight. The body learns to operate at low calorie intake and conserves energy. IF there is a LARGE INCREASE IN CALORIC INTAKE SUDDENLY, the body often CANNOT RECOVER FAST ENOUGH. A large amount of energy is necessary and a large amount of PHOSPHORUS is consumed as the body adapts to the increase in energy consumption. It may take 3-7 DAYS for the effects of refeeding to show up and providers should monitor their patients carefully. Although referral to a therapist is a good idea, it is not the priority of this visit. Encouraging the family is also important, but again, most importantly LAB TESTS should be obtained TO EVALUATE FOR REFEEDING SYNDROME. |
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What lab value is most diagnostic of refeeding syndrome?
A. Hypophosphatemia B. Hyponatremia C. Hypermagnesemia D. Hypokalemia |
A. Hypophosphatemia
This is the most common sequelae in refeeding. Other decreases occur in magnesium, potassium, and glucose. |
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Which scenario is most likely diagnostic for EDNOS?
A. Use of daily laxatives and binging episodes with subsequent vomiting for 6 months B. Eating uncontrollably and developmental delay C. Normal menstruation, use of laxatives for 1 month, and at 80% of ideal body weight D. Loss of menses for 2 years, weight at 75% of ideal body weight, spitting out food |
C. Normal menstruation, use of laxatives for 1 month, and at 80% of ideal body weight
This patient is the ONLY one who DOESN’T meet criteria for anorexia nervosa or bulimia nervosa because he or she has NOT had the behavior long enough and does not meet the weight criteria. Patient A meets criteria for bulimia. Patient B most likely has Prader Willi syndrome. Patient D meets criteria for anorexia nervosa. |
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The best treatment for total cure of partial epilepsy in a child is:
A. Cortical resection B. Phenytoin C. Vagus nerve stimulator (VNS) D. Ketogenic diet |
A. Cortical resection
This provides a CURE and complete remission of seizures. The other choices do NOT cure partial epilepsy. |
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A 14 year old patient presents with the following history: brief sudden generalized muscle contractions affecting the extremities – mainly upon awakening, duration of less than 2 minutes, no loss of consciousness is involved. Otherwise healthy without change in body habitus or evidence of cognitive decline. The most likely seizure type is:
A. Generalized tonic/clonic B. Complex partial C. Juvenile myoclonic epilepsy D. Atonic |
C. Juvenile myoclonic epilepsy
This is a common seizure type that occurs in ADOLESCENCE, mainly upon awakening; the other seizures occur randomly across all ages. |
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Surgical intervention for intractable epilepsy is most appropriate for which seizure type?
A. Atonic B. Myoclonic C. Clonic D. Complex partial |
D. Complex partial
Surgery is indicated for PARTIAL SEIZURES ONLY; the others listed are generalized seizures. |
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The antiepileptic medication known to cause anorexia and concomitant weight loss is:
A. Valproate B. Phenytoin C. Topiramate D. Lamotrigine |
C. Topiramate
All other meds either cause weight gain OR no change in weight. |
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The antiepileptic medication known to cause increased appetite and subsequent weight gain is:
A. Valproate B. Phenytoin C. Topiramate D. Lamotrigine |
A. Valproate
All other meds in the list either cause weight loss OR no change in weight |
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A 3 year old child comes into the clinic for a well child visit. The child was diagnosed with juvenile myoclonic epilepsy about 12 months ago. The mother expresses her concern that she caused this condition by traveling to Thailand while pregnant. The best response for the pediatric nurse practitioner would be:
A. I’ll put a referral to the air travel medicine department B. The cause of juvenile myoclonic epilepsy has been linked to genetics C. This disorder is caused by exposure to environmental toxins during your pregnancy D. Did you visit any other countries while pregnant with this child? |
B. The cause of juvenile myoclonic epilepsy has been linked to genetics
Juvenile myoclonic epilepsy is a genetic disorder located on the chromosome 6p15q14. The gene has not been identified yet. It has not been linked to infections, diseases, or fever. |
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The antiepileptic medication utilized for the treatment of both partial and generalized seizures is:
A. Lamotrigine B. Valproate C. Carbamazepine D. Topiramate |
B. Valproate
This drug is used for BOTH partial and generalized seizures. All the other meds on the list are used for PARTIAL seizures. |
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After vagus nerve stimulator (VNS) therapy, what percentage of patients with epilepsy will have greater than a 50% reduction in the number of seizures?
A. 5% B. 10% C. 33% D. 50% |
C. 33%
Vagus nerve stimulator therapy is most effective with generalized epilepsy. 1/3 of the patients will have greater than 50% reduction in seizures, 1/3 will have less than 50% reduction in seizures, and 1/3 will have no changes in their seizure frequency. |
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Which of the following test is the most definitive to use in the diagnosis of sickle cell anemia?
A. Bleeding time B. Genetic testing C. Hemoglobin electrophoresis D. Multimeric analysis |
C. Hemoglobin electrophoresis
This test determines the presence of hemoglobin S. |
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Which of the following conditions is NOT caused by a genetic mutation of chromosome 11?
A. Hemoglobin C B. Hemoglobin E C. Hemoglobin S D. alpha-thalassemia |
D. alpha-thalassemia
Alpha-thalassemia is a genetic mutation of chromosome 16 |
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Treatment of thalassemia trait should include:
A. Transfusions B. Bone marrow transplant C. Iron chelation therapy D. No treatment is needed |
D. No treatment is needed
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Treatment of thalassemia intermedia should include:
A. Transfusions B. Bone marrow transplant C. Iron chelation therapy D. No treatment needed |
A. Transfusions
Transfusions are often needed for thalassemia intermedia, and should be managed collaboratively with a pediatric hematologist. |
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It is appropriate to consider genotyping in children with alpha-thalassemia at high risk for loss of:
A. 1 or 2 genes B. 2 or 3 genes C. 3 or 4 genes D. 5 or 6 genes |
C. 3 or 4 genes
For populations that are at high risk for alpha-thalassemia, consider genotyping for loss of 3 or 4 genes. |
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Which of the following cardiovascular effects is NOT a long-term effect in a child with sickle-cell anemia?
A. Compensatory increased cardiac output B. Left ventricular hypertrophy as a result of chronic anemia C. Right ventricular hypertrophy as a result of immature RBC D. Pulmonary hypertension is rare except in those with acute or chronic pulmonary disease |
C. Right ventricular hypertrophy as a result of immature RBC
Individuals with sickle cell disease will develop chronic organ damage. Cardiovascular effects are left ventricular hypertrophy as a result of chronic anemia, compensatory increased cardiac output, and pulmonary hypertension (which is rare except in those with acute or chronic pulmonary disease). |
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What is the lift span of a RBC in people with hemoglobin C disease?
A. 100 days B. 70 days C. 40 days D. 20 days |
C. 40 days
A hgb C RBC life span is 40 days, while a normal RBC life span is 120 days |
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Which ethnic group has the highest overall hgb E incidence rate?
A. Mediterranean and Middle Easterners B. Southeast Asian and Native Americans C. Western Europeans D. South American |
B. Southeast Asian and Native Americans
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The lab results come back on Baby Presley. Which of the following labs are indicative of a definitive diagnosis of alpha-thalassemia?
A. FA+ hgb Bart’s B. FA+ hgb S C. FA+ hgb B D. FA+ hgb H |
A. FA+ hgb Bart’s
FA means that amount of fetal hgb is greater than adult hgb (which is normal for a newborn). Bart’s hgb is indicative of1-4 missing or dysfunctional genes. |
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When should Larry, a 1-week old infant diagnosed with alpha-thalassemia, have a follow-up visit?
A. In 1 week B. By 1 month of age C. By 1 year of age D. No follow-up is needed |
B. By 1 month of age
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A diagnosis of juvenile rheumatoid arthritis (JRA) would be suspected if a child presents with which set of symptoms?
A. Erythematous joints, joint pain, fever, rash B. Morning stiffness, altered mobility, joint pain, fever, rash C. Nausea, one-sided weakness, irritability, intolerance to heat or cold D. Change in daily activities, photosensitivity, anemia, loss of appetite |
B. Morning stiffness, altered mobility, joint pain, fever, rash
Children with JRA do NOT have the following sxs: erythematous joints, nausea, one-sided weakness, intolerance to heat or cold, or photosensitivity |
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Which one of the following diagnoses would you suspect in a 13 year old male who presents with inflammation in his right ankle and knees, no pain, rheumatoid factor negative, and ANA positive?
A. Oligoarthritis B. Polyarthritis C. Systemic JRA D. Osteoarthritis |
A. Oligoarthritis
Unlike the other classifications of JRA, oligoarthritis JRA is often ASYMMETRIC and the most commonly affected joints are the KNEES and ANKLES. UP TO FOUR JOINTS can be affected. Although inflammation is present, PAIN IS NOT ALWAYS REPORTED. Late-onset oligoarthritis tends to occur in males older than age 10. |
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Christina is a 12 year old with oligoarthritis who is currently taking naproxen for her JRA. She comes to clinic to have a preoperative clearance for arthroscopic surgery on her ankle in 5 days. What instructions should she receive regarding her naproxen?
A. Double-dosing of the naproxen after the surgery to help postoperative B. Continue taking the medication until the day of the surgery, then discontinue until 2 weeks postoperative C. Continue daily doses of naproxen pre-and-postoperatively D. Discontinue the naproxen immediately and resume only when instructed by a health care provider |
D. Discontinue the naproxen immediately and resume only when instructed by a health care provider
NSAIDs will thin the blood and may cause intraoperative and postoperative bleeding. To reduce the risk of bleeding during surgery, these medications should be stopped preoperatively. |
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Progressive joint involvement occurs in approximately what percentage of children with systemic JRA?
A. 30% B. 75% C. 50% D. 90% |
C. 50%
50% of children with systemic JRA have progressive joint involvement, as well as complications such as pericarditis and infection. The other 50% MAY have complete RESOLUTION of their symptoms BY ADULTHOOD. |
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Which of the following statements is FALSE?
A. The Rehabilitation Act 504 is a federal law for nondiscrimination against disabilities and requires special provisions to be made in schools B. Despite the type of JRA at onset, JRA can potentially become systemic C. Mouth sores are a symptom of JRA, not a side effect from medications such as methotrexate D. Daily fever over at least 2 weeks, with daily high-spiking fevers of greater than or equal to 39 C followed by normal or subnormal temperatures helps to classify systemic JRA |
C. Mouth sores are a symptom of JRA, not a side effect from medications such as methotrexate
Mouth sores are a side effect of methotrexate and other DMARDs (class of immunosuppresives), not a symptoms of JRA. |
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Nonpharmacologic approaches to JRA pain in children include all of the following EXCEPT:
A. Distraction B. Cognitive behavioral therapy C. Exercise D. Joint splinting |
D. Joint splinting
Splinting of the joints is used to maintain alignment, reduce flexion contractures, and provide support during functional activities. It is not necessarily done to control pain. |
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Kristen is a 4 year old who is newly diagnosed with JRA. Which of the following referrals should the PNP make for Kristen?
A. Ophthalmologist B. Cardiologist C. Urologist D. Pulmonologist |
A. Ophthalmologist
Children with JRA are at risk for developing UVEITIS; all children diagnosed with JRA should be evaluated by an ophthalmologist. |
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Which of the following statement is NOT true regarding Koebner’s phenomenon?
A. Trauma to uninvolved skin can trigger the onset of a skin disease B. It is associated with oligoarthritis form of JRA C. Lesions may mark the initial onset of psoriasis, or may be a new lesions in an existing case of psoriasis D. This phenomenon can be seen in various skin diseases |
B. It is associated with oligoarthritis form of JRA
Koebner’s phenomenon is indicative of SYSTEMIC JRA ONLY, and not the other two types of JRA. However, it is NOT exclusive to systemic JRA – it can be seen in CERTAIN OTHER SKIN DISEASES. |
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Which of the following is a FALSE statement?
A. Immunosusceptability and external environmental triggers are necessary for the development of JRA B. B-cell activation, complement consumption, release of interleukin-6 (IL-6), IL-13, tumor necrosis factor (TNF), and other proinflammatory cytokines lead to joint damage C. Siblings tend to develop the same type of JRA D. The United States and Canada currently adopt the JRA classification from the International League of Associations for Rheumatology (ILAR) |
D. The United States and Canada currently adopt the JRA classification from the International League of Associations for Rheumatology (ILAR)
Historically, the U.S. and Canada classify JRA using the American College of Rheumatology classifications. ILAR may be used in the future, but this has not been established yet. |
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Studies show that approximately 30% of youth diagnosed as having a learning disability have which comorbid condition?
A. Depression B. Childhood schizophrenia C. Eating disorder D. Conduct disorder |
D. Conduct disorder
Studies of youth diagnosed as having conduct disorder or young adults diagnosed as having a personality disorder show that 1/3 have unrecognized, or recognized and poorly treated, learning disabilities |
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The most widely studied drugs in the treatment of ADHD, the stimulants, affect:
A. Dopamine and norepinephrine B. 3-methoxyl-4-hydroxyphenyglycol (MHPG), a metabolite of norepinephrine C. Norepinephrine D. Dopamine |
A. Dopamine and norepinephrine
In part, hypotheses about the neurochemistry of the disorder have arisen from the impact of many medications that exert a positive effect. The most widely studied, the stimulants, affect both dopamine and norepinephrine, leading to a neurotransmitter hypothesis that include possible dysfunction in BOTH ADRENERGIC & DOPAMINERGIC SYSTEMS. |
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Hyperactivity, a primary concern to the diagnosis of ADHD may vary with the individual’s age and developmental level. A toddler or preschooler with this disorder would be different from normally active young children by:
A. Being impatient, blurting out answers to questions before the questions are asked B. Being preoccupied for the majority of the time C. Being constantly on the go and into everything; unable to sit and listen to a story D. Being increasingly aggressive in nature |
C. Being constantly on the go and into everything; unable to sit and listen to a story
Toddlers & preschoolers with this disorder differ from normally active young children by being constantly on the go and into everything; they dart back and forth, are “out the door before their coat is on,” jump or climb on furniture, run through the house, and have difficulty participating in sedentary group activities in preschool classes, such as listening to a story. |
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C. Being constantly on the go and into everything; unable to sit and listen to a story
Toddlers & preschoolers with this disorder differ from normally active young children by being constantly on the go and into everything; they dart back and forth, are “out the door before their coat is on,” jump or climb on furniture, run through the house, and have difficulty participating in sedentary group activities in preschool classes, such as listening to a story. |
B. Six or more symptoms of hyperactivity-impulsivity, but fewer than six symptoms of inattention that have persisted for more than 6 months.
ADHD, predominantly hyperactive-impulsive type should be used if six or more symptoms of hyperactivity-impulsivity, BUT FEWER than six symptoms of INATTENTION, have persisted for more than 6 months. Inattention may often still be a significant clinical feature in such cases. |
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Mark (11 year old ADHD, predominantly inattentive type, male) is unable to tolerate the prescribed stimulant medication. You decide to use desipramine 4.6 mg/kg/day, a nonstimulant medication, for Mark. You advise his parents that:
A. Periodic monitoring every 6 months will be required B. He may lose weight due to lack of appetite C. You will have to monitor for cardiovascular side effects (EKG) D. He is likely to develop tics |
C. You will have to monitor for cardiovascular side effects (EKG)
TRICYCLIC ANTIDEPRESSANTS SUCH AS DESIPRAMINE are effective in the treatment of ADHD. However, their use has been largely supplanted by the use of stimulants such as atomoxetine (Strattera) b/c of their low risk for cardiovascular toxicity, reduced need to monitor serum levels, and unlikelihood of exacerbating tics. |
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Mark’s (11 year old ADHD, predominantly inattentive type, male) teacher, parents, and yourself meet to determine a plan of treatment for him; you suggest:
A. Brief group therapy (four sessions) for social skill development B. Developing behavioral interventions with positive reinforcements C. Retaining Mark in regular classrooms because he prefers it D. That use of medication will be enough without psychosocial intervention |
B. Developing behavioral interventions with positive reinforcements
BRIEF GROUP INTERVENTIONS ARE NOT REASONABLE FOR THE CHILD WITH ATTENTION PROBLEMS. Social skills groups, training for parents, and BEHAVIORAL INTERVENTIONS that can be used consistently between home and school are often efficacious in the overall management of children w/ ADHD. Medication alone is NOT ENOUGH to satisfy the therapeutic needs of children with ADHD. |
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The prevalence of ADHD in school-aged children is estimated at:
A. 3 to 7% B. 20 to 25% C. 30% D. 75% |
A. 3 to 7%
This is school-aged children; the data on adolescents and adults are limited. |
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A first-line medication in treatment of ADHD for youth with comorbid tic disorders is:
A. Wellbutrin B. Clonidine C. Ritalin D. Concerta |
B. Clonidine
Originally used as an anti-HTN med for adults, clonidine (Catapres) has been considered a first-line therapy for children w/ ADHD with tic disorders and Tourette’s syndrome. Other first-line meds recommended include atomoxetine (Strattera) and guanfacine (Tenex). |
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The most recent American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters recommend the following monitoring for children treated with stimulant medications:
A. Height, weight, blood pressure, and pulse checked annually with a physical exam B. Height, weight, blood pressure, and pulse checked quarterly with a physical exam annually C. Height, weight, and eating patterns monitored weekly with a physical exam annually D. Height and weight monitored by the parents monthly with a physical exam annually |
B. Height, weight, blood pressure, and pulse checked quarterly with a physical exam annually
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Essential components of parent training programs for behavior management of their children with ADHD include:
A. To be nonresponsive to all behaviors, positive or negative B. Punishment of misbehavior at the end of the day C. Interrupting coercive interchange between parents and child D. To overly praise the behaviors of the child |
C. Interrupting coercive interchange between parents and child
Essential components of parent training for behavior management include: -interrupting the pattern of coercive and often escalating interchange between parent & child. -systematic implementation of positive parent-child exchanges that are noncontingent, which strengthens the parent-child bond. -praising appropriate behaviors, while as often as possible ignoring misbehavior. -implementation of disciplinary strategies sucha s time-out when the child’s misbehavior cannot be safely ignored. |
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Confidentiality is particularly challenging when working with a rural family and child with ADHD because the communities are small and you are likely to encounter this family in a social setting. A strategy to deal with this is:
A. There is no need for additional concerns about boundaries. B. Discuss with parents directly what you have heard about them. C. Avoid participating in any community activities they might attend. D. Pretend you don’t know them “professionally”. |
B. Discuss with parents directly what you have heard about them.
Boundaries, confidentiality, and conflicts of interest are particularly challenging in rural practice. It is important to keep an open mind, but to discuss with parents directly what you have heard about them, and clearly define boundaries between you and your patients, but also with the community. |
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Matt is a previously healthy 16 year old African Am boy, comes to you with complaints of fatigue & weight loss. Height is 155 cm. Weighs 41 kg. Afebrile, BP 142/82 mmHg. Matt has not seen a health provider in more than 8 years. Mother says that “He’s always been the runt of the litter. He’s a very picky eater.” She also says “He can’t keep up with his brothers and is failing school because he keeps falling asleep.” You order chemistries on Matt and find his creatinine is 2.8 mg/dl. All other labs are WNL.
Using the Schwartz formula for estimating creatinine clearance, what is Matt’s glomerular filtration rate (GFR)? A. 38.7 ml / min / 1.73 m^2 B. 46.2 ml / min / 1.73 m^2 C. 60.5 ml / min / 1.73 m^2 D. 94.5 ml / min / 1.73 m^2 |
A. 38.7 ml / min / 1.73 m^2
SCHWARTZ FORMULA = k x L / P(cr) k=0.7 (for ADOLESCENT BOY) L=height (in METERS) P(cr)=creatinine (in mg/MILLILITERS) Matt’s GFR = (0.7 x 1.55 meters) / 0.028mg/ml = 38.7 ml / min / 1.73 m^2 “k” constant for age groups: k=0.33 in preemie infants k=0.45 in term infants to 1 year old k=0.55 in children up to 13 years old k=0.70 in adolescent males (NOT FEMALES b/c f the presumed increase in male muscle mass, the constant remains 0.55 for FEMALES) |
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Matt is a previously healthy 16 year old African Am boy, comes to you with complaints of fatigue & weight loss. Height is 155 cm. Weighs 41 kg. Afebrile, BP 142/82 mmHg. Matt has not seen a health provider in more than 8 years. Mother says that “He’s always been the runt of the litter. He’s a very picky eater.” She also says “He can’t keep up with his brothers and is failing school because he keeps falling asleep.” You order chemistries on Matt and find his creatinine is 2.8 mg/dl. All other labs are WNL.
According to his estimated GFR (38.7 ml / min / 1.73 m^2), Matt’s kidney failure can be classified as what stage? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 |
C. Stage 3
Stage 3 is 30 – 59 ml / min / 1.73 m^2. CKD (Chronic Kidney Disease) STAGING by GFR in mL/min/1.73m^2): Stage 1: >90 (slight kidney damage w/ normal or increased filtration) Stage 2: 60-89 (mild decrease in kidney fxn) Stage 3: 30-59 (moderate decrease in kidney fxn) Stage 4: 15-29 (severe decrease in kidney fxn) Stage 5: <15 (kidney failure) |
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Matt is a previously healthy 16 year old African Am boy, comes to you with complaints of fatigue & weight loss. Height is 155 cm. Weighs 41 kg. Afebrile, BP 142/82 mmHg. Matt has not seen a health provider in more than 8 years. Mother says that “He’s always been the runt of the litter. He’s a very picky eater.” She also says “He can’t keep up with his brothers and is failing school because he keeps falling asleep.” You order chemistries on Matt and find his creatinine is 2.8 mg/dl. All other labs are WNL. His GFR is 38.7, and he has stage 3 chronic kidney disease.
The likely cause of Matt’s chronic kidney disease is: A. Wilms’ tumor B. Potter’s syndrome C. Autosomal dominant polycystic kidney disease D. Glomerulonephritis |
D. Glomerulonephritis
Glomerulonephritis is the MOST COMMON CAUSE OF CHRONIC KIDNEY DISEASE IN ADOLESCENT AFRICAN AMERICAN BOYS. Potter’s syndrome: bilateral renal agenesis, which is diagnosed in infancy. Wilms’ tumor: more common in preschool-age children Autosomal dominant polycystic kidney disease: most commonly diagnosed in the 6th to 7th decade of life. |
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Matt is a previously healthy 16 year old African Am boy, comes to you with complaints of fatigue & weight loss. Height is 155 cm. Weighs 41 kg. Afebrile, BP 142/82 mmHg. Matt has not seen a health provider in more than 8 years. Mother says that “He’s always been the runt of the litter. He’s a very picky eater.” She also says “He can’t keep up with his brothers and is failing school because he keeps falling asleep.” You order chemistries on Matt and find his creatinine is 2.8 mg/dl. All other labs are WNL. His GFR is 38.7, and he has stage 3 chronic kidney disease.
What other signs and symptoms are associated with Matt’s stage of chronic kidney disease (CKD)? A. Hypercalcemia, hypophosphatemia, and hyperactivity B. Change in urine output, anemia, and hyperparathyroidism C. Metabolic alkalosis and hyperalbuminemia D. Seizures, rash, and fine tremors |
B. Change in urine output, anemia, and hyperparathyroidism
CKD can cause an increase or decrease in urine output. As CKD progresses, the kidney DECREASE production of ERYTHROPOETIN, causing ANEMIA. The progressive inability to excrete phosphorus through the kidney and absorb calcium in the GI system causes an imbalance of calcium (HYPOCALCEMIA) and phosphorus (HYPERPHOSPHATEMIA). This triggers the parathyroid gland to INCREASE PROUDCTION OF PARATHYROID HORMONE. Progressive CKD also presents with increased fatigue, METABOLIC ACIDOSIS, and occasionally HYPOALBUMINEMIA. |
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Matt is a previously healthy 16 year old African Am boy, comes to you with complaints of fatigue & weight loss. Height is 155 cm. Weighs 41 kg. Afebrile, BP 142/82 mmHg. Matt has not seen a health provider in more than 8 years. Mother says that “He’s always been the runt of the litter. He’s a very picky eater.” She also says “He can’t keep up with his brothers and is failing school because he keeps falling asleep.” You order chemistries on Matt and find his creatinine is 2.8 mg/dl. All other labs are WNL. His GFR is 38.7, and he has stage 3 chronic kidney disease.
The next step would be to: A. Arrange for an urgent appointment with the local nephrologist B. Send him to the emergency department C. Start Matt on antihypertensive medication and see him back in 1 month D. Ask the patient to check his BP intermittently at the local pharmacy and follow up with you in 6 months |
A. Arrange for an urgent appointment with the local nephrologist
Matt should be seen by the local pediatric nephrologist within the next few days. He has significant CKD and though NOTHING ON HIS PHYSICAL EXAM OR LAB FINDINGS WARRANT IMMEDIATE TRANSPORT TO THE EMERGENCY DEPARTMENT, he should be seen as soon as possible. |
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In children under age 5, the most common cause of chronic renal failure is:
A. Systemic lupus erythematosus B. Congenital malformations or obstruction C. Drug-induced interstitial nephritis D. Poststreptococcal glomerulonephritis |
B. Congenital malformations or obstruction
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You are seeing a 4 year old white girl for her well child visit. Upon palpation of her abdomen, you note a large mass in her right upper quadrant. The likely diagnosis is:
A. Renal dysplasia B. Focal segmental glomerulosclerosis C. Wilms’ tumor D. Sickle cell nephropathy |
C. Wilms’ tumor
Wilms’ tumor presents in PRESCHOOL-AGE children and often a mass is palpable EITHER UNILATERALLY OR BILATERALLY. The remaining choices DO NOT PRESENT WITH ABDOMINAL MASSES. |
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The most practical way to estimate the creatinine clearance of a 18 month old child is:
A. Kidney biopsy B. Schwartz formula C. 24-hour urine collection D. Insulin urinary clearance |
B. Schwartz formula
Insulin clearance involves continuous infusion of medication and repeated blood sampling that is IMPRACTICAL in pediatrics. A 24-hour urine collection is EXTREMELY DIFFICULT to perform in an 18 month old, unless the child is catheterized with a Foley catheter during the collection period. Kidney biopsies do NOT provide any estimate of GFR. |
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Treatment of hyperkalemia includes:
A. ACE inhibitors B. Spironolactone C. Kayexalate D. Calcium carbonate |
C. Kayexalate
Kayexalate is sodium polystyrene sulfonate and EXCHANGES SODIUM FOR POTASSIUM IN THE SERUM AND EXCRETES IT THRU THE FECES. ACE inhibitors and spironolactone can INCREASE potassium. Calcium carbonate has NO EFFECT on serum potassium. |
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Nikki is a 7 year old girl who is 128.8 cm tall and has a serum creatinine of 1.9. Using the Schwartz formula for estimating creatinine clearance, what is Nikki’s GFR?
A. 30.5 ml / min / 1.73 m^2 B. 37.3 ml / min / 1.73 m^2 C. 47.4 ml / min / 1.73 m^2 D. 68.7 ml / min / 1.73 m^2 |
B. 37.3 ml / min / 1.73 m^2
SCHWARTZ FORMULA = k x L / P(cr) k=0.55 (for CHILDREN UP TO 13 YRS) L=height (in METERS) P(cr)=creatinine (in mg/MILLILITERS) Nikki’s GFR = (0.55 x 1.288 meters) / 0.019mg/ml = 37.3 ml / min / 1.73 m^2 “k” constant for age groups: k=0.33 in preemie infants k=0.45 in term infants to 1 year old k=0.55 in children up to 13 years old k=0.70 in adolescent males (NOT FEMALES b/c f the presumed increase in male muscle mass, the constant remains 0.55 for FEMALES) |
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Normal renal function at birth is:
A. 80-120 ml / min / 1.73 m^2 B. 60-80 ml / min / 1.73 m^2 C. 30-60 ml / min / 1.73 m^2 D. 10-30 ml / min / 1.73 m^2 |
C. 30-60 ml / min / 1.73 m^2
GFR increases postnatally and achieves adult normal by the age of 2. This progressive increase in GFR is thought to be related to increasing glomerular perfusion pressure, increases in renal blood flow, and maturation of cortical nephrons. |
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Abnormal development of nephrons with undifferentiated cells is indicative of:
A. Renal dysplasia B. Renal hypoplasia C. Cloacal abnormalities D. Ureteropelvic junction (UPJ) obstruction |
A. Renal dysplasia
Renal dysplasia = ABNORMAL DEVELOPMENT OF NEPHRONS w/ UNDIFFERENTIATED CELLS. Hypoplasia = the compromised growth and development of nephrons leading to a small kidney w/ fewer nephrons Cloacal abnormalities = occur during 4th and 6th weeks of fetal development when the cloaca fails to divide into an anterior urogenital sinus and a posterior anorectal canal. UPJ obstruction = narrowing or complete obstruction of the ureteropelvic junction. |
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Signs of Alport’s syndrome include:
A. Malar rash, edema, and proteinuria B. High-frequency sensorineural hearing loss and hematuria C. Lack of abdominal musculature, cryptorchidism, and dilated urinary tract D. Multiple cystic lesions and congenital hepatic fibrosis |
B. High-frequency sensorineural hearing loss and hematuria
These are classic sxs of Alport’s syndrome. Alport’s syndrome is caused by hereditary mutations that result in abnormalities in the basement membranes of the glomerulus (leading to hematuria, glomerulosclerosis, and ESRD), cochlea (causing deafness), and eye (resulting in lenticonus and perimacular flecks). (from Medscape) |
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Which statement is NOT true regarding primary preventive services for a child with chronic renal failure?
A. Growth assessment should be done annually B. Yearly attenuated virus vaccines are administered C. Evaluate blood pressure at each well child visit D. Live attenuated virus vaccines are contraindicated |
D. Live attenuated virus vaccines are contraindicated
Live attenuated virus vaccines are ONLY WITHHELD IN IMMUNOSUPPRESSED CHILDREN WITH CHRONIC RENAL FAILURE. Yearly influenza vaccines and monitoring of BP/growth are all important primary preventive care practices. |
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Ralph, a 5 year old who has chronic kidney failure, is scheduled to undergo a kidney transplant. Prior to surgery, it is very important to:
A. Assess his immunization status and give all necessary live virus vaccines if he is not immunosuppressed B. Withhold his annual influenza vaccine C. Send a urine culture and if positive, treat with appropriate antibiotics D. Discontinue dialysis 1 month prior to surgery |
A. Assess his immunization status and give all necessary live virus vaccines if he is not immunosuppressed
Live vaccines SHOULD BE GIVEN BEFORE A KIDNEY TRANSPLANT B/C THE CHILD WILL BE ON LIFE-LONG IMMUNOSUPPRESSIVE THERAPY. Most children with chronic renal failure will have bacteriuria and should NOT be treated with antibiotics UNLESS they have ASSOCIATED SXS OF A UTI such as fever, nausea, vomiting, and pain. Children with chronic renal failure should receive annual influenza immunizations. Dialysis-dependent children could not tolerate a month without treatment. |
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Folic acid supplementation is important for women of childbearing age to prevent neural tube defects. The recommended dosage for women who have had one child with myelomeningocele is:
A. 0.4 mg B. 0.8 mg C. 2.0 mg D. 4.0 mg |
D. 4.0 mg
The present standard for folic acid supplementation for all women of childbearing age is 0.4 mg. The dose is TEN TIMES that amount for women who have had ONE CHILD WITH MYELOMENINGOCELE (4.0 mg) |
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The incidence of scoliosis in the child with a myelomeningocele is:
A. 50% B. 90% C. 10% D. 30% |
Folic acid supplementation is important for women of childbearing age to prevent neural tube defects. The recommended dosage for women who have had one child with myelomeningocele is:
A. 0.4 mg B. 0.8 mg C. 2.0 mg D. 4.0 mg D. 4.0 mg The present standard for folic acid supplementation for all women of childbearing age is 0.4 mg. The dose is TEN TIMES that amount for women who have had ONE CHILD WITH MYELOMENINGOCELE (4.0 mg) |
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The PNP recognizes that the diagnosis of myelomeningocele describes a:
A. Herniated meningeal sac that protrudes through a vertebral arch B. Tube or hollow cavity with spinal fluid that connects the central canal of the cord and is enclosed in a membrane C. Condition in which the brain and spinal cord are exposed D. Cystic swelling of the meningeal sac that protrudes beyond the vertebral bodies and contains portions of the spinal cord and nerve roots |
D. Cystic swelling of the meningeal sac that protrudes beyond the vertebral bodies and contains portions of the spinal cord and nerve roots
Myelomeningocele is the only defect that also contains a portion of the spinal cord and nerve roots. A = meningocele (meningeal sac only) B = syringomeningocele (spinal fluid and sac) C = craniorachischisis or total dysraphism |
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You are reading the hx of a new patient, a 3 year old girl with repaired myelomeningocele, and note that the child has a ventriculoperitoneal shunt which was placed soon after the closure of the myelomeningocele. You understand that the most likely reason for the placement of this shunt was to:
A. Create a space for the cerebrospinal fluid in the spinal canal B. Drain an accumulation of pus from the brain caused by meningitis C. Drain cerebrospinal fluid entrapped in the fourth ventricle of the brain D. Drain an overproduction of cerebrospinal fluid |
C. Drain cerebrospinal fluid entrapped in the fourth ventricle of the brain
The VP shunt placed after closure of the myelomeningocele drains CSF that is entrapped in the brain due to an obstruction. That obstruction is usually a brain malformation that accompanies myelomeningocele, such as the Arnold-Chiari malformation. A = incorrect b/c VP shunt is not placed in spinal canal. B = incorrect b/c meningitis doesn’t occur in this type of patient D = incorrect b/c overaccumulation of CSF rarely occurs after surgery – it’s possible, but this is not the most likely reason why the VP shunt was needed |
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You are reviewing the chart of a new 4 year old patient who is in need of immunizations. The child was born with a meningocele defect at T10-L1. You would expect this child to:
A. Be sitting in a wheelchair B. Have crutches as an assistive device for walking C. Have ambulatory skills of a normal 4 year old D. Be wearing ankle-foot orthoses (AFOs) to ambulate |
C. Have ambulatory skills of a normal 4 year old
The cord and nerve roots are NOT part of the birth defect; thus, innervation to all muscle groups below the lesion are not affected. |
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The PNP recognizes that the Arnold-Chiari II malformation describes:
A. Stenosis of the 3rd ventricle of the brain B. Cystic formations throughout the cerebrum C. A fluid-filled canal in the cervical area of the spinal cord D. Elongation of the posterior cerebellum and brainstem into the foramen magnum |
D. Elongation of the posterior cerebellum and brainstem into the foramen magnum
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Urinary dysfunction with myelomeningocele is best monitored with the use of:
A. Serum evaluations of the child’s BUN and MRIs of the kidneys B. Serum creatinine and ultrasound of the urinary tract C. Intravenous pyelograms on an annual basis D. CBC with differential and KUB every 6 months |
B. Serum creatinine and ultrasound of the urinary tract
Serum creatinine is the most sensitive serum indicator of renal function and ultrasound of the urinary tract is the least invasive technique for assessing the KUB. A = incorrect, BUN is not as sensitive as creatinine, and MRI is not routine. C & D = incorrect, exposure to dangerous radioactivity associated with IVP and KUB. |
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Jill is a 12 year old girl with myelomeningocele and neurogenic bladder who presents at your office today. She has just returned from summer camp where she experienced several episodes of increased body temp, SOB, and fatigue. Your hx will take a special focus on:
A. Use of prophylactic antibiotics to prevent UTI B. Sxs of UTI over the past few weeks C. Menstrual hx, especially while she was at camp D. Use of anticholinergics for managing urinary continence |
D. Use of anticholinergics for managing urinary continence
Oxybutynin chloride can cause HEAT PROSTRATION b/c it limits the person’s ability to sweat. Patients who are taking oxybutynin and are involved in outside activities during the summer complain of feeling very tired and unable to catch their breat at the same time or soon before their body temp rises. Answer B is incorrect b/c SOB is not associated w/ symptomatic UTIs. |
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18 month old Joey who was born with a large myelomeningocele at L1-L5 has been brought to the clinic by his mother for his immunizations. He has an axillary temp of 38.4 C. Other vitals are WNL. Mom says she has been catheterizing him 4 times a day, his urine is clear and yellow with no foul odor. He does not have a cough, has been eating well, scooting himself around the house and even tries to pull himself up to a stand with his flaccid legs. On examination you note a red, warm to the touch area on his left thigh, there are no other remarkable findings in the physical exam. The diff dx highest on your list is:
A. Fractured left femur B. Urinary tract infection C. Deep vein thrombosis D. Phlebitis |
A. Fractured left femur
Children who do NOT have normal muscle innervation to provide the ability to bear weight develop OSTEOPENIA and as early as their teens, osteoporosis. The child who has no sensation is often UNAWARE of his or her legs and falls and/or bends the extremity to the point of FRACTURING A BONE. They DO NOT EXPERIENCE PAIN IN THE AFFECTED EXTREMITY. B = incorrect, urine is clear. C & D = incorrect, children w/ myelomeningocele do not develop DVT or phlebitis when they are otherwise healthy. |
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Cognitive deficits in children w/ myelodysplasias are common. A decrease in cognitive functioning in this population is directly related to the:
A. Type of myelodysplasia B. Level of the lesion C. Number of insertions of ventriculoperitoneal shunts D. Number of surgeries the child must have in the first 3 years of life |
C. Number of insertions of ventriculoperitoneal shunts
Research shows that the # of times a child experiences INCREASED ICP with resulting placement of shunts has a significant effect on the child’s cognition. |
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The current surgical management of the neurogenic bowel in children with myelomeningocele is commonly called:
A. Colostomy B. Ileostomy C. Decompression of the bowel D. MACE procedure |
D. MACE procedure
Colostomy and ileostomy WERE gold standards for managing bowel incontinence associated w/ neurogenic bowel. They were replaced in the 1990s with the surgical intervention called the Malone anterograde continent enema. There is no such procedure called “decompression of the bowel” to manage bowel incontinence. |
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Jenny, a 16 year old with myelomeningocele and neurogenic bladder, has come to your office today because she thinks she has another UTI. She is excited about a new surgery that will fix her bladder. She goes on to tell you that she will not leak urine or have to catheterize herself. You have known Jenny for several years and know she has trouble sticking to her catheterization schedule. You explain to Jenny that:
A. She will need to continue to catheterize herself the same way B. The surgery will allow her to catheterize an opening in her abdomen called a stoma C. The surgery results in an opening in her abdomen that drains urine continuously and she will have to wear a covering over the area to keep herself dry D. She has misunderstood and there are no surgeries to help people with neurogenic bladders stay dry |
B. The surgery will allow her to catheterize an opening in her abdomen called a stoma
The newest most helpful surgery for managing urinary incontinence in the paralyzed person is the continent appendicovesicuostomy. This is a surgical intervention resulting in a continent stoma located on the abdomen which the person catheterizes on the SAME SCHEDULE followed prior to surgery. Surgeons usually insist that the candidate for the surgery demonstrate motivation and ability to follow a self-catheterization schedule before performing the surgery. |
