final exam

Question 1

A child has mild persistent asthma. Appropriate daily medication should include
- A cough suppressant 
Correct!
-  A low-dose inhaled corticosteroid 
-  Short-acting beta-2 agonist 
-  An oral systemic corticosteroid

Answer 1

A LOW DOSE INHALED CORTICOSTEROID

A child with mild persistent asthma should be on an inhaled low-dose corticosteroid. Short-term oral corticosteroids may be needed during an exacerbation but should not be used daily. Cough suppressants are not recommended in children.

Question 2

Rachel, age 16 years, has had her asthma well controlled by using a beta-adrenergic metered dose inhaler. For the last month or so, she has had her sleep interrupted with wheezing. She thinks this happens almost every night lately. What is the appropriate intervention?
Prescribe an inhaled steroid.
Prescribe a cough suppressant for night time use only
Prescribe a longer-acting bronchodilator
Prescribe a short course of steroid therapy

Answer 2

PRESCRIBE AN INHALED STEROID
If an asthmatic develops persistent symptoms an inhaled steroid should be prescribed and used in conjunction with the beta-1 adrenergic metered-dose inhaler.

Question 3

Tyrell has arrived at the urgent care clinic with wheezing. He has a history of asthma and has been prescribed Flovent in the past but since he was well all summer he ran out of his med. He is 14 years old and weight 60 kg. His PEF is < 40% and he is using accessory muscles to breathe. His SaO2 is 86. Choose your next steps:

Face mask ventilation with nebulized SABA and Ipratropium
Start an IV for corticosteroids
Transfer to acute care area
O2 to achieve SaO2 > 90%

O2 to achieve SaO2>90%
High-dose inhaled SABA by nebulizer or MDI plus valved holding chamber
60 mg po prednisone

O2 to achiever SaO2.90%
4 puffs of Flovent (inhaled corticosteroid) for double dose
Repeat in 20 minutes

Answer 3

O2 to achieve SaO2>90%
High-dose inhaled SABA/IPRATROPIUM by nebulizer or MDI plus valved holding chamber
60 mg po prednisone

Question 4

A 6-year-old child with asthma is brought to the clinic because the parents have noticed daily wheezing for the past month requiring daily use of his SABA, and he has had a few night-time awakenings with wheezing as well. The PNP recognizes that this may indicate the child has:
Severe persistent asthma 
  Mild persistent asthma. 
  Moderate persistent asthma. 
  Intermittent asthma.

Answer 4

Moderate Persistent Asthma

Question 5

Choose the words that best complete the following sentence:

The majority of children with asthma develop symptoms between ages 3 and 6 years. Common symptoms of asthma include: Chonic cough, recurrent __________________, Recurrent ___________________, and recurrent ________________.

Wheezing, sick days, respiratory syncytial virus (RSV).
Sneezing, flu symptoms, bronchitis.
Wheezing, bronchitis, pneumonia
Lung obstruction, bronchitis, nosebleed

Answer 5

Wheezing, Bronchitis, Pneumonia

Question 6

_______________medications limit the underlying airway inflammation that contributes to asthma symptoms and are taken ______________.

Quick-relief; daily.
Quick relief, as needed.
Long-term control; twice a week.
Long-term control; daily.

Answer 6

Long-term control; daily

Question 7

You have been Ava’s PCP since she was 5 years-old. At that time, Ava had aczema and coughing and wheezing. Ava’s mother has asthma and, through history taking and exam, you diagnosed asthma in Ava, too. You have examined Ava frequently to adjust medications, but now she is stable. She consistently takes her medication and uses her Flovent inhaler daily. Her mother diligently keeps the house clean, especially the bedroom Ava shares with her sister. You are ready to step down Ava’s medication therapy, according to the National Heart, Lung, and Blood Institute’s step wise approach. How often should you examine Ava during this step-down period?

Every month
Every three months
Every year
Every six months

Answer 7

EVERY 3 MONTHS

Asthma is highly variable over time. See patients:
Every 2-6 weeks while gaining control
Every 1-6 months to monitor control
Every 3 months if step down in therapy is anticipated.”

Question 8

A 3-year-old boy presents to the emergency department with fever 103, drooling, hoarse cry, inspiratory retractions, stridor, and holding his head in a sniffing position. He is taken to the operating room for control of the airway.  What is the likely etiology?
  Staphylococcus aureus 
  Haemophilus influenzae 
  Streptococcus pneumoniae 
  Parainfluenza virus

Answer 8

Haemophilus influenzae

The child is showing symptoms and signs of epiglottitis which is an emergent condition. Progression to total airway obstruction may occur and result in respiratory arrest. Transfer him to an acute care are ASAP keeping him as calm and comfortable as possible.

The incidence has decreased significantly since the advent of the Haemophilus influenzae type B (HiB) vaccination but patients are still susceptible to the non typeable Haemophilus influenzae and not all children are vaccinated.

Question 9

5 month old (27 weeks gestation at birth) with fever, coryza, cough,increased work of breathing, and scattered rales.

Answer 9

Influenza A pneumonia

Question 10

A 5-year-old girl with fever, tachypnea, and lobar infiltrate. She has been taking amoxicillin for 6 days and is getting worse. Her chest xray shows empyema

Answer 10

Pneumococcal pneumonia

Question 11

A 14 year-old girl with low-grade fever, cough of 3 weeks’ duration, and new onset of wheezing. Her medical history is negative.

Answer 11

Mycoplasma pneumonia

Question 12

Common organisms causing pneumonia in newborn infants are:

Group B streptococci, gram-negative enteric bacilli, Chlamydia trachomatis
Haemophilus influenzae, Staphylococcus pneumonia, herpes simplex
Staphylococcus aureus, pseudomonas, group A beta-hemolytic streptococcus
Mycoplasma, Staphylococcus pneumoniae, Haemophilus influenzae

Answer 12

Group B streptococci, gram-negative enteric bacilli, Chlamydia trachomatis

Question 13

Manuel, a 9-month-old infant, has been hospitalized with laboratory-confirmed pertussis. Which of the following would be appropriate components of the management plan?

Treatment with erythromycin, prophylaxis of close contacts, report to state health department.
Antibiotic treatment with Augmentin, immediate booster immunization with DTaP, oxygen as needed.
Cough management with Robitussin DM, treatment with pertussis antitoxin, intensive care observation.
Prophylactic treatment of close family members, antibiotics to control secondary pneumonia, liquid diet until coughing subsides.

Answer 13

Treatment with erythromycin, prophylaxis of close contacts, report to state health department.

Question 14

The antibiotic of choice for a school-age child with suspected Mycoplasma pneumoniae would be:
  A cephalosporin 
  Amoxicillin 
  Penicillin 
  A macrolide

Answer 14

A macrolide

Question 15

Which of the following statements is true about chalazions?
Chalazions are more common in children with eczema.
Chalazions are caused by acute localized inflammation of one or more sebaceous glands of the eyelids, causing painful furuncle.
Chalazions should be treated with either erythromycin or sulfacetamide 10% eye ointment.
Chalazion is a chronic sterile inflammation of the eyelid resulting from a lipogranuloma of the Meibomian glands.

Answer 15

Chalazion is a chronic sterile inflammation of the eyelid resulting from a lipogranuloma of the Meibomian gland

Question 16

A 5-year-old child is brought to the clinic with bilateral purulent discharge from both eyes. Physical findings include conjunctival redness, bilateral nasal discharge, and a bulging tympanic membrane in the left ear. Based on the history and physical examination the most common causative organism is:
  Adenovirus 
  Streptococcus pneumoniae 
  Nontypeable Haemophilus influenzae 
  C. trachomatis

Answer 16

Nontypeable Haemophilus influenza

Non typeable H. influenza remains a common cause of AOM and it is the most common cause of otitis-conjunctivitis syndrome

Question 17

ou are evaluating a 9-year-old- girl in an urgent care clinic for a rash. Eight days ago, she was evaluated and treated 8 days ago for acute otitis media with oral amoxicillin and now, with the rash appearing, the mother is concerned about an allergic reaction to penicillin.

PE: On physical exam her temperature is 101, HR 94, RR 23, and BP 104/58. She has a diffuse symmetric urticaria, which her mother reports started on her abdomen and then spread outwards. She has a serpiginous rash at the interface of the dorsal and palmar aspect of the hands and feet. Her wrists, elbows, knees, and ankles are swollen and painful to move. She has periorbital edema but clear conjunctiva. She also has anterior and posterior cervical and axillary lymphadenopathy that is mildly tender.

What type of reaction is this?

Type III hypersensitivity reaction
Type I hypersensitivity reaction
Type II hypersensitivity reaction
Type IV hypersensitivity reaction

Answer 17

Type III hypersensitivity reaction

Question 18

Athletic acne

Answer 18

occurs on the forehead, chin, and shoulders, caused by helmets and pads.

Question 19

Hormonal Acne

Answer 19

a beard distribution.

Question 20

A pomadal distribution

Answer 20

occurs along the temple and forehead, as a result of pomades or oil-based cosmetics.

Question 21

An adolescent has acne characterized by papules and pustules mostly on the forehead and chin. What will the primary care pediatric nurse practitioner prescribe?

Benzoyl peroxide applied twice daily
Azelaic acid applied daily at nighttime
Tretinoin applied nightly after washing the face
Topical erythromycin with benzoyl peroxide

Answer 21

Topical erythromycin with benzoyl peroxide
Topical antibiotics combined with BPO are more effective than either drug alone and are especially effective in mild to moderate inflammatory acne or as adjunctive therapy with oral antibiotics. Azelaic acid is useful in persons with sensitive or dark skin and used for non-inflammatory acne. Topical antibiotics are best used in conjunction with BPO. Tretinoin is a keratolytic, useful for non-inflammatory acne.

Question 22

An African-American child has recurrent tinea capitis and has just developed a new area of alopecia after successful treatment several months prior. When prescribing treatment with griseofulvin and selenium shampoo, what else will the primary care pediatric nurse practitioner do?

Monitor CBC, LFT, and renal function during therapy.
Order oral prednisone daily for 5 to 14 days.
Prescribe oral itraconazole or terbinafine.
Perform fungal cultures on family members and pets.

Answer 22

Perform fungal cultures on family members and pets.
Because asymptomatic carriers may be present in the household, family members and pets should be cultured. It is not necessary to monitor lab work with griseofulvin unless there is a change in clinical status, due to the favorable safety profile of griseofulvin. Prednisone is used when severe inflammation is present. Oral itraconazole or terbinafine is used if resistance to griseofulvin occurs; this child has responded to griseofulvin.

Question 23

An infant is brought to clinic with bright erythema in the neck and flexural folds after recent treatment with antibiotics for otitis media. What is the treatment for this condition?

Topical keratolytics and topical antibiotics for 7 to 10 days
Topical nystatin cream applied several times daily until the rash is gone
1% hydrocortisone cream to affected areas for 1 to 2 days
Oral fluconazole 6 mg/kg on day 1, then 3 mg/kg/dose for 14 days

Answer 23

Topical nystatin cream applied several times daily .

Candida skin infections can occur in intertriginous areas in the neck, axilla, and groin, and appear as a bright erythematous rash. Topical nystatin is first-line therapy.

Fifteen percent hydrocortisone is used if inflammation is severe but not instead of topical antifungal therapy.

Oral fluconazole is used if resistant to treatment.

Keratolytics and antibiotics are used to treat superficial folliculitis.

Question 24

Michael has an area of inflammation on the neck that began after wearing a hand-made necklace. On examination, the skin appears chafed with mild erythematous patches. The lesions are very itchy. What is an appropriate initial treatment? Choose the two best answers.

Topical corticosteroids applied 2 to 3 times daily
Oral antihistamines given 4 times daily
Burow solution soaks and cool compresses
Application of a lanolin-based emollient

Answer 24

Topical corticosteroids applied 2 to 3 times daily & Oral antihistamines given 4 times daily

Lanolin-based emollients are contraindicated when inflammation is present.

Burow solution soaks are useful for vesicular rashes.

Oral antihistamines are not indicated unless itching and scratching occur. This child is itching so an antihistamine would be appropriate.

Question 25

When prescribing topical glucocorticoids to treat inflammatory skin conditions, the primary care pediatric nurse practitioner will:

initiate therapy with a high-potency glucocorticoid.
order lotions when higher potency is necessary.

Taper the strength of the steroids once the outbreak is fully controlled.

Use Class 1 topical steroid for the lowest potency.

Answer 25

Taper the strength of the steroids once the outbreak is fully controlled.

Question 26

Charley needs an occlusive dressing to treat lichen simplex chronicus.

Choose the three INCORRECT methods for applying the dressing.

Apply ointment before the dressing.

Plastic wrap should not be used.

The dressing should be applied to dry skin.

Change the dressing twice daily.

Answer 26

Plastic wrap should not be used.

The dressing should be applied to dry skin.

Change the dressing twice daily.

Question 27

A 14-year-old child has clusters of small, clear, tense vesicles with an erythematous base on one side of the mouth along the vermillion border, which are causing discomfort and difficulty eating. Which treatment will the primary care pediatric nurse practitioner not recommend as treatment?

Topical diphenhydramine and magnesium hydroxide

Topical acyclovir applied to lesions 4 times daily

Oral acyclovir 20 to 40 mg/kg/dose for 7 to 10 days
Mupirocin ointment applied to lesions 3 times daily

Answer 27

Mupirocin ointment applied to lesions 3 times daily

Mupirocin ointment is used for secondary bacterial infection.

Question 28

Ointments for psoriasis

Answer 28

Anthralin ointment is useful for plaques that are resistant to steroids.

Calcipotriol cream is effective for mild to moderate plaques, but when applied in excessive quantities over large areas can cause hypercalcemia.

Oral steroids are not indicated and may worsen symptoms by causing pustular flare.

Methotrexate is used for severe disease, and these symptoms indicate that this is moderate disease.

Question 29

A child has several circular, scaly lesions on the arms and abdomen, some of which have central clearing. The primary care pediatric nurse practitioner notes a smaller, scaly lesion on the child’s scalp. How will the nurse practitioner treat this child? Recommend OTC antifungal creams and shampoos.
Prescribe oral griseofulvin for 2 to 4 weeks.
Obtain scrapings of the lesions for fungal cultures.
Order prescription-strength antifungal creams.

Answer 29

Prescribe oral griseofulvin for 2 to 4 weeks.
Whenever tinea lesions occur on the scalp or nails, oral griseofulvin must be given for 2 to 4 weeks. Unless the infection is resistant to treatment, fungal cultures are not necessary. Topical medications alone are not effective for tinea capitus.

Question 30

A school-age child has several annular lesions on the abdomen characterized by central clearing with scaly, red borders. What is the first step in managing this condition?

Fluoresce the lesions with a Wood’s lamp.
Obtain fungal cultures of the lesions.
Treat empirically with antifungal cream.
Perform KOH-treated scrapings of the lesion borders.

Answer 30

Treat empirically with antifungal cream.
Unless the diagnosis is questionable, or if treatment failure occurs, tinea corporis is treated empirically with topical antifungal creams; therefore, it is not necessary to fluoresce the lesions, culture the lesions, or complete KOH testing of scrapings as an initial management step.

Question 31

A child is diagnosed with tinea versicolor. What is the correct management of this disorder?

Using ketoconazole 2% shampoo on lesions twice daily for 2 to 4 weeks
Oral antifungal treatment with fluconazole once weekly for 2 to 3 weeks
Application of selenium sulfide 2.5% lotion twice weekly for 2 to 4 weeks
Sun exposure for up to an hour every day for 2 to 4 weeks

Answer 31

Application of selenium sulfide 2.5% lotion twice weekly for 2 to 4 weeks
Selenium sulfide lotion or 1% shampoo is first-line treatment for children and younger adolescents. Oral antifungal medications are used in resistant cases in older adolescents. Sun exposure only intensifies lesions. Ketoconazole shampoo is used on older adolescents.

Question 32

A 9-year-old girl has a history of frequent vomiting and her mother has frequent migraine headaches. The child has recently begun having more frequent and prolonged episodes accompanied by headaches. An exam reveals abnormal eye movements and mild ataxia. What is the correct action?

Consult hospitalist or pediatric neurology team emergently for further workup.
Reassure the parent that this is expected with cyclic vomiting syndrome

Begin using an anti-migraine medication to prevent headaches.
Prescribe ondansetron and lorazepam to help manage symptoms.

Answer 32

Consult hospitalist or pediatric neurology team emergentlyfor further workup.
This child has an abnormal neurologic examination, which is a red flag warranting referral for further workup for children with cyclic vomiting syndrome. Anti-migraine medications are used in children over age 12 years and therefore should not be used for this patient. Ondansetron and lorazepam may be useful for unrelenting nausea and poor sleep, but this child needs to be referred to evaluate neurologic symptoms. These signs are not expected.

Question 33

A school-age child has had abdominal pain for 3 months that occurs once or twice weekly and is associated with a headache and occasional difficulty sleeping, often causing the child to stay home from school. The child does not have vomiting or diarrhea and is gaining weight normally. The physical exam is normal. According to Bishop, what is included in the initial diagnostic work-up for this child?

CBC, ESR, CRP, and fecal calprotectin
Stool for H. pylori antigen and serum IgA, IgG, tTg

CBC, ESR, CRP, UA, stool for ova, parasites, and culture

CBC, ESR, amylase, lipase, UA, and abdominal ultrasound

Answer 33

CBC, ESR, amylase, lipase, UA, and abdominal ultrasound
Bishop suggests these labs as an initial approach in children suspected of having functional abdominal pain, along with a 3-day trial of a lactose-free diet. Fecal calprotectin is added if the child has changes in stool habits suggestive of inflammatory changes in the intestinal tract.

Question 34

The parent of a 3-month-old reports that the infant arches and gags while feeding and spits up undigested formula frequently. The infant’s weight gain has dropped to the 5th percentile from the 12th percentile. What is the best course of treatment for this infant?

Institute an empiric trial of acid suppression with a proton pump inhibitor (PPI).

Perform esophageal pH monitoring to determine the degree of reflux.

Reassure the parent that these symptoms will likely resolve by 12 to 24 months.

Begin a trial of extensively hydrolyzed protein formula for 2 to 4 weeks.

Answer 34

Begin a trial of extensively hydrolyzed protein formula for 2 to 4 weeks.
Formula-fed infants may be given a trial of a hydrolyzed protein formula to see if improvement occurs. An empiric trial of a PPI may be used in children and adolescents but is not recommended in infants. Esophageal pH monitoring may be performed in consultation with a specialist but not as first-line evaluation. The infant has warning signs of GERD that require further investigation and not just reassurance.

Question 35

A school-age child has a 3-month history of dull, aching epigastric pain that worsens with eating and awakens the child from sleep. A complete blood count shows a hemoglobin of 8 mg/dL. What is the next step in management?

Empiric therapy for H. pylori (HP)
Administration of H2RA or PPI medications

Ordering an upper GI series

Referral for esophagogastroduodenoscopy (EGD)

Answer 35

Referral for esophagogastroduodenoscopy (EGD)
EGD is the procedure of choice in children for detecting PUD because it allows direct visualization of mucosa, localization of the source of bleeding, and collection of tissue specimens. Empiric therapy for HP is not recommended due to increased antibiotic resistance. An upper GI series may have false negative findings. Once peptic ulcer disease is diagnosed, H2RA or PPI medications are first-line drugs.