final exam Flashcards
(32 cards)
A parent who encourages competitiveness in a child who excels at a single sport but not in others may also encourage a sense of which characteristic?
A) Significance
B) Competence
C) Worthiness
D) Insecurity
Insecurity
Children who gain praise for external measures, such as performance of a sport, may end up unduly comparing themselves with others and feel insecure, inferior, and inadequate, even as they continue to excel in this sport. Competence comes from feeling capable and confident and able to approach new tasks. Significance comes from having a sense of belonging and being accepted unconditionally; this child’s self-worth is dependent on performance in a sport. Worthiness is based on an understanding of having a purpose in life and is also unconditional.
The primary care pediatric nurse practitioner is evaluating a 16-year-old adolescent male who is on the high school wrestling team and whose weight fluctuates as much as 7 or 8 pounds before matches. The child is eager to talk about the various trophies he has won. When he expresses confidence that he will get a wrestling scholarship for college, his father remarks that his grades will never be good enough for college, causing him to blame his teachers. The nurse practitioner may identify potential problems with what process?
A) Body image
B) Self-esteem
C)Personal identity
D)Role performance
Self-esteem
Children with poor self-esteem seek attention, importance, and security and may become self-absorbed with external markers of self-worth, such as performance in a sport. Another mark of insecurity is defensiveness, which this child exhibits by blaming his teachers for his poor grades. Children with body image problems become overly concerned with appearance and compare themselves to others. This child is losing and gaining weight to be better at wrestling, not to look different. Children with personal identity issues internalize negative perceptions of others and manifest feelings of inferiority. Children with role performance problems feel incompetent and are hesitant to try new things or become perfectionists to overcompensate.
The primary care pediatric nurse practitioner sees a 10-year-old child whose parent describes as a “class clown.” The child denies having problems at school, but acknowledges poor grades by saying, “I’m not very smart, I guess.” When counseling the parent about helping this child deal with this self-perception issue, the nurse practitioner will recommend which strategy?A) Help the child identify skills and activities that he is good at.
B) Spend time each evening helping the child with homework to improve grades.
C) Empower the child to make decisions and assume more responsibilities.
D) Work with the teacher to set appropriate limits on school behavior.
Correct Answer: Help the child identify skills and activities that he is good at.
This child exhibits problems with personal identity and copes by clowning around to avoid dealing with problems of inferiority about school performance. The parent should work with the child to find areas of strength and help the child become accomplished in those things to improve self-esteem.
The primary care pediatric nurse practitioner is performing an examination on a 2-year-old child who has been placed in emergency foster care with a grandparent after the child’s mother has been arrested for drug use. The child has a history of asthma with frequent exacerbations because of parental smoking. What is a priority for the nurse practitioner at this visit?
Providing a list of websites and community-based support groups for grandparents parenting grandchildren
Evaluation of financial resources, medical insurance, and access to health care and medications,
Teaching the grandparent about the need for consistency in routines and discipline for the child
Referral to a social worker to help the child deal with emotional conflict related to separation from the parent
Correct Answer: Evaluation of financial resources, medical insurance, and access to health care and medications
A high percentage of grandparents who parent grandchildren have financial difficulties and most cannot claim grandchildren as dependents for health care. This child has a chronic disease and will need medication and possibly hospitalization, so the PNP should assess resources and access to care. The other options are important but are not a priority in the initial visit.
During a well child examination on an infant who has colic, the primary care pediatric nurse practitioner learns that the infant’s mother is 17 years old and that the father, who is in the military, was deployed to wartime duty shortly after the baby was born. To determine the immediate risk of child maltreatment for this infant, the nurse practitioner will ask about topic:
childrearing and parenting styles.
spiritual beliefs and religious practices.
role responsibilities of the parents.
the location of extended family members.
Correct Answer: Assessment of resources, including the support of extended family members,
Assessment of resources, including the support of extended family members, is a key dimension of family functioning. In this case, the mother is young and alone and may lack the skills needed to cope with an infant with colic. Childrearing and parenting styles can affect the emotional and physical health of children who misbehave or who are learning how to behave in the world. An assessment of role responsibilities is important when there are disagreements about shared responsibilities. Assessing spiritual beliefs helps to determine the values ascribed to events. While all of these are important assessments, there is an urgent need to determine the level of support available to this mother.
The parent of a preschool-age child who is diagnosed with a sensory processing disorder (SPD) asks the primary care pediatric nurse practitioner how to help the child manage the symptoms. What will the nurse practitioner recommend?
Maintaining predictable routines as much as possible
Establishing a reward system for acceptable behaviors
Providing frequent contact, such as hugs and cuddling
Introducing the child to a variety of new experiences
Correct Answer: Children with SPD do best with an environment that is predictable and routine and the same from day to day.
Children with SPD do best with an environment that is predictable and routine and the same from day to day. Discipline and/or a reward system is not effective. Children with SPD can become overwhelmed by new experiences or frequent touch.
The parent of a school-age child who is overweight tells the primary care pediatric nurse practitioner that the child seems to crave high-calorie, high-carbohydrate foods, even when full. The nurse practitioner learns that the child is often irritable and sleepy at school in spite of sleeping 9 or 10 hours each night. What will the nurse practitioner recommend?
Assessment of leptin and ghrelin hormone levels
Consultation with a dietician to develop an appropriate diet
Taking one or two naps each day to increase the amount of sleep
Referral to a sleep disorder clinic for a sleep study
Correct Answer: Referral to a sleep disorder clinic for a sleep study
Obstructive sleep apnea has been suggested to be a contributing factor to the pathogenesis of obesity by inducing leptin resistance and increasing ghrelin levels, two hormones that regulate satiety. The child shows symptoms of these abnormalities by craving high-calorie comfort foods. The child should be evaluated for this underlying cause. Assessment of these hormone levels is not routinely done. Consultation with a dietician may be necessary at some point but does not get at the underlying problem. Increasing sleep time with naps has not been shown to counteract the obesity effect.
The parent of a 3-year-old child tells the primary care pediatric nurse practitioner that the child has never been able to fall asleep without a parent in the room. The child has a new sibling and the parent is concerned that the toddler’s cries will awaken the infant. What will the nurse practitioner counsel the parent?
Offering a reward for each night the child falls asleep without the parent in the room
Leaving the room as the child is falling asleep and returning at intervals to check on the child
Putting the child to bed at the same time every night and ignoring all sleep interfering behaviors
Taking away a favorite activity or video for each night the child fusses about the parent not being in the room
Correct Answer: Leaving the room as the child is falling asleep and returning at intervals to check on the child
Leaving the room as the child becomes drowsy and checking on the child at intervals is called graduated extinction and allows parents to ensure safety while helping the child to initiate and maintain sleep independently. The other measures may result in the toddler becoming upset and crying, which would awaken the baby. Rewards and punishments are not necessarily successful.
The parent of a child diagnosed with attention-deficit/hyperactivity disorder (ADHD) tells the primary care pediatric nurse practitioner that the child gets overwhelmed by homework assignments, doesn’t seem to know which ones to do first, and then doesn’t do any assignments. The nurse practitioner tells the parent that this represents impairment in which executive function?
Effort
Focus
Activation
Emotion
Correct Answer: Activation
Activation is an executive function that helps individuals organize, prioritize, and begin activities. This child cannot prioritize a group of assignments and winds up not doing any of them, showing an inability to prioritize and begin activities. Effort is the function associated with sustaining effort and regulating awareness. Emotion is the function of managing frustration. Focus is associated with sustaining and shifting attention to a task.
The primary care pediatric nurse practitioner is performing an examination on a 5-year-old child who exhibits ritualistic behaviors, avoids contact with other children, and has limited speech. The parent reports having had concerns more than 2 years ago about autism, but was told that it was too early to diagnose. What will the nurse practitioner do first?
Reassure the parent that if symptoms weren’t present earlier, the likelihood of autism is low.
Ask the parent to describe the child’s earlier behaviors from infancy through preschool.
Refer the child to a pediatric behavioral specialist to develop a plan of treatment and management.
Administer an M-CHAT screen to screen the child for communication and socialization delays.
Correct Answer: Ask the parent to describe the child’s earlier behaviors from infancy through preschool.
The DSM-5 criteria state that a patient must show symptoms from early childhood even if the symptoms are not recognized until later in life. The parent had noticed symptoms prior but was told not to worry; these symptoms should be evaluated in light of the current symptoms. The M-CHAT is used for infants and toddlers and not for school-age children. Autism symptoms are generally evident by age 3 years. The PNP should complete the assessment before making a referral.
The primary care pediatric nurse practitioner cares for a preschool-age child who was exposed to drugs prenatally. The child bites other children and has tantrums when asked to stop but is able to state later why this behavior is wrong. This child most likely has a disorder related to what process?
Social cognition
Executive function
Sensory processing
Information processing
Correct Answer: Executive function
Children with prenatal drug or alcohol exposure often have executive function disorders, characterized by an inability to stop or delay a response or interrupt an inappropriate behavior and an inability to modify emotional expression appropriately. Information processing refers to thinking and problem-solving ability. Sensory processing has to do with the ability to take in information through senses and to process it appropriately. Social cognition refers to the ability to interpret behavior and emotions of the self and others.
A newly divorced mother of a toddler reports that the child began having difficulty sleeping and nightmares along with exhibiting angry outbursts and tantrums 2 months prior. The primary care pediatric nurse practitioner learns that the child refuses to play with usual playmates and often spends time sitting quietly. What will the nurse practitioner do initially?
Consult with a child psychiatrist to prescribe medications.
Ask the mother about the child’s relationship with the father.
Recommend cognitive behavioral or psychodynamic therapy.
Refer the family to a child behavioral specialist for counseling.
Correct Answer: Ask the mother about the child’s relationship with the father.
The child exhibits signs of post traumatic stress disorder (PTSD). Because the parents are newly divorced, the PNP should evaluate the child’s previous interactions with the father to determine whether violence occurred. If PTSD is likely, referral to social service agencies may be warranted. Pediatric mental health specialists may be involved once a diagnosis is established and may order medications.
Which of the following statements is correct about oppositional defiant disorder (ODD)?
Symptoms of Oppositional Defiant Disorder usually progress to Conduct Disorder as the child matures.
Patients with ODD are aware their behavior is problematic.
Symptoms are more prominent at home than at school and social settings.
ODD includes criminal behavior in symptomatology
Correct Answer: Symptoms are more prominent at home than at school and social settings.
Symptoms are more prominent at home than at school and social settings. The fit between parent and child is often difficult, which results in more conflicts and problems. ODD does not include always include criminal behavior, vandalism, running away, and cruelty to animals such as conduct disorder does Patients with ODD are often unaware of their behavior as problematic. The attribute their behavior to the adults in their lives who they consider to be the problem. The majority of ODD children do NOT progress to conduct disorder
Trauma-informed care (TIC) includes understanding the effects of childhood trauma and thoroughly integrating into your treatment protocols, effective practices and policies to address it. Which of the following statements is NOT one of the four Rs of TIC?
Review potential triggers with patients regularly to help them learn to adapt their responses to protect themselves from further trauma
Respond with necessary adjustments in your language and behavior to the child’s environment and to policies, procedures and practices to support the child’s recovery and resilience
Recognize that childhood trauma can affect family members, service providers and others who may experience secondary stress
Recognize the symptoms of trauma and how trauma may influence a child’s engagement in activities and services, interactions with others and responsiveness to rules and guidelines
Correct Answer: Review potential triggers with patients regularly to help them learn to adapt their responses to protect themselves from further trauma
1. Realize the widespread nature of childhood trauma and its effects on the child and family members, service providers and others who may experience secondary stress or trauma-related reactions from exposure to another person’s traumatic experience.
2. Recognize the symptoms of trauma and how they can vary by sex, age and type of trauma or setting. Adults in a child’s life should understand that the child’s trauma reactions are adaptive efforts to protect themselves. TIC recognizes that trauma may influence a child’s engagement in activities and services, interactions with others, and responsiveness to rules and guidelines.
3. Respond with necessary adjustments in your language and behavior to the child’s environment and to policies, procedures and practices to support the child’s recovery and resilience.
4. Resist re-traumatization by actively shaping a child’s environments to avoid triggers and to protect from further trauma.
A child has a fever and arthralgia. The primary care pediatric nurse practitioner learns that the child had a sore throat 3 weeks prior and auscultates a murmur in the clinic. Which test will the nurse practitioner order?
ASO titer
Rapid strep test
Throat culture
Anti-DNase B test
ASO titer
This child has symptoms and a history consistent with ARF. The ASO titer peaks in 3 to 6 weeks and will confirm a recent strep infection.
The anti-DNase B test will also confirm a recent strep infection, but this doesn’t peak until 6 to 8 weeks after the initial infection. A rapid strep test and throat culture do not differentiate the carrier state from
An adolescent female reports poor sleep, fatigue, muscle and joint paint, and anxiety lasting for several months. The primary care pediatric nurse practitioner notes point tenderness at several sites. What will the nurse practitioner do next?
Evaluate the adolescent’s pain using a numeric pain scale.
Reassure the adolescent that this condition is not life-threatening.
Refer the adolescent to a rheumatologist for further evaluation.
Obtain ANA, CBC, liver function, and muscle enzymes tests
Refer the adolescent to a rheumatologist for further evaluation.Children with widespread musculoskeletal pain and painful point tenderness may have fibromyalgia and should be referred.
The Widespread Pain Index is used to define the degree of pain.
Laboratory studies are of little benefit when diagnosing fibromyalgia.
Even though children need reassurance that this disease is not life-threatening, this is not the next action.
An 8-year-old boy has a recent history of an upper respiratory infection and comes to the clinic with a maculopapular rash on his lower extremities and swelling and tenderness in both ankles. The pediatric nurse practitioner performs a UA, which shows proteinuria and hematuria and diagnoses HSP. What ongoing evaluation will the nurse practitioner perform during the course of this disease?
Chest radiographs
Blood pressure measurement
Liver function studies
ANA titers
Blood pressure measurement Hypertension is a serious risk of HSP, so repeated BP measurement is indicated.
Skin rash: Starts as a pinkish maculopapular rash and progresses from red to purple to brown palpable purpura
* Arthritis
- Warmth, swelling, and erythema over the joints
- Periarthritis is common and involves the knees and ankles
- Diffuse abdominal pain on palpation
- Edema of the scrotum, eyes, or hands
- Hypertension: Repeated blood pressure measurement and follow-up due to subclinical disease
ANA titers are not measured with HSP.
Chest radiographs are performed only if indicated.
LFTs are not indicated; the predominant risk is to the kidneys.
A 12-year-old child is brought to the clinic with joint pain, a 3-week history of low-grade fever, and a facial rash. The primary care pediatric nurse practitioner palpates an enlarged liver 2 cm below the subcostal margin along with diffuse lymphadenopathy. An ANA test is positive. Which test may be ordered to confirm a diagnosis of SLE?
Anti-Ro antibodies
Anti-Sm antibodies
Anti-La antibodies
Anti-double-strand DNA antibodies
Anti-double-strand DNA antibodies
Anti-double-strand DNA antibodies are present in most people with SLE and are generally exclusively seen in cases of SLE and not other diseases.
Initial laboratory testing includes CBC, ANA, ESR, CRP, serum chemical analysis (metabolic and protein screen), and urinalysis. The ANA test is positive in more than 97% to 99% of children who have active, untreated SLE and titers above 1:1080 point to the diagnosis; however, ANA specificity is as low as 36%. A negative ANA makes SLE diagnosis less likely; however, there is always a risk of a rare false-negative test. A positive ANA with clinical findings consistent with SLE should be followed up with testing for disease-specific types of ANA (e.g., antibodies to Sm, Ro, or La). The ANA autoantibody profile screens for anti-Sm, anti-Ro, anti-La, anti-double-strand DNA, and anti-ribonucleoprotein (anti-RNP) antibodies (Siegel et al., 2017). Antibody testing for double-stranded DNA and extractable nuclear antigen panel (anti-Smith antibody) and anti-RNP antibody (RNP) should be done as it is specific for SLE and is present in up to 50% of patients with SLE (Siegel et al., 2017). Anti-Ro (anti–SSA) and anti-La (anti-SSb) antibodies are also associated with SLE.
A child who had GABHS 2 weeks prior is in the clinic with periorbital edema, dyspnea, and elevated blood pressure. A urinalysis reveals tea-colored urine with hematuria and mild proteinuria. What will the primary care pediatric nurse practitioner do to manage this condition?
Prescribe a 10- to 14-day course of high-dose amoxicillin.
Refer the child to a pediatric nephrologist for hospitalization.
Reassure the parents that this condition will resolve spontaneously.
Prescribe high-dose steroids in consultation with a nephrologist.
Refer the child to a pediatric nephrologist for hospitalization.
This child has symptoms of post-streptococcal glomerulonephritis and signs indicating a need for hospitalization: elevated BP, edema, and dyspnea. The PNP should refer the child to a nephrologist for hospital admission and care. Amoxicillin is not indicated; this condition is an immunologic response to GABHS and not an infection. Steroids are not effective in treating this disease. Although the condition usually does self-resolve, the child needs hospitalization for close monitoring and follow-up.
A healthy 14-year-old female has a dipstick urinalysis that is positive for 5-6 RBCs per hpf but otherwise normal. What is the first question the primary care pediatric nurse practitioner will ask this patient?
“Have you had a recent fever?”
“When was your last menstrual period (LMP)?”
“Are you taking any medications?”
“Are you sexually active?”
When was your last menstrual period (LMP)?”
Menstrual blood may appear in urine and is a common cause of urine with RBCs present, so this would be an appropriate first question of an adolescent. Asking about sexual activity or recent fevers may be part of the diagnostic reasoning if common causes are not present. Medications may discolor the urine but do not cause RBCs to be present.
A 6-year-old girl presents with bloody diarrhea for one day. Diarrhea has been going around at the school. A stool culture grows E. coli 0157:H7. Which of the following is the most appropriate explanation for not starting antibiotics in this patient?
Antibiotics will lengthen the course of the infection
Antibiotics will add cost to this self-limiting disease
Antibiotics may increase the risk of developing HUS
Antibiotics are not effective for inflammatory diarrhea
Antibiotics may increase the risk of developing HUS E coli O157:H is associated with the development of hemolytic uremic syndrome (HUS). Antibiotics can cause the premature release of toxins from dying bacteria, resulting in worsening symptoms and increasing the likelihoos of developing HUS.
Antibiotic may lengthen the course of the disease, but this not the best answer to this question
While antibiotics may increase the cost of treatment for this patient, they increase the risk of HUS and prolong the shedding of toxins in the stool
Antibiotic are indicated in certain causes of inflammatory diarrhea including Shigella and Campylobacter infections.
A child has gross hematuria, abdominal pain, and arthralgia as well as a purpuric rash. What diagnosis is most likely?
purpuric rash
Systemic lupus erythematosus
Henoch-Schönlein purpura
Rhabdomyosarcoma
Sickle cell disease
Henoch-Schönlein purpura
HSP may presents with gross hematuria in the presence of abdominal pain with or without bloody stools, arthralgias, and a purpuric rash. Rhabdomyosarcoma is characterized by gross hematuria and voiding dysfunction. Sickle cell disease can cause gross hematuria but not always.
A child is diagnosed with nephrotic syndrome, and the pediatric nurse practitioner provides primary care in consultation with a pediatric nephrologist. The child was treated with steroids and responded well to this treatment. What will the nurse practitioner tell the child’s parents about this disease?
“Future episodes are likely to have worse outcomes.”
“Steroids will be used when relapses occur.”
“This represents a cure from this disease.”
“Your child will need to take steroids indefinitely.”
“Steroids will be used when relapses occur.” In situations in which a child responds well to steroids, this shows promise of a good prognosis, indicating that the child may be treated successfully with steroids during future anticipated relapses. The fact that a child is a “steroid responder” indicates that future episodes of treatment will be successful and have positive outcomes.
This disease is chronic and not curable. Steroid use with children who respond positively is intermittent during episodes of relapse.
Steroids are not given continuously and are not seen as prophylactic.
A child who has nephrotic syndrome is on a steroids and a salt-restricted diet for a relapse of symptoms. A dipstick urinalysis shows 1+ protein, down from 3+ at the beginning of the episode. In consultation with the child’s nephrologist, what is the correct course of treatment considering this finding?
Begin a taper of the steroid medication while continuing salt restrictions.
Continue with steroids and salt restrictions until the urine is negative for protein.
Discontinue the steroids and salt restrictions now that improvement has occurred.
Relax salt restrictions and continue administration of steroids until proteinuria is gone.
Continue with steroids and salt restrictions until the urine is negative for protein. Steroid medications and salt restrictions are continued until proteinuria resolves.
Once remission occurs, steroid therapy is tapered and weaned over several months. There is less chance of relapse if corticosteroids are continued for several months after the first episode.
Nephrotic syndrome is a complex, often chronic disorder that responds to careful management with a gratifying long-term positive outcome. The diagnosis is made with 95% certainty on clinical impressions. A major goal is to control edema while awaiting definitive remission.
* Consultation with and/or referral to a nephrologist should occur because of the constantly changing strategies for managing these children.
* Hospitalization may be necessary initially if the disease is severe.
* Prednisone (2 mg/kg/day; maximum 60 mg) to induce remission, which can occur as early as 14 days as evidenced by diuresis. Steroids are continued for at least 4 to 6 weeks (Pais and Avner, 2016b). Relapses are treated with a short course of steroids and the patient is weaned as soon as the proteinuria resolves.
* Non-corticosteroid medications (cyclophosphamide and cyclosporine) are used by nephrologists if the child is steroid-dependent, steroid-resistant, or relapses frequently (Pais and Avner, 2016b).
* Activity and diet recommendations: No limitation is placed on activity. During active disease, salt may be restricted by the nephrologist. At other times, a diet appropriate for age is recommended.
* Diuretics and albumin replacement are sometimes used in the acute phase. Home BP monitoring may be recommended.
* Daily home proteinuria testing may be recommended to monitor the child and promptly identify exacerbations. Relapses are persistent proteinuria greater than 2+ every day for 3 days.
