Nursing 6435 Test bank questions Burns: Pediatric Primary Care, 6th Edition

Nursing 6435 Test bank questions Burns: Pediatric Primary Care, 6th Edition Chapter 25: Atopic, Rheumatic, and Immunodeficiency Disorders Test Bank Multiple Choice 1. 1. The parent of a school-age child reports that the child usually has allergic rhinitis symptoms beginning each fall and that non-sedating antihistamines are only marginally effective, especially for nasal obstruction symptoms. What will the primary care pediatric nurse practitioner do? a. a. Order an intranasal corticosteroid to begin 1 to 2 weeks prior to pollen season. b. b. Prescribe a decongestant medication as adjunct therapy during pollen season. c. c. Recommend adding diphenhydramine to the child’s regimen for additional relief. d. d. Suggest using an over-the-counter intranasal decongestant. ANS: A Intranasal corticosteroids are a key component in long-term therapy to manage symptoms associated with AR. These should be begun 1 to 2 weeks prior to the beginning of pollen season. Decongestants are not recommended for long-term use because of side effects. Diphenhydramine causes daytime drowsiness. 1. 2. The primary care pediatric nurse practitioner sees a child for follow-up care after hospitalization for ARF. The child has polyarthritis but no cardiac involvement. What will the nurse practitioner teach the family about ongoing care for this child? a. a. Aspirin is given for 2 weeks and then tapered to discontinue the medication. b. b. Prophylactic amoxicillin will need to be given for 5 years. c. c. Steroids will be necessary to prevent development of heart disease. d. d. The child will need complete bedrest until all symptoms subside. ANS: A ASA is given for arthritis for 2 weeks and then will be tapered. Children with ARF will need penicillin prophylaxis, not amoxicillin. Steroids are sometimes used for symptomatic relief but do not prevent chronic heart disease. Bed rest is indicated only when cardiac symptoms occur.1. 3. A school-age child with asthma is seen for a well child checkup and, in spite of “feeling fine,” has pronounced expiratory wheezes, decreased breath sounds, and an FEV1 less than 70% of personal best. The primary care pediatric nurse practitioner learns that the child’s parent administers the daily medium-dose ICS but that the child is responsible for using the SABA. A treatment of 4 puffs of a SABA in clinic results in marked improvement in the child’s status. What will the nurse practitioner do? a. a. Have the parent administer all of the child’s medications. b. b. Increase the ICS medication to a high-dose preparation. c. c. Reinforce teaching about the importance of using the SABA. d. d. Teach the child and parent how to use home PEF monitoring. ANS: D Home PEF monitoring is useful for children to identify when symptoms are worsening. This child does not appear to notice the presence of airway tightness or wheezing and so might benefit from PEF monitoring to know when to use the SABA. School-age children should be learning how to manage their chronic disease, so having the parent administer all medications is not the best choice, especially since use of the SABA is still dependent on the child’s report of symptoms. Since the child responded well to administration of the SABA, increasing the dose of ICS should not be done unless better management is not effective. Reinforcing the teaching is part of the plan but, unless the child is aware of symptoms, may not occur. 1. 4. A child has a fever and arthralgia. The primary care pediatric nurse practitioner learns that the child had a sore throat 3 weeks prior and auscultates a murmur in the clinic. Which test will the nurse practitioner order? a. a. Anti-DNase B test b. b. ASO titer c. c. Rapid strep test d. d. Throat culture ANS: B This child has symptoms and a history consistent with ARF. The ASO titer peaks in 3 to 6 weeks and will confirm a recent strep infection. The antiDNase B test will also confirm a recent strep infection, but this doesn’t peak until 6 to 8 weeks after the initial infection. A rapid strep test and throat culture do not differentiate the carrier state from a true infection. 1. 5. The primary care pediatric nurse practitioner is prescribing ibuprofen for a 25 kg child with JIA who has oligoarthitis. If the child will take 4 doses per day, what is the maximum amount the child will receive per dose? a. a. 200 mg b. b. 250 mg c. c. 400 mgd. d. 450 mg ANS: B The maximum dose is 40 mg/kg/day divided into 3 to 4 doses. 25 kg × 40 mg = 1000/4 = 250 mg. 1. 6. A school-age child who uses a SABA and an inhaled corticosteroid medication is seen in the clinic for an acute asthma exacerbation. After 4 puffs of an inhaled short-acting B2-agonist (SABA) every 20 minutes for three treatments, spirometry testing shows an FEV1 of 60% of the child’s personal best. What will the primary care pediatric nurse practitioner do next? a. a. Administer an oral corticosteroid and repeat the three treatments of the inhaled SABA. b. b. Admit the child to the hospital for every 2 hour inhaled SABA and intravenous steroids. c. c. Give the child 2 mg/kg of an oral corticosteroid and have the child taken to the emergency department. d. d. Order an oral corticosteroid, continue the SABA every 3 to 4 hours, and follow closely. ANS: D Children with an incomplete response (FEV1 between 40% and 69% of personal best) should be given oral steroids and instructed to continue the SABA every 3 to 4 hours with close follow-up. Hospitalization is not necessary unless severe distress occurs. An FEV1 less than 40% after treatment indicates a need to be seen in the ED. 1. 7. An adolescent who has asthma and severe perennial allergies has poor asthma control in spite of appropriate use of a SABA and a daily high-dose inhaled corticosteroid. What will the primary care pediatric nurse practitioner do next to manage this child’s asthma? a. a. Consider daily oral corticosteroid administration. b. b. Order an anticholinergic medication in conjunction with the current regimen. c. c. Prescribe a LABA/inhaled corticosteroid combination medication. d. d. Refer to a pulmonologist for omalizumab therapy. ANS: D Children older than 12 years who have moderate to severe allergy-related asthma and who react to perennial allergens may benefit from omalizumab as a second-line treatment when symptoms are not controlled by ICSs. The PNP should refer children to a pulmonologist for such treatment. Daily oral corticosteroid medications are not recommended because of the adverse effects caused by prolonged use of this route. Anticholinergic medications are generally used for acute exacerbations during in-patient stays or in the ED. A LABA/ICS combination will not produce different results.1. 8. A 4-month-old infant has a history of reddened, dry, itchy skin. The primary care pediatric nurse practitioner notes fine papules on the extensor aspect of the infant’s arms, anterior thighs, and lateral aspects of the cheeks. What is the initial treatment? a. a. Moisturizers b. b. Oral antihistamines c. c. Topical corticosteroids d. d. Wet wrap therapy ANS: A Moisturization is the first-line therapy to interrupt the itch-scratch-itch cycle. Oral antihistamines are used mostly to allow sleep during nighttime pruritus. Topical corticosteroids are used if moisturization is not effective. Wet wrap therapy is used to treat flares with recalcitrant disease. 1. 9. An 8-year-old child is diagnosed with systemic lupus erythematosus (SLE), and the child’s parent asks if there is a cure. What will the primary care pediatric nurse practitioner tell the parent? a. a. Complete remission occurs in some children at the age of puberty. b. b. Periods of remission may occur but there is no permanent cure. c. c. SLE can be cured with effective medication and treatment. d. d. The disease is always progressive with no cure and no remissions. ANS: B Periods of remission do occur in some children with SLE for unknown reasons, but there is no permanent remission or cure. For some children with Juvenile Idiopathic Arthritis (JIA), complete remission occurs at puberty. 1. 10. The primary care pediatric nurse practitioner is examining a school-age child who has had several hospitalizations for bronchitis and wheezing. The parent reports that the child has several coughing episodes associated with chest tightness each week and gets relief with an albuterol metered-dose inhaler. What will the nurse practitioner order? a. a. Allergy testing b. b. Chest radiography c. c. Spirometry testing d. d. Sweat chloride test ANS: C Spirometry testing is the gold standard for diagnosing asthma and is then used on a regular basis to monitor, evaluate, and manage asthma. Allergy testing should be considered but is not diagnostic of asthma. Chest radiography should not be routine. A sweat chloride test is used based on history.1. 11. The primary care pediatric nurse practitioner examines a child who has had stiffness and warmth in the right knee and left ankle for 7 or 8 months but no back pain. The nurse practitioner will refer the child to a rheumatology specialist to evaluate for a. a. enthesitisrelated JIA. b. b. oligoarticular JIA. c. c. polyarticular JIA. d. d. systemic JIA. ANS: B Oligoarticular JIA is characterized by mild, painless asymmetric joint involvement without systemic symptoms. Enthesitis-related JIA involves arthritis of the lower limbs, especially the hips, intertarsal joints, and sacroiliac joints, with swelling, tenderness, and warmth. Polyarticular JIA involves 5 or more joints. Systemic JIA presents with systemic symptoms, such as fever. 1. 12. A child who has been diagnosed with asthma for several years has been using a short-acting B2-agonist (SABA) to control symptoms. The primary care pediatric nurse practitioner learns that the child has recently begun using the SABA two or three times each week to treat wheezing and shortness of breath. The child currently has clear breath sounds and an FEV1 of 75% of personal best. What will the nurse practitioner do next? a. a. Add a daily inhaled corticosteroid. b. b. Administer 3 SABA treatments. c. c. Continue the current treatment. d. d. Order an oral corticosteroid. ANS: A The child is showing a need to step up treatment based on the frequency of symptoms, greater than twice each week. The PNP should order an inhaled corticosteroid maintenance medication to control symptoms and reduce the need for a SABA. The child is not having an acute exacerbation, so does not need 3 SABA treatments. Oral corticosteroids are given for moderate obstruction, 70%. 1. 13. The primary care pediatric nurse practitioner is evaluating an 11month-old infant who has had three viral respiratory illnesses causing bronchiolitis. The child’s parents both have seasonal allergies and ask whether the infant may have asthma. What will the nurse practitioner tell the parents? a. a. “Although it is likely, based on family history, it is too soon to tell.” b. b. “There is little reason to suspect that your infant has asthma.” c. c. “With your infant’s history of bronchiolitis, asthma is very likely.” d. d. “Your infant has definitive symptoms consistent with a diagnosis of asthma.”ANS: A A genetic predisposition for the development of an IgE-mediated response to aeroallergens is the strongest identifiable predisposing risk factor for asthma, but asthma is rarely diagnosed before age 12 months due to the high rate of viral-induced bronchiolitis. The PNP should be cautious about diagnosing asthma until wheezing without an association to viral illnesses occurs. This infant has clear risk factors for asthma; however, bronchiolitis is not a known risk factor. 1. 14. 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? a. a. ANA titers b. b. Blood pressure measurement c. c. Chest radiographs d. d. Liver function studies ANS: B Hypertension is a serious risk of HSP, so repeated BP measurement is indicated. 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. 1. 15. A 12-year-old child is brought to the clinic with joint pain, a 3week 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? a. a. Anti-double-strand DNA antibodies b. b. Anti-La antibodies c. c. Anti-Ro antibodies d. d. Anti-Sm antibodies ANS: A 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. AntiSM antibodies are diagnostic of SLE but are only seen in 30% of patients with SLE. 1. 16. A 10-year-old child has a 1-week history of fever of 104°C that is unresponsive to antipyretics. The primary care pediatric nurse practitioner examines the child and notes bilateral conjunctival injection and a polymorphous exanthema, with no other symptoms. Lab tests show elevated ESR, CRP, and platelets. Cultures are all negative. What will the nurse practitioner do? a. a. Begin treatment with intravenous methyl prednisone. b. b. Consider IVIG therapy if symptoms persist one more week. c. c. Order a baseline echocardiogram today and another in 2 weeks. d. d. Reassure the child’s parents that this is a self-limiting disorder. ANS: C An echocardiogram should be obtained as soon as the diagnosis of Kawasaki disease (KD) is established, as a baseline study, with subsequent studies in 2 weeks and in 6 to 8 weeks. This child has fever and only two other symptoms, which may be consistent with atypical KD. Atypical KD is more common in very young children and in children over 9 years of age, and coronary artery involvement is found more frequently in children with atypical KD. Methyl prednisone is given for children with IVIG-resistant disease. IVIG should be begun ideally in the first 10 days of the illness. Although KD is a self-limiting disorder, the risk of coronary artery involvement is high, so this must be evaluated and treated. 1. 17. The primary care pediatric nurse practitioner is reviewing the rheumatology plan of care for a child who is diagnosed with SLE. Besides reinforcing information about prescribed medications, what will the nurse practitioner teach the family to help minimize flaring of episodes? a. a. Have the child rest between activities. b. b. Obtain regular ophthalmology exams. c. c. Participate in low-impact exercises. d. d. Use UVA and UVB sunscreen daily. ANS: D Sunlight is a known trigger of SLE so patients should be advised to use a UVA and UVB sunscreen both indoors and out. Resting between activities is recommended for children with JIA. Children should participate in low-impact activities, but this does not reduce the number of flares. Ophthalmology exams are recommended for children with JIA. 1. 18. The primary care pediatric nurse practitioner is performing a well-baby checkup on a 6- month-old infant and notes a candida diaper rash and oral thrush. The infant has had two ear infections in the past 2 months and is in the 3rd percentile for weight. What will the nurse practitioner do? a. a. Order a CBC with differential and platelets and quantitative immunoglobulins. b. b. Order candida and pneumococcal skin tests and lymphocyte surface markers. c. c. Refer the infant to an immunologist for evaluation of immunodeficiency. d. d. Refer the infant to an otolaryngologist to evaluate recurrent otitis media.ANS: A Infants with warning signs of immunodeficiency, such as recurrent infections, skin infections, and oral thrush, should be evaluated. The initial step is to order a CBC with differential, platelets, and immunoglobulins. If this is not helpful, referral to an immunologist for further testing, such as candida and pneumococcal skin tests and lymphocyte surface markers, is warranted. Referral to an otolaryngologist is not indicated. 1. 19. An adolescent who has exercise-induced asthma (EIA) is on the high school track team and has recently begun to practice daily during the school week. The adolescent uses 2 puffs of albuterol via a metereddose inhaler 20 minutes before exercise but reports decreased effectiveness since beginning daily practice. What will the primary care pediatric nurse practitioner do? a. a. Counsel the adolescent to decrease the number of practices each week. b. b. Increase the albuterol to 4 puffs 20 minutes prior to exercise. c. c. Order a daily inhaled corticosteroid medication. d. d. Prescribe cromolyn sodium in addition to the albuterol. ANS: C Children with EIA should use 2 puffs of a B2-agonist and/or cromolyn MDI 15 to 30 minutes prior to exercise, but, since tolerance may develop if a B2agonist is used more than a few times a week, it should not be used as a controller monotherapy. Those who exercise regularly should use an ICS as a controller medication. Patients with asthma should be encouraged to exercise to improve overall health. Increasing the albuterol dose will not overcome the tolerance. And ICS is a preferred controller medication. 1. 20. An adolescent female reports poor sleep, fatigue, muscle and joint paint, and anxiety lasting for several months. The primary care pediatric nurse practitioner notes point tenderness at several sites. What will the nurse practitioner do next? a. a. Evaluate the adolescent’s pain using a numeric pain scale. b. b. Obtain ANA, CBC, liver function, and muscle enzymes tests. c. c. Reassure the adolescent that this condition is not lifethreatening. d. d. Refer the adolescent to a rheumatologist for further evaluation. ANS: D Children with widespread musculoskeletal pain and painful point tenderness may have fibromyalgia and should be referred. The Widespread Pain Index is used to define the degree of pain. Laboratory studies are of little benefit when diagnosing fibromyalgia. Even though children need reassurance that this disease is not life-threatening, this is not the next action.1. 21. The primary care pediatric nurse practitioner is managing care for a child who has JIA who has a positive ANA. Which specialty referral is critical for this child? a. a. Cardiology b. b. Ophthalmology c. c. Orthopedics d. d. Pain management ANS: B An ophthalmology consultation is critical for children with JIA who have a positive ANA. Uveitis occurs in up to 35% of children with JIA who have a positive ANA. Other specialists may be consulted for specific symptoms. 1. 22. The parent of a school-age child who is diagnosed with oligoarticular JIA asks the primary care pediatric nurse practitioner what exercises the child may do to help reduce symptoms. What will the nurse practitioner recommend? a. a. Running b. b. Swimming c. c. Weights d. d. Yoga ANS: B Swimming is an excellent exercise for children with JIA because water therapy and the use of heat or cold reduce pain and stiffness, unless they have severe anemia or cardiac involvement. Chapter 28: Neurologic Disorders Test Bank Multiple Choice 1. The parents of an 18-month-old child bring the child to the clinic after observing a brief seizure of less than 2 minutes in their child. In the clinic, the child has a temperature of 103.1°F, and the primary care pediatric nurse practitioner notes a left otitis media. The child is alert and responding normally. What will the nurse practitioner do? a. Order a lumbar puncture, complete blood count, and urinalysis. b. Prescribe an antibiotic for the ear infection and reassure the parents. c. Refer to a pediatric neurologist for anticonvulsant and antipyretic prophylaxis. d. Send the child to the emergency department for EEG and possible MRI. ANS: BThis child has symptoms of a simple febrile seizure with a focal site of infection and an otherwise normal exam. While this is very frightening to the family, the PNP should treat the infection and provide reassurance to the parents. Lumbar puncture may be performed in infants younger than 12 months. Prophylactic medications aren’t indicated for febrile seizures. Antipyretics aren’t useful, since most seizures occur when the temperature is either rising or falling. EEG and MRI are not indicated when focal neurological signs are not present. 2. A child who has sustained a head injury after falling on the playground is brought to the clinic. The parents report that the child cried immediately and was able to walk around after falling. The primary care pediatric nurse practitioner notes slight slurring of the child’s speech and the child has vomited twice in the exam room. Which course of action is warranted? a. Admit the child to the hospital for a neurology consult. b. Observe the child in the clinic for several hours. c. Order a head CT and observe the child at home. d. Send the child home with instructions for follow-up. ANS: A Children with certain symptoms, such as vomiting or slurred speech after a head injury, should be admitted to the hospital for neurologic consultation. If the child had not exhibited these symptoms, any of the other options would be acceptable. 3. A female infant who was developing normally stops meeting developmental milestones at age 12 months and then begins losing previously acquired skills. What will the primary care pediatric nurse practitioner expect to tell the parents about this child’s prognosis? a. Cognitive development will be normal but motor skills will be lost. b. Physical and speech therapy will help the infant regain lost skills. c. The child’s intellectual development will not progress further. d. This is a temporary condition with full recovery expected. ANS: C This child has symptoms of Rett syndrome, which affects females more than males and is characterized by a plateau of development with eventual loss of milestones. Intellectual development remains at the level of plateau. Physical therapy, occupational therapy, and speech therapy help to preserve functional abilities but do not improve skills. The condition is progressive, with variable life expectancy. 4. To evaluate brain tissue disorders in infants, which test is useful? a. Computerized tomography b. Head radiographsc. Magnetic resonance imaging d. Ultrasonography ANS: D Ultrasonography is used to evaluate brain tissue in infants. CT scans expose patients to high levels of radiation, so they are not used unless indicated. Radiographs have relatively diagnostic value for the neurologic system. Magnetic resonance imaging is useful but is expensive and usually requires sedation. 5. A child who has had a single non-febrile seizure has a normal neurologic exam. Which diagnostic test is indicated? a. Computerized tomography (CT) b. Electroencephalogram (EEG) c. Magnetic resonance imaging (MRI) d. Polysomnography ANS: B An EEG is standard for all children after a first non-febrile seizure. CT is not routinely used because of radiation exposure. MRI is used if cognitive changes or postictal focal dysfunction persists, if the seizure lasts longer than 15 minutes, if the child is younger than 6 months of age, and if any new onset of focal neurologic deficit has occurred. Polysomnography is used to assess nocturnal seizures. 6. During a well baby exam on a 9-month-old infant, the parent reports that the baby always uses the left hand to pick up objects and asks if the baby will be left-handed. What will the primary care pediatric nurse practitioner do? a. Explain that it is too soon to tell which hand the infant will prefer later. b. Perform a careful assessment of fine and gross motor skills. c. Teach the parent to encourage the infant to use both hands. d. Tell the parent that a hand preference usually develops between 6 and 12 months. ANS: B Hand preference before 1 year of age is usually suspect for cerebral palsy and may indicate a lack of motor skills in the other hand. The PNP should perform a careful assessment of fine and gross motor skills. Infants should not exhibit a hand preference until after 1 year of age, so the correct response is to assess further. 7. Because of their inability to ambulate, children with cerebral palsy should be evaluated for which nutrients? a. Calcium and vitamin D b. Fat-soluble vitamins c. Iron and zincd. Sodium and potassium ANS: A Children who do not place weight on their bones are at risk for osteopenia and should have vitamin D and calcium levels monitored and supplemented if indicated. 8. A 14-year-old child has a headache, unilateral weakness, and blurred vision preceded by fever and nausea. The child’s parent reports a similar episode several months prior. The primary care pediatric nurse practitioner will consult with a pediatric neurologist to order a. a lumbar puncture. b. an electroencephalogram (EEG). c. neuroimaging with magnetic resonance imaging (MRI). d. positron emission tomography (PET) scan. ANS: C Children who have MS exhibit the symptoms described above and are usually diagnosed with a gadolinium enhanced MRI. Lumbar puncture may be performed later to identify oligoclonal bands. An EEG is used to diagnose seizure activity. PET scans are used to detect tumors. 9. The pediatric nurse practitioner provides primary care for a 5-year-old child who has cerebral palsy who exhibits athetosis and poor weight gain in spite of receiving high-calorie formula to supplement intake. The child has had several episodes of pneumonia in the past year. Which specialty consultation is a priority for this child? a. Feeding clinic to manage caloric intake b. Neurology to assess medication needs c. Pulmonology for possible tracheotomy d. Surgery for possible fundoplication and gastrostomy ANS: D Children with CP who have athetosis often have increased calorie needs up to 50% to 100% higher than others. This child is unable to gain adequate weight in spite of receiving extra calories. The child also has possible aspiration pneumonia, probably due to difficulty swallowing or GERD. A fundoplication and gastrostomy can help to prevent GERD and to provide nutrition that doesn’t involve swallowing. The feeding clinic would increase calories and nutrients but, without a gastrostomy, cannot increase actual intake. The child is not having seizures or drooling that contribute to this problem, so medications aren’t necessary. Unless there is an airway problem, tracheotomy is not indicated. 10. When performing a neurologic exam to assess for meningeal signs in an infant, the primary care pediatric nurse practitioner will attempt to elicit the Kernig sign bya. bending the infant at the waist to touch fingers to toes. b. extending the leg at the knee with the infant supine. c. flexing the infant’s neck to touch chin to chest. d. turning the infant’s head from side to side. ANS: B In an infant, the Kernig sign is elicited by extending the leg at the knee with the infant in a supine position while observing for facial grimacing. Older children can bend at the waist to touch the toes to elicit the Kernig sign. The Brudzinski sign is elicited by passively flexing the neck to cause the patient to spontaneously flex the hip and knees. Turning the infant’s head from side to side is not done to elicit either sign. 11. The primary care pediatric nurse practitioner performs a well baby exam on a term 4-monthold infant and observes flattening of the left occiput, bossing of the right occiput, and anterior displacement of the left ear. The parents report performing various positioning maneuvers, but say that the baby’s head shape has worsened. What will the nurse practitioner recommend to correct this finding? a. Allow the infant to sleep on the tummy when the parents are in the room. b. Lay the infant in the “back to sleep” position, alternating the left and right occiput. c. Order a head CT to evaluate the infant for craniosynostosis. d. Refer the infant for orthotic cranial molding helmet therapy. ANS: D This infant was term and likely has positional plagiocephaly, which has not responded to repositioning efforts, so a referral should be made for an orthotic helmet. Tummy time is performed when the infant is awake and the parents are present. The “back to sleep” position with alternation of left and right is a repositioning maneuver. Craniosynostosis is characterized by bossing and deformity that follow cranial suture lines. 12. A 4-year-old child who has previously met developmental milestones is not toiled trained. The primary care pediatric nurse practitioner notes decreased reflexes in the lower extremities and observe a dimple above the gluteal cleft. Which diagnosis may be considered for this child? a. Arnold-Chiari malformation b. Reye syndrome c. Spina bifida cystica d. Tethered cord ANS: DTethered cord occurs when the caudal end of the spinal cord, causing abnormal stretching and damage to nerve cells, fibers, and blood vessels. This can cause symptoms of neurologic deterioration such as incontinence of bladder and bowel and loss of reflexes and sensation in the legs. ArnoldChiari malformation involves a downward herniation of the caudal end of the cerebellar vermis, which can cause brainstem and upper cervical cord compression. Reye syndrome involves swelling in the brain and signs of increased intracranial pressure. Spina bifida cystica is a myelomeningocele, with symptoms present at birth. A child with a recent history of URI reports tingling and pain in one ear followed by sagging of one side of the face. The primary care pediatric nurse practitioner observes that the child cannot close the eye or mo Burns: Pediatric Primary Care, 6th Edition Chapter 29: Eye Disorders Test Bank Multiple Choice 13. The primary care pediatric nurse practitioner is treating an infant with lacrimal duct obstruction who has developed bacterial conjunctivitis. After 2 weeks of treatment with topical antibiotics along with massage and frequent cleansing of secretions, the infant’s symptoms have not improved. Which action is correct? a. Perform massage more frequently. b. Prescribe an oral antibiotic. c. Recommend hot compresses. d. Refer to an ophthalmologist. ANS: D Infants treated for a secondary bacterial conjunctivitis with lacrimal duct obstruction who do not improve after 1 to 2 weeks of topical antibiotic therapy must be referred to an ophthalmologist for possible lacrimal duct probe. Performing the massage more often or applying hot compresses will not help clear the infections. Oral antibiotics are not indicated. 14. The primary care pediatric nurse practitioner performs a well child examination on a 9- month-old infant who has a history of prematurity at 28 weeks’ gestation. The infant was treated for retinopathy of prematurity (ROP) and all symptoms have resolved. When will the infant need an ophthalmologic exam? a. At 12 months of age b. At 24 months of age c. At 48 months of age d. At 60 months of age ANS: A Children who have a history of ROP requiring treatment, even if ROP has completely resolved, will need yearly ophthalmologic follow-up. Less frequent follow-up is required for children with ROP who did not require treatment. 15. A school-age child is hit in the face with a baseball bat and reports pain in one eye. The primary care pediatric nurse practitioner is able to see a dark red fluid level between the cornea and iris on gross examination, but the child resists any exam with a light. Which action is correct? a. Administer an oral analgesic medication. b. Apply a Fox shield and reevaluate the eye in 24 hours. c. Instill anesthetic eyedrops into the affected eye. d. Refer the child immediately to an ophthalmologist. ANS: D This child has a traumatic injury with hyphema to the eye, and an ophthalmologist must examine the eye to rule out orbital hematoma or retinal detachment. Any further attempt to examine the child may result in further injury. A Fox shield is used once more serious injury is excluded. 16. During a well-baby assessment on a 1-week-old infant who had a normal exam when discharged from the newborn nursery 2 days prior, the primary care pediatric nurse practitioner notes moderate eyelid swelling, bulbar conjunctival injections, and moderate amounts of thick, purulent discharge. What is the likely diagnosis? a. Chemical-induced conjunctivitis b. Chlamydia trachomatis conjunctivitis c. Herpes simplex virus (HSV) conjunctivitis d. Neisseria gonorrhea conjunctivitis ANS: B C. trachomatis conjunctivitis usually begins between 5 to 14 days of life and causes moderate eyelid swelling, palpebral or bulbar conjunctivitis, and moderate, thick, purulent discharge. Chemical-induced conjunctivitis manifests as nonpurulent discharge. HSV is characterized by serosanguinous discharge. N. gonorrhea causes acute conjunctival inflammation and excessive purulent discharge. 17. The primary care pediatric nurse practitioner applies fluorescein stain to a child’s eye. When examining the eye with a cobalt blue filter light, the entire cornea appears cloudy. What does this indicate? a. The cornea has not been damaged. b. There is too little stain on the cornea. c. There is damage to the cornea. d. There is too much stain on the cornea. ANS: D When fluorescein stain is applied and the entire cornea appears cloudy, it means that there is too much of the stain. Damaged areas of the cornea should appear greenish after staining with fluorescein dye. 18. During a well child assessment of an African-American infant, the primary care pediatric nurse practitioner notes a dark red-brown light reflex in the left eye and a slightly brighter, redorange light reflex in the right eye. The nurse practitioner will a. dilate the pupils and reassess the red reflex. b. order auto-refractor screening of the eyes. c. recheck the red reflex in 1 month. d. refer the infant to an ophthalmologist. ANS: D Any asymmetry, dark or white spots, opacities, or leukokoria should be referred immediately to a pediatric ophthalmologist. The PNP does not dilate pupils or order auto-refractor exams; these are done by an ophthalmologist. Because retinoblastoma is a concern, any unusual finding should be immediately referred. 19. The primary care pediatric nurse practitioner performs a Hirschberg test to evaluate a. color vision. b. ocular alignment. c. peripheral vision. d. visual acuity. ANS: B The Hirschberg test, or corneal light reflex, assesses ocular mobility and alignment by looking for symmetry of reflected light. Color vision testing is performed with Richmond pseudo-isochromatic plates. Peripheral vision is tested by watching the child’s response to objects as they are moved in and out of the visual fields. Visual acuity is performed using eye charts or visualevoked potential readings. 20. The primary care pediatric nurse practitioner performs a well baby assessment of a 5-day-old infant and notes mild conjunctivitis, corneal opacity, and serosanguinous discharge in the right eye. Which course of action is correct? a. Administer intramuscular ceftriaxone 50 mg/kg. b. Admit the infant to the hospital immediately. c. Give oral erythromycin 30 to 50 mg/kg/day for 2 weeks. d. Teach the parent how to perform tear duct massage. ANS: B The infant has symptoms consistent with HPV conjunctivitis and requires hospitalization for topical and systemic antiviral medications to prevent spread to the central nervous system, mouth, and skin. IM ceftriaxone is given for gonococcal conjunctivitis. Oral erythromycin is given for chlamydial conjunctivitis. Tear duct massage is performed for lacrimal duct obstruction. 21. The primary care pediatric nurse practitioner performs a vision screen on a 4-month-old infant and notes the presence of convergence and accommodation with mild esotropia of the left eye. What will the nurse practitioner do? a. Patch the right eye to improve coordination of the left eye. b. Reassure the parents that the infant will outgrow this. c. Recheck the infant’s eyes in 2 to 4 weeks. d. Refer the infant to a pediatric ophthalmologist. ANS: D Esotropia that continues or occurs at 3 to 4 months of age is abnormal, so the infant should be referred to a pediatric ophthalmologist. The PNP does not determine whether an eye patch should be used. Because it is abnormal at this age, the PNP will not reassure the parents that the infant will outgrow this. Esotropia after 3 to 4 months of age must be evaluated by a specialist and not reevaluated in 2 to 4 weeks. 22. A toddler exhibits exotropia of the right eye during a cover-uncover screen. The primary care pediatric nurse practitioner will refer to a pediatric ophthalmologist to initiate which treatment? a. Botulinum toxin injection b. Corrective lenses c. Occluding the affected eye for 6 hours per day d. Patching of the unaffected eye for 2 hours each dayANS: D Deviations are initially treated by patching the unaffected eye for 2 hours each day to force the affected eye to move correctly. Botulinum toxin injection may be used with some deviations but is not a first-line therapy. Corrective lenses alone improve amblyopia in 27% of patients. The unaffected eye is patched; 2 hours per day is as effective as 6 hours per day. 23. A preschool-age child is seen in the clinic after waking up a temperature of 102.2°F, swelling and erythema of the upper lid of one eye, and moderate pain when looking from side to side. Which course of treatment is correct? a. Admit to the hospital for intravenous antibiotics. b. Obtain a lumbar puncture and blood culture. c. Order warm compresses 4 times daily for 5 days. d. Prescribe a 10- to 14-day course of oral antibiotics. ANS: A This child has periorbital cellulitis and must be hospitalized because of having pain with movement of the eye, indicating orbital involvement. LP is performed on infants under 1 year of age. Warm compresses are used for mild cases. Oral antibiotics are not indicated. 24. A preschool-age child who attends day care has a 2-day history of matted eyelids in the morning and burning and itching of the eyes. The primary care pediatric nurse practitioner notes yellow-green purulent discharge from both eyes, conjunctival erythema, and mild URI symptoms. Which action is correct? a. Culture the conjunctival discharge. b. Observe the child for several days. c. Order an oral antibiotic medication. d. Prescribe topical antibiotic drops. ANS: D Young children with bacterial conjunctivitis may be treated with topical antibiotic drops. Culturing the eyes is not necessary unless there is no improvement. While most cases of bacterial conjunctivitis are self-limiting, using a topical antibiotic will hasten the return to day care. Oral antibiotics are not indicated. 25. The primary care pediatric nurse practitioner observes a tender, swollen red furuncle on the upper lid margin of a child’s eye. What treatment will the nurse practitioner recommend? a. Culture of the lesion to determine causative organism b. Referral to ophthalmology for incision and drainage c. Topical steroid medication d. Warm, moist compresses 3 to 4 times dailyANS: D The child has symptoms of hordeolum, or stye. Although these often rupture spontaneously, warm, moist compresses may hasten this process. It is not necessary to culture the lesion unless symptoms do not resolve. Referral to ophthalmology is made if the hordeolum does not rupture on its own. Steroids are not indicated. 26. A school-age child is seen in the clinic after a fragment from a glass bottle flew into the eye. What will the primary care pediatric nurse practitioner do? a. Refer immediately to an ophthalmologist. b. Attempt to visualize the glass fragment. c. Irrigate the eye with sterile saline. d. Instill a topical anesthetic. ANS: A The PNP should never attempt to remove an intraocular foreign body or any projectile object but should refer immediately to an ophthalmologist. Visualizing the object, irrigating the eye, or instilling drops may further injure the eye. 27. A 14-year-old child has a 2-week history of severe itching and tearing of both eyes. The primary care pediatric nurse practitioner notes redness and swelling of the eyelids along with stringy, mucoid discharge. What will the nurse practitioner prescribe? a. Saline solution or artificial tears b. Topical mast cell stabilizer c. Topical NSAID drops d. Topical vasoconstrictor drops ANS: C This child has symptoms of allergic conjunctivitis. Topical NSAIDs work for acute symptoms to reduce inflammation and may be used in children over age 12 years. Saline solution or artificial tears are useful for milder symptoms. Topical mast cell stabilizers are useful for chronic symptoms and maintenance therapy. Topical vasoconstrictors should be avoided because of rebound hyperemia. 28. During a well child exam on a 4-year-old child, the primary care pediatric nurse practitioner notes that the clinic nurse recorded “20/50” for the child’s vision and noted that the child had difficulty cooperating with the exam. What will the nurse practitioner recommend? a. Follow up with a visual acuity screen in 6 months. b. Refer to a pediatric ophthalmologist. c. Re-test the child in 1 year.d. Test the child’s vision in 1 month. ANS: D Children age 4 years and older who have difficulty cooperating with a vision screen should be retested in 1 month; if they continue to have difficulty cooperating, they should be referred for a formal examination. Children who are 3 years old should be re-evaluated in 6 months. Burns: Pediatric Primary Care, 6th Edition Chapter 27: Hematologic Disorders Test Bank Multiple Choice 29. The primary care pediatric nurse practitioner sees a 12-month-old infant who is being fed goat’s milk and a vegetarian diet. The child is pale and has a beefy-red, sore tongue and oral mucous membranes. Which tests will the nurse practitioner order to evaluate this child’s condition? a. Hemoglobin electrophoresis b. RBC folate, iron, and B12 levels c. Reticulocyte levels d. Serum lead levels ANS: B Infants and children who are fed goat’s milk or who are on a strict vegetarian diet are at risk for folic acid and vitamin B12 deficiency. These should be evaluated, along with iron, to rule out IDA. Hemoglobin electrophoresis is used to evaluate diseases associated with altered hemoglobin, such as betathalassemia and sickle cell anemia, neither of which is indicated by this child’s history. Reticulocyte levels are evaluated to evaluate transient erythroblastopenia of childhood, a condition that frequently follows a viral infection. Serum lead levels are not indicated based on this history. 30. A 2-year-old child who has SCA comes to the clinic with a cough and a fever of 101.5°C. The child currently takes penicillin V prophylaxis 125 mg orally twice daily. What will the primary care pediatric nurse practitioner do? a. Admit the child to the hospital to evaluate for sepsis. b. Give intravenous fluids and antibiotics in clinic. c. Increase the penicillin V dose to 250 mg. d. Order a chest radiograph to rule out pneumonia.ANS: A Fever and pulmonary symptoms are two conditions warranting referral or emergency admission to the hospital to rule out sepsis and acute chest syndrome. Increasing the dose of penicillin V or giving IV antibiotics is not indicated. 31. The primary care pediatric nurse practitioner evaluates a 5-year-old child who presents with pallor and obtains labs revealing a hemoglobin of 8.5 g/dL and a hematocrit of 31%. How will the nurse practitioner manage this patient? a. Prescribe elemental iron and recheck labs in 1 month. b. Reassure the parent that this represents mild anemia. c. Recommend a diet high in iron-rich foods. d. Refer to a hematologist for further evaluation. ANS: A The child has mild to moderate iron-deficiency anemia and will need iron supplementation. The hemoglobin, hematocrit, and reticulocytes should be reevaluated in 4 weeks after initiation of treatment. The child needs iron supplementation, so reassurance alone is not indicated. It is difficult to get iron from foods, so supplementation will be needed. Children with hemoglobin levels less than 4 g/dL and some children with hemoglobin levels less than 7 g/dL must be referred. 32. The primary care pediatric nurse practitioner is examining a 5-year-old child who has had recurrent fevers, bone pain, and a recent loss of weight. The physical exam reveals scattered petechiae, lymphadenopathy, and bruising. A complete blood count shows thrombocytopenia, anemia, and an elevated white cell blood count. The nurse practitioner will refer this child to a specialist for a. bone marrow biopsy. b. corticosteroids and IVIG. c. hemoglobin electrophoresis. d. immunoglobulin testing. ANS: A This child has symptoms and initial lab tests consistent with leukemia and should be referred to a pediatric hematologist-oncologist for a bone marrow biopsy for a definitive diagnosis. Corticosteroids and IVIG are given for severe ITP. Hgb electrophoresis is used to diagnose SCA. Immunoglobulins are evaluated when immune deficiency syndromes are suspected. 33. The pediatric nurse practitioner provides primary care for a 30-monthold child who has sickle cell anemia who has had one dose of 23-valent pneumococcal vaccine. Which is an appropriate action for health maintenance in this child?a. Administer an initial meningococcal vaccine. b. Begin folic acid dietary supplementation. c. Decrease the dose of penicillin V prophylaxis. d. Give a second dose of 23-valent pneumococcal vaccine. ANS: A Invasive bacterial infection is the leading cause of death in young children with SCA. Meningococcal vaccine should be given initially for all children over the age of 2 years and a booster dose given every 5 years after that. Folic acid supplementation is often used for adults but not for children unless there is a documented deficiency. Penicillin V prophylaxis is started at 2 months of age, with the dose increased at age 3 years. The 23-valent pneumococcal polysaccharide second dose is given 5 years after the first. 34. The primary care pediatric nurse practitioner reviews hematology reports on a child with beta-thalassemia minor and notes an Hgb level of 8 g/dL. What will the nurse practitioner do? a. Evaluate serum ferritin. b. Order Hgb electrophoresis. c. Prescribe supplemental iron. d. Refer for RBC transfusions. ANS: A Children with beta-thalassemia minor may have low hemoglobin without iron deficiency so, before prescribing iron, the PNP should measure serum iron levels or serum ferritin. Hgb electrophoresis is indicated in a child whose diagnosis is unknown to diagnose this disorder. Supplemental iron should only be ordered when there is documented iron deficiency. RBC transfusions are controversial and used only for more severe iron deficiency. 35. A school-age child comes to the clinic for evaluation of excessive bruising. The primary care pediatric nurse practitioner notes a history of an upper respiratory infection 2 weeks prior. The physical exam is negative for hepatosplenomegaly and lymphadenopathy. Blood work reveals a platelet count of 60,000/mm3 with normal PT and aPTT. How will the nurse practitioner manage this child’s condition? a. Admit to the hospital for IVIG therapy. b. Begin a short course of corticosteroid therapy. c. Refer to a pediatric hematologist. d. Teach to avoid NSAIDs and contact sports. ANS: D This child has symptoms, a history, and lab work that indicate idiopathic thrombocytopenic purpura. Since platelets are greater than 20,000/mm3, management without specific therapy may be done on an outpatient basis by teaching the family to avoid things that contribute to bleeding. IVIG therapy is used for children with active, severe bleeding. Corticosteroids are given for platelet counts less than 20,000/mm3. Referral to a hematologist is necessary for more severe cases. 36. A toddler who presents with anemia and reticulocytopenia has a history of a gradual decrease in energy and increase in pallor beginning after a recent viral infection. How will the primary care pediatric nurse practitioner treat this child? a. Closely observe the child’s symptoms and lab values. b. Consult with a pediatric hematologist. c. Prescribe supplemental iron for 4 to 6 months. d. Refer for transfusions to correct the anemia. ANS: A This child has symptoms and a history consistent with transient erythroblastopenia of childhood (TEC), which is usually self-limited. The PNP should monitor the child closely without treatment unless the anemia gets worse. Any of the other options may be necessary if the child’s condition worsens. 37. The primary care pediatric nurse practitioner is managing care for a child diagnosed with irondeficiency anemia who had an initial hemoglobin of 8.8 g/dL and hematocrit of 32% who has been receiving ferrous sulfate as 3 mg/kg/day of elemental iron for 4 weeks. The child’s current lab work reveals elevations in Hgb/Hct and reticulocytes with a hemoglobin of 10.5 g/dL and a hematocrit of 36%. What is the next step in management of this patient? a. Continue the current dose of ferrous sulfate and recheck labs in 1 to 2 months. b. Discontinue the supplemental iron and encourage an iron-enriched diet. c. Increase the ferrous sulfate dose to 4 to 6 mg/kg/day of elemental iron. d. Refer the child to a pediatric hematologist to further evaluate the anemia. ANS: A This child has mild to moderate anemia and is showing a good response to the current dose of iron. Ferrous sulfate should be continued for at least 2 to 3 months to normalize hemoglobin, and then continue for 2 to 4 months to replace depleted iron stores. There is no need to increase the dose, since the child is responding appropriately to the current dose. Children with hemoglobin levels less than 4 g/dL should be referred. 38. The primary care pediatric nurse practitioner is performing a well child examination on a school-age child who has a history of cancer treated with cranial irradiation. What will the nurse practitioner monitor in this child? a. Cardiomyopathy and arrhythmias b. Leukoencephalopathyc. Obesity and gonadal dysfunction d. Peripheral neuropathy and hearing loss ANS: B Leukoencephalopathy is a late effect of cancer treatment associated with cranial irradiation. Cardiomyopathy and arrhythmias are related to anthracycline use. Obesity and gonadal dysfunction result from neuroendocrine effects of chemotherapeutic agents. Peripheral neuropathy and hearing loss occur after cisplatin use. 39. A complete blood count on a 12-month-old infant reveals microcytic, hypochromic anemia with a hemoglobin of 9.5 g/dL. The infant has mild pallor with no hepatosplenomegaly. The primary care pediatric nurse practitioner suspects a. hereditary spherocytosis. b. iron-deficiency anemia. c. lead intoxication. d. sickle-cell anemia. ANS: B Iron-deficiency anemia is the most common type of anemia in infants and children, accounting for approximately 90% of cases. It is characterized by decreased hemoglobin, with microcytic, hypochromic RBCs. Hereditary spherocytosis is characterized by pallor and jaundice with splenomegaly. Lead intoxication is accompanied by neurobehavioral problems. Sickle-cell anemia involves the presence of HgbS. 40. The primary care pediatric nurse practitioner performs a well baby examination on a 4- month-old infant who is exclusively breastfed and whose mother plans to introduce only small amounts of fruits and vegetables in addition to breastfeeding. To ensure that the infant gets adequate amounts of iron, what will the nurse practitioner recommend? a. Elemental iron supplementation of 1 mg/kg/day until cereals are added b. Elemental iron supplementation of 3 mg/kg/day for the duration of breastfeeding c. Monitoring the infant’s hemoglobin and hematocrit at every well-baby checkup d. Offering iron-fortified formula to ensure adequate iron intake ANS: A Infants who are exclusively breastfeeding or who receive more than half of their diet from breast milk should be given 1 mg/kg/day of supplemental iron until iron-containing foods are added to the diet. It is not necessary to monitor Hgb/Hct regularly unless the child has symptoms. Formula is not necessary for breastfeeding infants.41. The primary care pediatric nurse practitioner reviews a child’s complete blood count with differential white blood cell values and recognizes a “left shift” because of a. a decreased eosinophil count. b. a decreased lymphocyte count. c. an elevated monocyte count. d. an elevated neutrophil count. ANS: D A left shift occurs when there is an increase in the number of circulating immature neutrophils and indicates a bacterial infection or an inflammatory disorder. Eosinophils are associated with an antigen-antibody response and are elevated with exposure to allergens, inflammation of skin, or parasites. Lymphocytes are non-granulocytes that are elevated with viral infections. Monocytes are non-granulocytes and are elevated in infections and inflammation and some leukemias; elevations of non-granulocytes are referred to as a “right shift.” Burns: Pediatric Primary Care, 6th Edition Chapter 22: Prescribing Medications in Pediatrics Test Bank Multiple Choice 42. The single mother of a 4-year-old who attends day care tells the primary care pediatric nurse practitioner that she had difficulty giving her child a twice-daily amoxicillin for 10 days to treat otitis media during a previous episode several months earlier because she works two jobs and is too busy. The child has an ear infection in the clinic today. What will the nurse practitioner do? a. Administer an intramuscular antibiotic. b. Order twice-daily amoxicillin for 5 days. c. Prescribe azithromycin once daily for 5 days. d. Reinforce the need to adhere to the plan of care. ANS: C To improve adherence, the PNP should shorten the length of treatment, if possible and, if possible, reduce the number of times per day that a medication is given. This mother indicated that she had difficulty giving two doses per day, so a once daily for 5 days medication is ideal. It is not necessary to give an IM injection unless the child refuses to take the medication. Reinforcing the need to adhere to the plan is important but does not address the underlying difficulty associated with scheduling.43. The primary care pediatric nurse practitioner is considering use of a relatively new drug for a 15-month-old child. The drug is metabolized by the liver, so the nurse practitioner will consult a pharmacologist to discuss giving the drug: a. less often or at a lower dose. b. more often or at a higher dose. c. via a parenteral route. d. via the oral route. ANS: A Infants metabolize drugs more slowly than older children due to decreased levels of oxidases and conjugating enzymes produced in the immature liver, so they may need drugs given less often or at lower doses to avoid toxicity. The route does not necessarily play a role in this case. 44. The parent of a school-age child who has asthma tells the primary care pediatric nurse practitioner that the child often comes home from school with severe wheezing after gym class and needs to use his metered-dose inhaler right away. What will the nurse practitioner do? a. Recommend that the child go to the school nurse when symptoms start. b. Review the child’s asthma action plan and possibly increase his steroid dose. c. Suggest asking the school to excuse the child from gym class. d. Write the prescription for two metered-dose inhalers with spacers. ANS: D When children have to take a medication at school or day care, the PNP should dispense two units of the medication so that one can remain at school and one at home to avoid missed doses. The school nurse will not be able to order a medication that the child does not have available. The child is missing his rescue medication and just needs access to his inhaler. It is not necessary to excuse the child from gym class if his symptoms can be controlled. 45. A pharmaceutical company has developed a new drug that was tested only on adults. The FDA has declared this drug to have potential benefits for ill children. According to the Pediatric Research Equity Act (PREA), what may the pharmaceutical company be required to do? a. Conduct pediatric drug studies to determine whether the drug is safe and effective in children. b. Provide labeling stating that the safety and efficacy of the drug is not established for children. c. Receive a patent extension for conducting pediatric studies to determine use in children.d. Survey existing data about the drug to determine potential use in the pediatric population. ANS: A The PREA gives the FDA more leverage over the types of new drugs developed for children and can require pharmaceutical companies to conduct pediatric drug trials if the FDA declares a drug as possibly useful to ill children or one that might be used by a substantial number of children. The Food and Drug Administration Modernization Act (FDAMA) allowed labeling that “safety and effectiveness in pediatric patients have not been established” on drugs with insufficient evidence to support pediatric indications. The Best Pharmaceuticals of Children Act (BPCA) grants a patent extension when a drug company voluntarily studies a known or new drug in children. The FDAMA also requires pharmaceutical companies to survey existing data and determine potential drug use and indications in pediatric populations. 46. The primary care pediatric nurse practitioner is considering using a drug for an “off-label” use in a child. The nurse practitioner has used the drug in a similar situation previously, has consulted a pharmacology resource and the FDA website, and has determined that there are no significant contraindications and warnings for this child. What else must the nurse practitioner do when prescribing this drug? a. Discuss recommendations with the parents and document their consent. b. Document anecdotal reports of previous use of the drug by other providers. c. Follow up daily with the parents to determine safe administration of the drug. d. Report this use to the FDA Medwatch website for tracking purposes. ANS: A Many prescriptions are written for “off-label” uses for children because the drug doesn’t have enough substantial evidence for FDA approval. The PNP should make sure to discuss the drug and this use with the family and document the decision-making process and their consent for this use. It is not enough to base a decision solely on what someone else has done. Unless the drug is experimental or has many serious adverse effects, close daily monitoring is not necessary. The PNP is not required to report off-label drug use to the FDA. 47. The primary care pediatric nurse practitioner prescribes a new medication for a child who develops a previously unknown adverse reaction. To report this, the nurse practitioner will : a. access the BPCA website. b. call the PREA hotline. c. log onto the FDA Medwatch website. d. use the AAP online PediaLink program. ANS: CThe FDA Medwatch website is available for reporting of drug-related adverse effects, and all providers are encouraged to report these here. BPCA and PREA are legislative acts and do not have a hotline or website for adverse effects reporting. The AAP PediaLink program is a source for labeling changes of drugs. 48. The primary care pediatric nurse practitioner is treating a toddler who has a lower respiratory tract illness with a low-grade fever. The child is eating and taking fluids well and has normal oxygen saturations in the clinic. The nurse practitioner suspects that the child has a viral pneumonia and will : a. order an anti-viral medication and schedule a follow-up appointment. b. prescribe a broad-spectrum antibiotic until the lab results are received. c. teach the parents symptomatic care and order labs to help with the diagnosis. d. write a prescription for an antibiotic to be given if the child’s condition worsens. ANS: C To decrease antibiotic overuse and resistance, the PNP should order an antibiotic only if laboratory data confirm a bacterial infection. This child is mildly ill and can be treated symptomatically. It is not necessary to treat with an anti-viral medication. A broad-spectrum antibiotic will only increase the risk of antibiotic resistance. Writing a prescription for the parents to fill if needed is not recommended; parents may give an antibiotic believing that it is indicated when it is not. 49. The primary care pediatric nurse practitioner is counseling an adolescent who was recently hospitalized for an asthma exacerbation and learns that the child usually forgets to use twicedaily inhaled corticosteroid medications that are supposed to be given at 0800 and 2000 each day. Which strategy may be useful in this case to improve adherence? a. Ask the adolescent to identify two times each day that may work better. b. Consider having the school nurse supervise medication administration. c. Prescribing a daily oral corticosteroid medication instead. d. Suggest that the parent enforce the medication regimen each day. ANS: A When working with adolescents who take medication, it is important to allow the adolescent to have input into dosing schedules and what works for them. Having the school nurse supervise does not allow autonomy and creates continued dependency. Daily oral corticosteroids are not used for maintenance. The PNP should assist the family with transitioning the adolescent from parent to teen administration and not suggest that parents enforce medication rule Burns: Pediatric Primary Care, 6th Edition Chapter 41: Genetic DisordersTest Bank Multiple Choice 50. Which diagnostic study may be ordered when the provider wishes to detect the presence of additional genetic material on a chromosome? a. Chromosomal microarray b. FISH c. Karyotype d. Molecular testing ANS: B Fluorescence in-situ hybridization is used to locate and detect a specific area of a particular chromosome, including subtle missing, additional, or rearranged chromosomal material. Chromosomal microarray is used to detect micro-deletions or duplications in any of the chromosomes but not specific gene mutations. Karyotype testing is used to identify and evaluate the size, shape, and number of chromosomes. Molecular testing is used to detect specific single gene mutations. 51. What is an important responsibility of the primary care pediatric nurse practitioner to help determine genetic risk factors in families? a. Assessing physical characteristics of genetic disorders b. Knowing which genetic screening tests to perform c. Making appropriate referrals to pediatric geneticists d. Obtaining a three-generation pedigree for each family ANS: D In primary care practice, taking the time to collect a child’s family health history and pedigree can be just as important as information from a laboratory test and gives useful information about possible genetic disorders present in a family. The other skills are necessary if there is concern that a genetic disorder exists. 52. Which type of mutation is responsible for many single-gene genetic disorders? a. Copy number variations b. Nucleotide repeat expansions c. Point mutations d. Single nucleotide polymorphisms (SNP) ANS: CPoint mutations are single base pair changes capable of changing the function of a gene or gene product. Copy number variations involve larger areas of chromosomes beyond point mutations and provide the genetic basis for many psycho-behavioral diseases. Nucleotide repeat expansions occur beyond single point changes; genetic changes occur when the number of repeats increases beyond the tolerated limit. SNPs are alterations that contribute to multifactorial disorders. 53. Cystic fibrosis is a r