Exam 4

The majority of child abuse victims falls into which of the following age ranges? a. over 10 years b. 8 to 10 years c. 6 to 8 years d. under 6 years

D

Which of the following outcomes is most important in the nursing care plan for a family engaging in physical abuse of the children? a. The child will remain safe with no evidence of physical abuse or neglect. b. The parents will demonstrate at least one nurturing behavior. c. The parents will discuss normal growth and development for the age of the child. d. The child will report all instances of threatened or actual abuse and neglect.

A

Which of the following statements best defines the term child maltreatment? a. intentional injury of a child b. not giving a child what he or she wants c. failure to provide what a child needs d. accidental harm to a child by someone

A

Which of the following statements best defines the term physical abuse? a. bodily injury to a person that seems to have been inflicted by other than accidental means b. purposefully beating a child so that there are highly visible marks on the childs body c. use of the hands applied to a child in an excessively forceful manner d. any damage to a child that involves the use of muscle-applied force

A

Which of the following statements best describes the term stocking or glove type burn? a. The burn has the look of a stocking or glove because the child tried to protect him- or herself from being immersed in hot scalding water. b. The parents have dipped the child into hot liquid while he or she was asleep. c. The child was wearing a stocking or a glove then immersed in hot liquid. d. The parent was wearing heavy gloves or stockings on his or her hands while immersing the child in hot liquids or hot scalding water.

A

When the nurse sees a child who has burns on the backs of the legs and the top of the buttocks, and an area that is not burned in the center of the buttocks, the nurse will: a. tend to believe the parents who say the child got into the tub accidentally before it cooled off b. suspect that the childs buttocks were held forcibly against the bottom of the tub c. suspect that the parents poured hot liquids on some areas of the legs and buttocks d. think that the child backed up against a heater or was held there by the parents

B

Which of the following children is in a high-risk family for less nurturing and more hurtful behavior? a. a child being raised by grandparents b. a child who is forbidden from playing with other children c. a child being raised by two men d. a child in a nuclear family there both parents have full-time jobs

B

Which of the following is the best example of psychological abuse that is an act of commission? a. not attending parents night at the school b. telling a child that he or she is dumb and will not amount to anything c. forgetting to give a child money or food for lunch d. not getting a child his or her vaccinations for school and having problems from this

B

Which of the following is the most common type of mistreatment of children? a. physical abuse b. neglect c. sexual abuse d. emotional maltreatment

B

Which of the following is the second major cause of abuse-related deaths? a. burns b. abdominal injuries c. falls due to pushing or dropping d. poisioning

B

The nurse notices that a child has reddish blue to purple bruises that have margins. How old are these bruises? a. 5 days b. 7 days c. more than 10 days d. less than 1 day

D

Which of the following examples best defines the term role reversal? a. The child assumes a caregiver role toward the caregiver. b. The good child takes on a bad child role. c. A person who has been a good provider quits his or her job. d. A lazy person becomes very productive in the family.

A

In the sociological model of family violence, family violence is viewed as: a. a pattern of behavior that is passed from generation to generation b. a pattern of harm within the nuclear family with no outside persons involved c. any harmful action(s) between related persons no matter how distant the relationship is d. harmful activities within a group designated as family no matter what the relationship

A

Most child abuse deaths occur for which of the following reasons? a. neurological injuries, with most of these being head injuries b. bleeding from cuts c. smothering or serious lack of oxygen for any number of reasons d. abdominal injuries

A

Risk factors for shaken baby syndrome include: a. stressful life events b. gender with women mostly responsible c. multiple births within a family d. age of parents, especially elder parents

A

The nurse is developing a care plan for the parents of a toddler who was born prematurely and was in the neonatal intensive care unit for 2 months. The mother has been using a belt to discipline the child. The father is not very attentive to the needs of the mother or the baby. Which of the following nursing diagnoses would best fit this situation? a. interrupted family processes due to disrupted attachment b. deficient knowledge related to lack of parenting instructions c. high risk for injury to others related to mood disturbance d. marital discord in need of therapy related to lack of information

A

The nurse is working with a teenage girl who has been having sex with an adult male. The nurse is aware that this constitutes a. statutory rape b. permissive sex c. sex with permission d. an offense

A

The school nurse is working with a child who seems angry and hits or hurts other children. Children who hurt other children are most often: a. victims of abuse themselves b. victims of manic depressive illness c. individuals who are neurologically impaired d. persons with brain damage

A

The school nurse notices a child who has a frightened look then adults approach, appears sad, hangs around after school, and seems reluctant to go home. This child seemed very distressed then a classmate was crying after falling on the playground. The nurse tried to console this child while consoling the injured child. The school nurse realizes that this child has some of the classic symptoms of: a. a physically abused child b. autism c. mental retardation d. early mental illness

A

The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry; has no lunch money; and is always tired. When the nurse asks the boy about his tiredness, he talks of playing outside until midnight. The nurse will suspect that this child is: a. a victim of child neglect b. the victim of poverty c. an orphan d. being raised by a parent of low intelligence quotient (IQ)

A

Theorists believe that the behavior of caregivers who psychologically abuse their children stem from: a. not having experienced warm, caring parenting as children, not having their emotional needs met, and getting low levels of support b. criminal minds who are cunning and calculate how to be mean to children and punish them c. biochemical changes in the brain causing some people to have increased and even insatiable sexual urges toward children d. a childish mind that relates better to children than to adults who engage in problem solving and more adult behaviors

A

The nurse working in the pediatric clinic notices that a newborn seems particularly fussy. The mother verifies that this is a very fussy baby and that it is impossible to soothe the baby. In thinking through what to further assess and what to teach the mother, the nurse will keep in mind that fussy babies are: a. often in some kind of pain b. somewhat neurologically unstable c. often victims of the mothers drug use d. at greater risk for abuse

D

Nurses have an integral role in preventing child abuse and family violence through which of the following interventions? Select all that apply. a. educating the public b. supporting mental health initiatives c. becoming involved in health policy d. supporting family health initiatives

A, B, C, D

A nurse is asked to describe the concept of attachment between a young child and the caregiver to a group of families planning to adopt internationally. Which of the following statements made by the nurse describes the qualities involved in attachment of the parent and child? Select all that apply. a. being emotionally available b. allowing the child to grieve independently for the loss of his or her familiar surroundings c. offer protection and warmth to the child despite attachment challenges d. set firm parameters and allowed the child to deal with disappointment

A, C

11. A 3-year-old child with pressure-equalizing tubes (PET) in both ears has otalgia in one ear. The primary care pediatric nurse practitioner is able to visualize the tube and does not see exudate in the ear canal and obtains a type A tympanogram. What will the nurse practitioner do? a. Order ototopical antibiotic/corticosteroid drops. b. Prescribe a prophylactic antibiotic medication. c. Reassure the parent that this is a normal exam. d. Refer the child to an otolaryngologist for follow-up

ANS: A A normal, or type A, tympanogram in a child with PET may indicate a clogged tube. Ototopical antibiotic/corticosteroid drops can occasionally clear a clogged PET. Prophylactic antibiotics are not recommended to prevent otitis media. It is not necessary to refer unless the pain continues in spite of standard measures.

3. A child is diagnosed with community-acquired pneumonia and will be treated as an outpatient. Which antibiotic will the primary care pediatric nurse practitioner prescribe? a. Amoxicillin b. Azithromycin c. Ceftriaxone d. Oseltamivir

ANS: A Amoxicillin is given to children with community-acquired pneumonia. Azithromycin is used to treat atypical pneumonia. Ceftriaxone is used for inpatient treatment. Oseltamivir is used for viral pneumonia.

7. What will the primary care pediatric nurse practitioner teach the parents of a child who has new pressure-equalizing tubes (PET) in both ears? a. Parents should notice improved hearing in their child. b. PET will help by reducing the number of ear infections the child has. c. The child should use earplugs when showering or bathing. d. The tubes will most likely remain in place for 3 to 4 years.

ANS: A By reducing middle ear fluid, the child with hearing loss from this condition should show improvement in hearing. Children may still have infections but without persistent effusion. Earplugs are not necessary unless the child's head is submerged. PETs usually fall out on their own; if they are still in place 2 to 3 years after placement, they should be removed by the otolaryngology surgeon.

7. A child is in the clinic because of symptoms of purulent, foul-smelling nasal discharge from the right nostril. Nasal visualization reveals something shiny in a mass of mucous in the nasal cavity. What will the primary care pediatric nurse practitioner do? a. Attempt to remove the mass gently using alligator forceps. b. Perform a saline nasal rinse using a water jet device. c. Refer the child to a pediatric otolaryngologist. d. Suction the mucoid mass using a bulb syringe.

ANS: A Children often insert foreign bodies into their nasal cavities and, if undetected for any period of time, will develop foul-smelling, unilateral, purulent nasal discharge. The foreign body may become embedded in granulation tissue or mucosa. If possible, the PNP should attempt removal if the FB is visible and can be easily removed without causing trauma. Saline nasal rinses with pressure may push the FB farther into the cavity. Referral to ENT may be necessary if attempts to remove the FB are not successful. Suction is not indicated.

2. The primary care pediatric nurse practitioner performs a well child examination on a 9-month-old infant who has a history of prematurity at 28 weeks' gestation. The infant was treated for retinopathy of prematurity (ROP) and all symptoms have resolved. When will the infant need an ophthalmologic exam? a. At 12 months of age b. At 24 months of age c. At 48 months of age d. At 60 months of age

ANS: A Children who have a history of ROP requiring treatment, even if ROP has completely resolved, will need yearly ophthalmologic follow-up. Less frequent follow-up is required for children with ROP who did not require treatment.

1. A child who has otitis externa has severe swelling of the external auditory canal that persists after 2 days of therapy with ototopical antibiotic/corticosteroid drops. What is the next step in treatment for this child? a. Insert a wick into the external auditory canal. b. Irrigate the external auditory canal with saline. c. Order systemic corticosteroids. d. Prescribe an oral antibiotic medication.

ANS: A If significant swelling is present, inserting a wick into the EAC is helpful and should be impregnated with antibiotics as long as it is in place. Irrigation is contraindicated during an acute infection. Systemic steroids and antibiotics are not indicated.

14. A school-age child is seen in the clinic after a fragment from a glass bottle flew into the eye. What will the primary care pediatric nurse practitioner do? a. Refer immediately to an ophthalmologist. b. Attempt to visualize the glass fragment. c. Irrigate the eye with sterile saline. d. Instill a topical anesthetic.

ANS: A The PNP should never attempt to remove an intraocular foreign body or any projectile object but should refer immediately to an ophthalmologist. Visualizing the object, irrigating the eye, or instilling drops may further injure the eye.

11. A preschool-age child is seen in the clinic after waking up a temperature of 102.2°F, swelling and erythema of the upper lid of one eye, and moderate pain when looking from side to side. Which course of treatment is correct? a. Admit to the hospital for intravenous antibiotics. b. Obtain a lumbar puncture and blood culture. c. Order warm compresses 4 times daily for 5 days. d. Prescribe a 10- to 14-day course of oral antibiotics.

ANS: A This child has periorbital cellulitis and must be hospitalized because of having pain with movement of the eye, indicating orbital involvement. LP is performed on infants under 1 year of age. Warm compresses are used for mild cases. Oral antibiotics are not indicated.

3. A school-age child has a history of chronic otitis media and is seen in the clinic with vertigo. The primary care pediatric nurse practitioner notes profuse purulent otorrhea from both pressure-equalizing tubes and a pearly-white lesion on one tympanic membrane. Which condition is most likely? a. Cholesteatoma b. Mastoiditis c. Otitis externa d. Otitis media with effusion

ANS: A This child has symptoms of cholesteatoma, especially with a pearly white lesion on the TM. Mastoiditis involves the mastoid bone behind the ear.

14. A school-age child has had nasal discharge and daytime cough but no fever for 12 days without improvement in symptoms. The child has not had antibiotics recently and there is no significant antibiotic resistance in the local community. What is the appropriate treatment for this child? a. Amoxicillin 45 mg/kg/day b. Amoxicillin 80-90 mg/kg/day c. Amoxicillin-clavulanate 80-90 mg/kg/day d. Saline irrigation for symptomatic relief

ANS: A This child meets criteria for treatment of acute rhinosinusitis (ARS) based on duration of symptoms without clinical improvement. The initial treatment is amoxicillin 45 mg/kg/day. The higher dose is used to treat ARS in communities with resistant S. pneumonia. If antibiotics have been used previously, amoxicillin-clavulanate is used. The use of buffered isotonic saline into the nasal cavity by squeeze bottle or neti pot (in late childhood and adolescence) may be helpful, but the clinical guidelines do not support or negate the use of saline.

2. A previously healthy school-age child develops a cough and a low-grade fever. The primary care pediatric nurse practitioner auscultates wheezes in all lung fields. Which diagnosis will the nurse practitioner suspect? a. Atypical pneumonia b. Bacterial pneumonia c. Bronchiolitis d. Bronchitis

ANS: A Wheezing in a child over 5 years of age without a history of wheezing may point to an atypical pneumonia. Bacterial pneumonia is characterized by diminished breath sounds or crackles along with high fever. Bronchiolitis causes coarse wheezing. Bronchitis is characterized by cough without adventitious lung sounds.

1. In a respiratory disorder causing a check-valve obstruction, which symptoms will be present? a. Air entry on inspiration with expiratory occlusion b. Complete obstruction on inspiration and expiration c. Narrowing of the lumen with increased air flow resistance d. Obstruction of air entry with unimpeded expiratory air flow

ANS: A With check-valve or ball-valve obstruction, air entry is possible, but the lumen is completely occluded during expiration so that air escape is impossible. A complete obstruction does not allow inspiratory or expiratory air flow. A bypass valve obstruction allows air flow but with increased resistance. There is no obstruction that impedes inspiration while allowing expiratory air flow.

7. The primary care pediatric nurse practitioner performs a Hirschberg test to evaluate a. color vision. b. ocular alignment. c. peripheral vision. d. visual acuity.

ANS: B The Hirschberg test, or corneal light reflex, assesses ocular mobility and alignment by looking for symmetry of reflected light. Color vision testing is performed with Richmond pseudo-isochromatic plates. Peripheral vision is tested by watching the child's response to objects as they are moved in and out of the visual fields. Visual acuity is performed using eye charts or visual-evoked potential readings.

4. During a well-baby assessment on a 1-week-old infant who had a normal exam when discharged from the newborn nursery 2 days prior, the primary care pediatric nurse practitioner notes moderate eyelid swelling, bulbar conjunctival injections, and moderate amounts of thick, purulent discharge. What is the likely diagnosis? a. Chemical-induced conjunctivitis b. Chlamydia trachomatis conjunctivitis c. Herpes simplex virus (HSV) conjunctivitis d. Neisseria gonorrhea conjunctivitis

ANS: B C. trachomatis conjunctivitis usually begins between 5 to 14 days of life and causes moderate eyelid swelling, palpebral or bulbar conjunctivitis, and moderate, thick, purulent discharge. Chemical-induced conjunctivitis manifests as nonpurulent discharge. HSV is characterized by serosanguinous discharge. N. gonorrhea causes acute conjunctival inflammation and excessive purulent discharge.

5. An adolescent has suspected infectious mononucleosis after exposure to the virus in the past week. The primary care pediatric nurse practitioner examines the adolescent and notes exudate on the tonsils, soft palate petechiae, and diffuse adenopathy. Which test will the primary care pediatric nurse practitioner perform to confirm the diagnosis? a. Complete blood count b. EBV-specific antibody testing c. Heterophile antibody testing d. Throat culture

ANS: B EBV-specific IgG antibody testing is the specific serologic test for EBV infection. Heterophile antibody testing can be helpful in school-age children and adolescents after the first week of infection. A CBC can identify lymphocytosis with atypical lymphocytes but is non-specific. A throat culture is performed to identify bacterial causes; however, in this case of known exposure to EBV this would not be the appropriate confirmatory test.

15. The primary care pediatric nurse practitioner manages care in conjunction with a pediatric pulmonologist for a child with cystic fibrosis. Which medication regimen is used to facilitate airway clearance for this child? a. Ibuprofen and azithromycin b. Inhaled dornase alfa c. Ivacaftor d. Prophylactic clindamycin

ANS: B Inhaled dornase alfa is given to promote airway clearance by reducing mucus viscosity. Ibuprofen and azithromycin is given to reduce chronic airway inflammation. Ivacaftor is given to patients with specific gene mutations. Antibiotic therapy is based on regular sputum cultures.

9. A child with a history of otitis externa asks about ways to prevent this condition. What will the primary care pediatric nurse practitioner recommend? a. Cleaning ear canals well after swimming b. Drying the ear canal with a hair dryer c. Swimming only in chlorinated pools d. Using cerumenolytic agents daily

ANS: B Otitis externa is most frequently caused by retained moisture in the ear canal after swimming and when the protective barriers on the skin break down. Drying the ear canals with a hair dryer on a low setting helps to remove the moisture. Cleaning the ear canals, swimming in chlorinated water, and using a cerumenolytic remove the wax that protects the ear canal from superficial infection.

13. A child complains of itching in both ears and is having trouble hearing. The primary care pediatric nurse practitioner notes periauricular edema and marked swelling of the external auditory canal and elicits severe pain when manipulating the external ear structures. Which is an appropriate intervention? a. Obtain a culture of the external auditory canal. b. Order ototopical antibiotic/corticosteroid drops. c. Prescribe oral amoxicillin-clavulanate. d. Refer the child to an otolaryngologist.

ANS: B Ototopical antibiotic/corticosteroid drops are the mainstay of therapy for OE. It is not necessary to obtain a culture unless the infection does not respond to treatment. Oral antibiotics are not indicated unless impetigo occurs and is severe. A referral to a specialist is not recommended

14. The primary care pediatric nurse practitioner notes a small, round object in a child's external auditory canal, near the tympanic membrane. The child's parent thinks it is probably a dried pea. What will the nurse practitioner do to remove this object? a. Irrigate the external auditory canal to flush out the object. b. Refer the child to an otolaryngologist for removal. c. Remove the object with a wire loop curette. d. Use a bayonet forceps to grasp and remove the object

ANS: B Spherical objects are the most difficult to remove and should be referred. Irrigation is not recommended for objects made of organic material and also increases the risk of pushing the object farther down.

8. 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.

6. An 18-month-old child with no previous history of otitis media awoke during the night with right ear pain. The primary care pediatric nurse practitioner notes an axillary temperature of 100.5°F and an erythematous, bulging tympanic membrane. A tympanogram reveals of peak of +150 mm H2O. What is the recommended treatment for this child? a. Amoxicillin 80 to 90 mg/kg/day in two divided doses b. An analgesic medication and watchful waiting c. Ceftriaxone 50 to 75 mg/kg/dose IM given once d. Ototopical antibiotic drops twice daily for 5 days

ANS: B This child has no previous history and only has a mild fever and can be managed by watchful waiting, with parents given instructions about when and why to notify the provider. Analgesia is essential so that the child can be comfortable. If antibiotics are indicated as a result of no improvement after 48 to 72 hours, amoxicillin is the first-line drug. Ceftriaxone is given if the child is vomiting. Topical antibiotics are given when there is a perforation in the tympanic membrane.

5. The primary care pediatric nurse practitioner diagnoses acute otitis media in a 2-year-old child who has a history of three ear infections in the first 6 months of life. The child's tympanic membrane is intact and the child has a temperature of 101.5°F. What will the nurse practitioner prescribe for this child? a. Amoxicillin twice daily for 10 days b. An analgesic medication and watchful waiting c. Antibiotic ear drops and ibuprofen d. Ceftriaxone given once intramuscularly

ANS: B This child has no recent history, is over 24 months, and has relatively mild symptoms, so can be treated by watchful waiting with adequate follow-up and analgesic medication. Antibiotics are not indicated unless the child worsens or does not improve in 48 to 72 hours.

8. The parent of a 4-month-old infant is concerned that the infant cannot hear. Which test will the primary care pediatric nurse practitioner order to evaluate potential hearing loss in this infant? a. Acoustic reflectometry b. Audiometry c. Auditory brainstem response (ABR) d. Evoked otooacoustic emission (EOAE) testing

ANS: C ABR is not a direct measure of hearing but allows for inferences to be made about hearing thresholds and is useful for identifying hearing loss in a young infant. Although sedation is occasionally required, this test is useful in infants and young children unable to cooperate with EOAE or audiometry. Acoustic reflectometry is used to detect middle ear effusion. Audiometry requires a cooperative child. EOAE is used for universal screening in newborns. The American Academy of Pediatrics (AAP) Bright Futures guidelines (AAP, 2014) recommends pure-tone audiometry at 3, 4, 5, 6, 8, 10, 12, 15, and 18 years of age.

10. A 3-year-old child has had one episode of acute otitis media 3 weeks prior with a normal tympanogram just after treatment with amoxicillin. In the clinic today, the child has a type B tympanogram, a temperature of 102.5°F, and a bulging tympanic membrane. What will the primary care pediatric nurse practitioner order? a. A referral for tympanocentesis b. Amoxicillin twice daily c. Amoxicillin-clavulanate twice daily d. Intramuscular ceftriaxone

ANS: C Amoxicillin-clavulanate should be given for failed therapy with amoxicillin or when the child has had AOM treated with amoxicillin within the past month.

2. A 7-month-old infant has had two prior acute ear infections and is currently on the 10th day of therapy with amoxicillin-clavulanate after a failed course of amoxicillin. The primary care pediatric nurse practitioner notes marked middle ear effusion and erythema of the TM. The child is irritable and has a temperature of 99.8°F. What is the next step in management of this child's ear infection? a. Order a second course of amoxicillin-clavulanate. b. Perform tympanocentesis for culture. c. Prescribe clindamycin twice daily. d. Refer the child to an otolaryngologist.

ANS: D Children who have persistent infection who have failed appropriate therapy and those who have had three or more episodes of AOM in 6 months should be referred to an otolaryngologist. Ceftriaxone is ordered when Augmentin fails. The PNP does not perform tympanocentesis. Clindamycin is used for ceftriaxone failure but only if the susceptibilities are known.

11. The parent of a toddler and a 4-week-old infant tells the primary care pediatric nurse practitioner that the toddler has just been diagnosed with pertussis. What will the nurse practitioner do to prevent disease transmission to the infant? a. Administer the initial diphtheria, pertussis, and tetanus vaccine. b. Instruct the parent to limit contact between the toddler and the infant. c. Order azithromycin 10 mg/kg/day in a single dose daily for 5 days. d. Prescribe erythromycin 10 mg/kg/dose four times daily for 14 days.

ANS: C Chemoprophylaxis for pertussis exposure is recommended for all household and close contacts of infected persons regardless of immunization status. Azithromycin is the drug of choice for infants from 1 month to 6 months of age. Administering the vaccine is not indicated since there isn't sufficient time to develop immunity. Infants under 1 month of age should not receive erythromycin because of the increased risk for pyloric stenosis associated with this drug

4. A child who was treated with amoxicillin and then amoxicillin-clavulanate for acute otitis media is seen for follow-up. The primary care pediatric nurse practitioner notes dull-gray tympanic membranes with a visible air-fluid level. The child is afebrile and without pain. What is the next course of action? a. Administering ceftriaxone IM b. Giving clindamycin orally c. Monitoring ear fluid levels for 3 months d. Watchful waiting for 48 to 72 hours

ANS: C Children with AOM may have effusion up to 3 months after the acute infection. The child should be monitored to ensure that this resolves. Antibiotics are not indicated. There is no acute infection, so watchful waiting for worsening of symptoms is not indicated.

6. A 4-year-old child with an upper respiratory tract infection has cloudy nasal discharge and moderate nasal congestion interfering with sleep. The parent asks what product to use to help with symptoms. What will the primary care pediatric nurse practitioner recommend? a. Antihistamines b. Decongestant sprays c. Saline rinses d. Zinc supplements

ANS: C Normal saline nose drops, nasal rinses, or sprays are helpful for all ages of children to clear nasal passages. The use of decongestants, antihistamines, and cough medicine does not shorten the course of a disease. While their use may help with relieving nasal symptoms, their use is not recommended for children younger than 6 years old. Zinc is not recommended in children because of potential side effects and questionable efficacy.

8. A 5-year-old child has enlarged tonsils and a history of four throat infections in the previous year with fever, cervical lymphadenopathy, and positive Group A Streptococcus pyogenes (GABHS) cultures. The parent reports that the child snores at night and expresses concerns about the child's quality of sleep. The next step in managing this child's condition is to : a. continue to observe the child for two or more GABHS infections. b. prescribe prophylactic antibiotics to prevent recurrent infection. c. refer to a pulmonologist for polysomnography evaluation. d. refer to an otolaryngologist for possible tonsillectomy.

ANS: C The potential for sleep apnea should be evaluated since the parent reports snoring and concerns with sleep in a child with frequent throat infections. This child has not had a high enough number of GABHS throat infections to warrant tonsillectomy and should be watched. Prophylactic antibiotics are not indicated.

12. The primary care pediatric nurse practitioner obtains a tympanogram on a child that reveals a sharp peak of -180 mm H2O. What does this value indicate? a. A normal tympanic membrane b. Middle ear effusion c. Negative ear pressure d. Tympanic membrane perforation

ANS: C The type C tympanogram has a sharp peak between -100 and -200 mm H2O and reflects negative ear pressure. A normal tympanogram has a sharp positive peak or a type A tympanogram. Middle ear effusion and a TM perforation both cause a type B tympanogram with either no peak or a flattened wave.

15. A 14-year-old child has a 2-week history of severe itching and tearing of both eyes. The primary care pediatric nurse practitioner notes redness and swelling of the eyelids along with stringy, mucoid discharge. What will the nurse practitioner prescribe? a. Saline solution or artificial tears b. Topical mast cell stabilizer c. Topical NSAID drops 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.

12. A school-age child has an abrupt onset of sore throat, nausea, headache, and a temperature of 102.3°F. An examination reveals petechiae on the soft palate, beefy-red tonsils with yellow exudate, and a scarlatiniform rash. A Rapid Antigen Detection Test (RADT) is negative. What is the next step in management for this child? a. Consider a sexual abuse diagnosis. b. Obtain an anti-streptococcal antibody titer. c. Perform a follow-up throat culture. d. Prescribe amoxicillin for 10 days.

ANS: C While an RADT has a high specificity, it has variable sensitivity, and a negative test does not mean that streptococcal infection is not present. A culture should be performed to confirm the diagnosis. If the throat culture is negative for GABHS, other causes, such as gonococcal infection, may be considered but are less likely. The RADT does not assess for sexual abuse. An ASO titer is not useful in the diagnosis of acute pharyngitis, since the titers remain elevated for months after an acute infection. Amoxicillin is not indicated unless infection is confirmed.

6. During a well child assessment of an African-American infant, the primary care pediatric nurse practitioner notes a dark red-brown light reflex in the left eye and a slightly brighter, red-orange light reflex in the right eye. The nurse practitioner will a. dilate the pupils and reassess the red reflex. 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.

16. During a well child exam on a 4-year-old child, the primary care pediatric nurse practitioner notes that the clinic nurse recorded "20/50" for the child's vision and noted that the child had difficulty cooperating with the exam. What will the nurse practitioner recommend? a. Follow up with a visual acuity screen in 6 months. b. Refer to a pediatric ophthalmologist. c. Re-test the child in 1 year. d. Test the child's vision in 1 month.

ANS: D Children age 4 years and older who have difficulty cooperating with a vision screen should be retested in 1 month; if they continue to have difficulty cooperating, they should be referred for a formal examination. Children who are 3 years old should be re-evaluated in 6 months.

10. A school-age child has frequent nosebleeds. Nasal visualization reveals fresh clots and excoriated nasal mucosa but no visible site of bleeding. Coagulation studies are normal. In spite of symptomatic measures, the child continues to have nosebleeds. What is the next course of action? a. Cauterize the mucosa with silver nitrate sticks. b. Order a topical vasoconstrictor medication. c. Prescribe a barrier agent such as petrolatum jelly. d. Refer to an otolaryngologist for further evaluation.

ANS: D Children with persistent epistaxis should be referred for evaluation and treatment after usual symptomatic measures are ineffective. Cautery works well for exposed vessels, but the site must be easily accessible, visible, and not bleeding briskly. Topical vasoconstrictors are occasionally used. Petrolatum jelly has not been shown to be effective.

10. A toddler exhibits exotropia of the right eye during a cover-uncover screen. The primary care pediatric nurse practitioner will refer to a pediatric ophthalmologist to initiate which treatment? a. Botulinum toxin injection b. Corrective lenses c. Occluding the affected eye for 6 hours per day d. Patching of the unaffected eye for 2 hours each day

ANS: D Deviations are initially treated by patching the unaffected eye for 2 hours each day to force the affected eye to move correctly. Botulinum toxin injection may be used with some deviations but is not a first-line therapy. Corrective lenses alone improve amblyopia in 27% of patients. The unaffected eye is patched; 2 hours per day is as effective as 6 hours per day.

9. 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.

1. The primary care pediatric nurse practitioner is treating an infant with lacrimal duct obstruction who has developed bacterial conjunctivitis. After 2 weeks of treatment with topical antibiotics along with massage and frequent cleansing of secretions, the infant's symptoms have not improved. Which action is correct? a. Perform massage more frequently. b. Prescribe an oral antibiotic. c. Recommend hot compresses. d. Refer to an ophthalmologist.

ANS: D Infants treated for a secondary bacterial conjunctivitis with lacrimal duct obstruction who do not improve after 1 to 2 weeks of topical antibiotic therapy must be referred to an ophthalmologist for possible lacrimal duct probe. Performing the massage more often or applying hot compresses will not help clear the infections. Oral antibiotics are not indicated.

4. After 14 days of treatment with amoxicillin 45 mg/kg/day for acute rhinosinusitis, a child continues to have mucopurulent nasal discharge along with induration, swelling, and erythema of both eyelids. What is the next course of treatment? a. Amoxicillin 80 mg/kg/day for 14 days b. Amoxicillin-clavulanate for 10 to 14 days c. Antibiotic ophthalmic drops for 5 to 7 days d. Referral to a pediatric otolaryngologist

ANS: D The child has symptoms consistent with periorbital or preseptal inflammation and needs a referral to an otolaryngologist or infectious disease specialist. For uncomplicated persistent rhinosinusitis, amoxicillin-clavulanate should be prescribed. These symptoms are not consistent with conjunctivitis, so antibiotic eyedrops are not indicated. Although increasing the dose of amoxicillin may be part of the treatment, referral to a pediatric otolaryngologist is a priority.

17. The primary care pediatric nurse practitioner evaluates a child who awoke with a sore throat and high fever after a nap. The child appears anxious and is sitting on the parent's lap with the neck hyperextended. The physical exam reveals stridor, drooling, nasal flaring, and retractions. What will the nurse practitioner do next? a. Administer a broad-spectrum intravenous antibiotic. b. Obtain blood and throat cultures and start antibiotic therapy. c. Send the child to radiology for a lateral neck radiograph. d. Transport the child to the hospital via emergency medical services

ANS: D The child has symptoms of epiglottitis and should be transported immediately for emergency treatment via ambulance. All of the other options may be initiated at the hospital once the diagnosis is more certain. If the possibility of epiglottitis is thought to be remote, a lateral neck radiograph may be obtained prior to visualizing the throat. If epiglottitis is suspected, visualizing the throat is contraindicated.

13. The primary care pediatric nurse practitioner observes a tender, swollen red furuncle on the upper lid margin of a child's eye. What treatment will the nurse practitioner recommend? a. Culture of the lesion to determine causative organism b. Referral to ophthalmology for incision and drainage c. Topical steroid medication d. Warm, moist compresses 3 to 4 times daily

ANS: D The child has symptoms of hordeolum, or stye. Although these often rupture spontaneously, warm, moist compresses may hasten this process. It is not necessary to culture the lesion unless symptoms do not resolve. Referral to ophthalmology is made if the hordeolum does not rupture on its own. Steroids are not indicated.

9. A 5-month-old infant who has a 3-day history of cough and rhinorrhea has developed symptoms of respiratory distress with audible expiratory wheezes and increased coughing. The infant's immunizations are up-to-date. The physical exam reveals a respiratory rate of 50 breaths per minute, coarse expiratory wheezing, and prolonged expiration. An oxygen saturation is 96% on room air. What is the recommended treatment for this infant? a. Administer a trial of bronchodilators. b. Obtain a viral culture of nasal washings. c. Order an oral corticosteroid medication. d. Recommend increased fluids and close follow-up.

ANS: D The infant has bronchiolitis and is stable. Increasing fluids and following up closely are indicated as long as oxygen saturations and hydration are normal. Bronchodilator trials are not recommended because of the risk of adverse effects and questionable efficacy. Viral cultures are performed if hospitalization is necessary or when symptoms are severe. Corticosteroid medications are not indicated.

The social-interactional systemic perspective of child abuse and neglect says that the legitimization of violence in the family is due to which of the following factors? a. family pathology of a genetic nature b. increased availability of pornography c. emphasis on hiding sexuality and not being open d. societys attitudes, beliefs, and values

D

3. A school-age child is hit in the face with a baseball bat and reports pain in one eye. The primary care pediatric nurse practitioner is able to see a dark red fluid level between the cornea and iris on gross examination, but the child resists any exam with a light. Which action is correct? a. Administer an oral analgesic medication. 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. A 2-year-old child is brought to the clinic after developing a hoarse, bark-like cough during the night with "trouble catching his breath" according to the parent. The history reveals a 2 day history of low-grade fever and upper respiratory symptoms. On exam, the child has a respiratory rate of 40 breaths per minute, occasional stridor when crying, and a temperature of 101.3°F. What is the next step in treatment for this child? a. Administer intramuscular dexamethasone. b. Admit the child for inpatient hospitalization. c. Give the child a racemic epinephrine treatment in the office. d. Prescribe oral dexamethasone for 2 days.

ANS: D This child has croup with milder symptoms and may be managed at home with oral steroids. IM steroids are given to children who are vomiting. Inpatient admission is considered for children with respiratory distress (rates between 70 and 90 breaths per minute, severe retractions, and stridor at rest). Racemic epinephrine is useful for more severe symptoms, especially for stridor, but is done in the ED or hospital and should always be combined with a steroid.

13. A child has an acute infection causing lower airway obstruction. Which initial symptom is expected in this child? a. Atelectasis b. Barrel chest c. Over-inflation d. Wheezing

ANS: D Wheezing is the principal sound patients make if the obstruction allows enough air to pass through the narrowed lumen when lower airway obstruction occurs. Eventually, over-inflation and atelectasis occur. Barrel chest is the result of chronic over-inflation.

5. The primary care pediatric nurse practitioner applies fluorescein stain to a child's eye. When examining the eye with a cobalt blue filter light, the entire cornea appears cloudy. What does this indicate? a. The cornea has not been damaged. b. There is too little stain on the cornea. c. There is damage to the cornea. d. There is too much stain on the cornea.

ANS: D When fluorescein stain is applied and the entire cornea appears cloudy, it means that there is too much of the stain. Damaged areas of the cornea should appear greenish after staining with fluorescein dye.

12. A preschool-age child who attends day care has a 2-day history of matted eyelids in the morning and burning and itching of the eyes. The primary care pediatric nurse practitioner notes yellow-green purulent discharge from both eyes, conjunctival erythema, and mild URI symptoms. Which action is correct? 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.

What is the characteristic pattern of the burn in a flexion burn? a. tiger pattern b. zigzag c. concentric circles d. zebra pattern

D

A parent brings a toddler to the pediatric clinic. The nurse observes a number of bruises on the child in various stages of healing. The parent claims the toddler bruises easily. The best action on the part of the pediatrician and the nurse would be to: a. believe the parents and schedule an appointment in 2 weeks b. report this to child and family services and order a screening battery of bleeding and clotting blood work c. check with the other parent or another caregiver to see what he or she might be able to add to this history d. tell the parent that it is clear that he or she is lying and to tell the truth

B

The nurse assessing a child who is suspected of being a victim of abuse will interview the child privately and will: a. find out what the child was doing before the injuries occurred b. reassure the child that he or she is not in trouble and that the child has not done anything wrong c. tell the child that he or she has nothing to fear from the parents or the legal system d. see what the child has done in response to any abusive behavior from the parents

B

The nurse is caring for an infant who shows no distress then her parents leave, and then they return the infant ignores her parents. There was no evidence of distress while the parents were gone. This type of attachment between the infant and parents is most likely which of the following types of attachment? a. secure b. avoidant c. ambivalent d. detached

B

The nurse will establish which of the following kinds of relationships with the family and the person suspected of having Munchausen syndrome by proxy? a. distant b. trusting c. uninvolved d. opponent

B

The school nurse observes parents interacting with a school-aged child and notices that they do not show any affection toward the child and there is no evidence of emotional support or supervision. Later the nurse learns from the child that he must take care of all his own hygiene tasks, has to find something to eat on his own, and his parents never say anything nice about him. The nurse at this point believes that the parents are engaging in: a. physical abuse b. psychological abuse c. poor parenting d. withholding of love

B

What is meant by the term flexion burns? a. a burn caused by a cigarette or other hot object applied to the elbow of a bent arm b. the body part immersed in hot liquids is held in a flexed position c. the burn is so serious the child cannot flex his or her extremity d. the parent flexed his or her own arms to avoid being burned while burning the child

B

When caregivers lack knowledge about parenting, lack parenting skills, and are emotionally immature, the child often assumes which of the following roles? a. victim b. caregiver role toward the caregiver c. regressed child of regressed caregivers d. scapegoat

B

When family violence is passed from generation to generation, this type of abuse has which of the following characteristics? a. It continues without changing to another type. b. The form of abuse may change. c. It usually gets more violent. d. It is more detrimental to the child from generation to generation.

B

Which of the following children are at greatest risk of abuse or neglect by the parents? a. postmaturity babies b. 13-year-old children c. children with high intelligent quotient (IQ) d. premature infants

D

Which of the following statements best describes Munchausen syndrome by proxy? a. The child has uncontrollable facial and vocal tics as a result of emotional abuse by caregivers. b. Caregivers make up signs and symptoms of disease or unnecessarily expose their child to harmful medical interventions and painful invasive procedures. c. The parents give the children no attention unless they are exhibiting signs and symptoms of illness. d. Relatives of a child get all the attention in the family and the child is forced to fake illness to get any attention at all.

B

Which of the following statements best describes acquaintance rape or date rape? a. then two people dont love each other and engage in sexual activities b. sexual intercourse committed with force or the threat of force without a persons consent c. then someone on a date tricks the other person into having sexual intercourse d. sexual intercourse then one person engaging in the activity is unsure about wanting to do so

B

A child is brought to the pediatric clinic for immunizations for school. The parent wants the immunizations to be given in the arm. The nurse explains that at least one of the injections has to be given in the buttocks. When the nurse pulls the diaper down, the nurse sees bite marks around the genital and buttock area. Which of the following explanations is most likely? a. A neighborhood toddler is in a biting stage. b. This child is in a biting stage, and the parents bit him back to get him to stop biting. c. The child is a victim of sexual or physical abuse. d. This must have happened then the dog slept with the child.

C

A child of Russian parentage is brought to the hospital with what appears to be second-degree burns. The nurse is aware of a Russian practice of treating headaches and abdominal pain by creating a vacuum under a cup or glass then a small amount of burning material is placed on the skin. This practice is called: a. tassos b. mal de vaso c. ventosos d. veritas

C

According to the social-interactional systemic perspective of child abuse and neglect, four factors place the family members at risk for abuse. These risk factors are the family itself, the caregiver, the child, and: a. chronic poverty b. genetics c. the presence of a family crisis d. the national emphasis on sex

C

An infant is separated from his parents for a few minutes while the nurse weighs him. The infant seems distressed and looks around for the mother. The mother soothes the infant then the nurse is through weighing him. This type of attachment between mother and baby is most likely which of the following types of attachment? a. avoidant b. disorganized c. secure d. strange

C

Asian parents bring their child to the hospital with what appears to be burns or abrasions on the neck, spines, and ribs. The parents use the words cao gao. The nurse is aware that these physical findings and the term cao gao refers to: a. an Asian practice of burning and inflicting pain on children who wont obey b. parents rubbing a pumice stone over a childs body to sand off evil spirits c. rubbing a coin or a spoon heated in oil on an ill childs neck, spine, and ribs d. burning incense on a rice paper on a childs upper body to bring good luck

C

Nudity, disrobing, and genital exposure by an adult in front of a child, as well as observing a child undressed, sexual touching, and contact for prostitution or child pornography, are said to be: a. traumatization b. familarization c. exploitation d. fraternization

C

The adult abuser who receives a diagnosis of Munchausen syndrome by proxy: a. is the victim of unnecessary medical treatment at the hands of another adult b. was the victim of unnecessary treatment in the past and now carries this pattern on c. uses this disease to escape from poor self-esteem, marital, physical, or mental problems d. is an uncaring and cunning individual who has psychological problems similar to antisocial behavior

C

The majority of perpetrators of abuse to children reported to state Child Protective Service agencies as suspected victims of abuse and neglect are: a. neighbors within one block b. strangers c. parents d. relatives other than parents

C

When there is a depressed parent in the family, it is most likely that the depression will have which of the following effects? a. will not affect the persons ability or performance in parenting b. will cause the parent who is depressed to try harder to be a good parent c. places the parent at risk for physically or emotionally abusing the children d. will be seen in the child during the growing-up years

C

Which of the following explains why children between the ages of 1 and 5 are more at risk than older children for getting serious burn injuries? a. They tend to aggravate and make their parents angry more than older children do. b. Children this age are small and cannot fight back then parents are abusive. c. The skin of a child is thinner and much more sensitive than an adults skin. d. Children this age are more curious and tend to get into things very quickly.

C

Which of the following statements best describes child abandonment? a. leaving town quickly and never looking back b. failure to pick up children promptly then others are caring for them or failure to let the children know there you are c. desertion of a child without arranging for reasonable care and providing no communication about caregivers location d. caregivers intentionally withholding, without cause or excuse, care, presence, love, protection, maintenance, and affection

C

Which of the following is a classic sign of shaken baby syndrome? a. chills and fever b. fear and withdrawal c. edema of the extremities and bloated appearance to the abdominal area of the body d. retinal hemorrhage, usually bilaterally with subdural or subarachnoid hemorrhages

D

Which of the following signs or symptoms would most lead the nurse to believe a child is being psychologically abused? a. working hard to get along well with other children b. high self-esteem and good academic performance c. a close peer group since preschool d. self-defeating and self-mutilating behaviors

D

Which of the following statements best describes child neglect? a. not giving ones child all the toys and advantages that other parents provide b. not sending a brilliant child to college or otherwise providing for the childs future c. not providing special dance lessons or music lessons then the child asks for these lessons d. then a child experiences predictable injury or impairment because of caregiver inattention

D

A child comes to the clinic with bruises that are yellow-brown and fading. Based on the characteristics of these bruises, how old is the injury? a. 3 days b. 4 days c. 6 days d. over 1 week

D

A father calls emergency medical services (EMS) for his 1-year-old infant who was vomiting and then experienced a series of seizures. Upon admission to the hospital, the infant was listless and irritable, had bradycardia, and had periods of apnea. The infant has now lapsed into a coma. Which of the following conditions will the nurse and the health care team members suspect and most want to rule out? a. spinal meningitis b. encephalitis c. fever-induced seizures d. shaken baby syndrome (SBS)

D

Incest is most likely to occur between: a. family members in a household of poverty b. parents and children c. high achievers d. siblings

D