37,

6. During a well child examination of an infant, the primary care pediatric nurse practitioner notes 10 café au lait spots on the infant's trunk. What is the potential concern associated with this finding? a. Endocrine disorders b. Malignancy c. Neurofibromatosis d. Sturge-Weber syndrome

ANS: C Café au lait spots are significant for neurofibromatosis and should be referred if more than 5 lesions are present. Atypical nevi are concerning for malignancy. Port-wine stains are concerning for Sturge-Weber syndrome. Acanthosis is a sign of diabetes.

21. A child will need an occlusive dressing to treat lichen simplex chronicus. What will the primary care pediatric nurse practitioner tell the parents about applying this treatment? a. Apply ointment before the dressing. b. Plastic wrap should not be used. c. The dressing should be applied to dry skin. d. Change the dressing twice daily.

ANS: A Occlusive dressings are placed over creams and ointments to enhance hydration and absorption of topical medications. Plastic wrap is often used. The medications and dressings should be applied to damp skin. The dressing should not be left on more than 8 hours.

12. A child who has psoriasis, who has been using a moderate-potency topical steroid on thick plaques on the extremities and a high-potency topical steroid on more severe plaques on the elbows and knees, continues to have worsening of plaques. In consultation with a dermatologist, which treatment will be added? a. Anthralin ointment in high strength applied for 10 to 30 minutes daily b. Calcipotriol cream applied liberally each day to the entire body c. Oral steroids and methotrexate therapy until plaques resolve d. Wideband ultraviolet therapy for 15 minutes twice daily

ANS: A Anthralin ointment is useful for plaques that are resistant to steroids. Calcipotriol cream is effective for mild to moderate plaques, but when applied in excessive quantities over large areas can cause hypercalcemia. Oral steroids are not indicated and may worsen symptoms by causing pustular flare. Methotrexate is used for severe disease, and these symptoms indicate that this is moderate disease. If UV light is used, narrowband UVB light therapy is preferred in children for safety and efficacy.

22. A previously healthy school-age child develops herpes zoster on the lower back. What will the primary care pediatric nurse practitioner do to manage this condition? a. Order Burow solution and warm soothing baths as comfort measures. b. Prescribe oral acyclovir 30 mg/kg/day in 4 doses/day for 5 days. c. Recommend topical antihistamines to control itching. d. Stress the need to remain home from school until the lesions are gone.

ANS: A Children with herpes zoster should be treated with comfort measures (symptomatic treatment). Oral acyclovir is not recommended for all children but may be useful in children who are immunosuppressed or have more severe forms. Topical antihistamines are used with caution in children because of the risk of toxicity. If the lesions can be covered, children do not need to be kept home from school.

26. An adolescent who had cradle cap as an infant is in the clinic with thick crusts of yellow, greasy scales on the forehead and behind the ears. What will the primary care pediatric nurse practitioner recommend? a. Daily application of ketoconazole 2% topical cream b. High-potency topical corticosteroids applied daily c. Mineral oil and shampoo on the affected areas d. Selenium sulfide shampoo twice weekly to the face

ANS: A For facial dermatitis, daily ketoconazole 2% topical cream may be used. If steroids are prescribed, only low-dose steroids should be used on the face. Mineral oil and shampoo are recommended for cradle cap in infants. Selenium sulfide shampoo is used for scalp dermatitis.

7. A child is diagnosed with tinea versicolor. What is the correct management of this disorder? a. Application of selenium sulfide 2.5% lotion twice weekly for 2 to 4 weeks b. Oral antifungal treatment with fluconazole once weekly for 2 to 3 weeks c. Sun exposure for up to an hour every day for 2 to 4 weeks d. Using ketoconazole 2% shampoo on lesions twice daily for 2 to 4 weeks

ANS: A Selenium sulfide lotion or 1% shampoo is first-line treatment for children and younger adolescents. Oral antifungal medications are used in resistant cases in older adolescents. Sun exposure only intensifies lesions. Ketoconazole shampoo is used on older adolescents.

4. A child who has been taking antibiotics is brought to the clinic with a rash. The parent reports that the child had a fever associated with what looked like sunburn and now has "blisters" all over. A physical examination shows coalescent target lesions and widespread bullae and areas of peeled skin revealing moist, red surfaces. What will the primary care pediatric nurse practitioner do? a. Consult with a pediatric intensivist for admission to a pediatric intensive care unit. b. Order oral acyclovir 20 mg/kg/day in two doses for 6 to 12 months. c. Prescribe systemic antihistamines and antimicrobial medications as prophylaxis. d. Recommend analgesics, cool compresses, and oral antihistamines for comfort.

ANS: A This child has symptoms consistent with toxic epidermal necrolysis, which is potentially life-threatening. Children with symptoms should be admitted to the PICU for management. The other options are treatments for erythema multiforme, a more benign, viral-induced rash. Oral acyclovir is given when herpes simplex infection is possible.

16. A 9-month-old infant has vesiculopustular lesions on the palms and soles, on the face and neck, and in skin folds of the extremities. The primary care pediatric nurse practitioner notes linear and S-shaped burrow lesions on the parent's hands and wrists. What is the treatment for this rash for this infant? a. Ivermectin 200 mcg/kg for 7 to 14 days, along with symptomatic treatment for itching b. Permethrin 5% cream applied to face, neck, and body and rinsed off in 8 to 14 hours c. Treatment of all family members except the infant with permethrin 5% cream and ivermectin d. Treatment with permethrin 5% cream for 7 days in conjunction with ivermectin 200 mcg/kg

ANS: B Permethrin 5% cream is the drug of choice for treating scabies and is intended for use in infants as young as 2 months of age. Infants will get lesions on the face and neck, and permethrin may be applied to the face, avoiding the eyes. Ivermectin is not recommended for children under 5 years old. Treatment must include the infant as well as all family members whether symptomatic or not.

1. A 3-year-old child has head lice. What will the initial treatment recommendation be to treat this child? a. Lindane b. Permethrin c. Pyrethrin d. Spinosad

ANS: B Permethrin is the treatment of choice for head lice because of its safety and efficacy. Pyrethrin has more treatment failures and is not the first-line treatment. Lindane has neurotoxic side effects and is only recommended when treatment failure occurs. Spinosad is used in children 4 years and older

11. A child is brought to clinic with several bright red lesions on the buttocks. The primary care pediatric nurse practitioner examines the lesions and notes sharp margins and an "orange peel" look and feel. The child is afebrile and does not appear toxic. What is the course of treatment for these lesions? a. Hospitalize the child for intravenous antibiotics and possible I&D of the lesions. b. Initiate empiric antibiotic therapy and follow up in 24 hours to assess response. c. Obtain blood cultures prior to beginning antibiotic treatment. d. Perform gram stain and culture of the lesions before initiating antibiotics.

ANS: B The child has clinical signs of erysipelas, which is a superficial variant of cellulitis. Because the child is afebrile and doesn't appear toxic, outpatient antibiotics with 24-hour follow-up can be initiated. If the child does not respond or becomes toxic, hospitalization and IV antibiotics are indicated. Blood cultures rarely are positive. Gram stain and cultures are performed if unusual organisms are suspected or if pus is present.

13. The primary care pediatric nurse practitioner notes velvety, brown thickening of skin in the axillae, groin, and neck folds of an adolescent Hispanic female who is overweight. What is the initial step in managing this condition? a. Consultation with a pediatric dermatologist b. Performing metabolic laboratory tests c. Prescribing topical retinoic acid cream d. Referral to a pediatric endocrinologist

ANS: B The initial step is to determine whether metabolic syndrome is the underlying cause for these lesions, which, according to the other physical findings, is most likely. If hyperinsulinemia is present, referral to a pediatric endocrinologist is the next step. A dermatology referral is not indicated. Unless the lesions are thick or cause discomfort, prescribing retinoic acid is not necessary.

14. A pre-school age child has honey-crusted lesions on erythematous, eroded skin around the nose and mouth, with satellite lesions on the arms and legs. The child's parent has several similar lesions and reports that other children in the day care have a similar rash. How will this be treated? a. Amoxicillin 40 to 5 mg/kg/day for 7 to 10 days b. Amoxicillin-clavulanate 90 mg/kg/day for 10 days c. Bacitracin cream applied to lesions for 10 to 14 days d. Mupirocin ointment applied to lesions until clear

ANS: B When children have multiple impetigo lesions or non-bullous impetigo with infection in multiple family members or child care groups, oral antibiotics are indicated. Amoxicillin-clavulanate is a first-line drug for this indication. Amoxicillin is not used for skin infections. Bacitracin is bacteriostatic and may be used when only a few lesions are present and if bacterial resistance is not an issue. Mupirocin is used for mild impetigo when the case is isolated.

15. The primary care pediatric nurse practitioner is teaching a parent of a child with dry skin about hydrating the skin with bathing. What will the nurse practitioner include in teaching? a. Apply lubricating agents at least 1 hour after the bath. b. Have the child soak in a lukewarm water bath. c. Keep the child in the bath until the skin begins to "prune." d. Soaping should be done at the beginning of the bath.

ANS: B When using bathing to hydrate dry skin, lukewarm water should be used. Lubricating agents should be applied immediately after patting the skin dry. The bath should last long enough to allow the skin to become moisturized without becoming supersaturated or "pruned." Soaping and shampooing should be performed at the end of the bath followed by thorough rinsing.

8. An African-American child has recurrent tinea capitis and has just developed a new area of alopecia after successful treatment several months prior. When prescribing treatment with griseofulvin and selenium shampoo, what else will the primary care pediatric nurse practitioner do? a. Monitor CBC, LFT, and renal function during therapy. b. Order oral prednisone daily for 5 to 14 days. c. Perform fungal cultures on family members and pets. d. Prescribe oral itraconazole or terbinafine.

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

24. A child is brought to the clinic with a generalized, annular rash characterized by raised wheals with pale centers. On physical examination, the child's lungs are clear and there is no peripheral edema. A history reveals ingestion of strawberries earlier in the day. What is the initial treatment? a. Aqueous epinephrine 1:1000 subcutaneously b. Cetirizine once in clinic and then once daily for 2 weeks c. Diphenhydramine 0.5 to 1 mg/kg/dose every 4 to 6 hours d. Prednisone 1 to 2 mg/kg/day for 1 week with rapid taper

ANS: C Diphenhydramine is given initially as long as anaphylaxis and angioedema are not present. Aqueous epinephrine is used for anaphylaxis and angioedema. Cetirizine is less effective than diphenhydramine. Prednisone is used for refractory episodes.

27. A school-age child is brought to clinic after a pediculosis capitis infestation is reported at the child's school. If this child is positive, what will the primary care pediatric nurse practitioner expect to find on physical examination, along with live lice near the scalp? a. Excoriated macules along the child's collar and underwear lines b. Inflammation and pustules on the face and neck c. Itching of the scalp, with skin excoriation on the back of the head d. Linear or S-shaped lesions in webs of fingers and sides of hands

ANS: C Head lice commonly cause itching of the scalp, especially on the back of the head and neck, along with skin excoriation, and may be the only initial sign. Excoriated lesions along underwear lines are typical of body lice. Inflammation and pustules occur with acne. Linear or S-shaped lesions occur with scabies infestations.

2. An adolescent has acne with lesions on the cheeks and under the chin. Which distribution is this? a. Athletic b. Frictional c. Hormonal d. Pomadal

ANS: C Hormonal acne has a beard distribution. Athletic acne occurs on the forehead, chin, and shoulders, caused by helmets and pads. Frictional occurs where bras, tight clothes, and headbands rub. A pomadal distribution occurs along the temple and forehead, as a result of pomades or oil-based cosmetics.

23. A child has small, firm, flesh-colored papules in both axillae which are mildly pruritic. What is an acceptable initial approach to managing this condition? a. Application of trichloroacetic acid 25% to 50% using a dropper b. Applying liquid nitrogen for 2 to 3 seconds to each lesion c. Reassuring the parents that these are benign and may disappear spontaneously d. Referral to a dermatologist for manual removal of lesions with curettage

ANS: C Molluscum contagiosum is a benign viral skin infection; most lesions disappear within 6 months to 2 years. An initial "wait and see" approach is acceptable. If itching is severe, the risk is autoinoculation and spread of lesions, along with increased discomfort and then other treatment measures may be attempted, depending on the severity. Topical medications, such as trichloroacetic acid or liquid nitrogen may be used if the lesions become uncomfortable or persist and should be used with caution. More severe outbreaks may require removal with curettage.

18. A school-age child has a rash without fever or preceding symptoms. Physical examination reveals a 3-cm ovoid, erythematous lesion on the trunk with a finely scaled elevated border, along with generalized macular, ovoid lesions appearing in a "Christmas tree" pattern on the child's back. What is the initial action? a. Obtain a KOH preparation of a skin scraping to verify the diagnosis. b. Prescribe topical steroid creams to shorten the course of the disease. c. Reassure the child's parents that the rash is benign and self-limited. d. Recommend topical antihistamines and emollients to control the spread

ANS: C This rash is typical of pityriasis rosea, a benign, self-limited papulosquamous disease that is not contagious. Patients may be reassured that this is the case. Because the herald lesion is characteristic, it is not necessary to obtain a KOH scraping to look for tinea corporis. Topical steroids do not alter the course of the disease. Topical antihistamines and emollients may be used if itching occurs, but this is not the initial management action.

5. An adolescent has acne characterized by papules and pustules mostly on the forehead and chin. What will the primary care pediatric nurse practitioner prescribe? a. Azelaic acid applied daily at nighttime b. Benzoyl peroxide applied twice daily c. Topical erythromycin with benzoyl peroxide d. Tretinoin applied nightly after washing the face

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

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

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

3. An infant is brought to clinic with bright erythema in the neck and flexural folds after recent treatment with antibiotics for otitis media. What is the treatment for this condition? a. 1% hydrocortisone cream to affected areas for 1 to 2 days b. Oral fluconazole 6 mg/kg on day 1, then 3 mg/kg/dose for 14 days c. Topical keratolytics and topical antibiotics for 7 to 10 days d. Topical nystatin cream applied several times daily

ANS: D Candida skin infections can occur in intertriginous areas in the neck, axilla, and groin, and appear as a bright erythematous rash. Topical nystatin is first-line therapy. Fifteen percent hydrocortisone is used if inflammation is severe but not instead of topical antifungal therapy. Oral fluconazole is used if resistant to treatment. Keratolytics and antibiotics are used to treat superficial folliculitis.

17. An adolescent female has grouped vesicles on her oral mucosa. To determine whether these are caused by HSV-1 or HSV-2, the primary care pediatric nurse practitioner will order which test? a. Direct fluorescent antibody test b. Enzyme-linked immunosorbent assay c. Tzanck smear d. Viral culture

ANS: D Oral lesions are possible with both forms of herpesvirus. Viral culture is the gold standard for distinguishing HSV-1 from HSV-2. DFA and ELISA are usually used only with severe forms of infection. Tzanck smear dose not distinguish HSV-1 from HSV-2.

19. An adolescent who recently spent time in a hot tub while on vacation has discrete, erythematous 1- to 2-mm papules that are centered around hair follicles on the thighs, upper arms, and buttocks. How will the primary care pediatric nurse practitioner manage this condition? a. Culture the lesions and treat with appropriate IM antibiotics. b. Hospitalize for incision and drainage and intravenous antibiotics. c. Order an antistaphylococcal beta-lactamase-resistant antibiotic. d. Prescribe topical keratolytics and topical antibiotics.

ANS: D This adolescent has hot-tub folliculitis that is superficial at this point and may be treated with topical keratolytics and topical antibiotics. Culture is indicated if the lesions are resistant to treatment. IV and oral antibiotics and I&D are indicated for more severe episodes.

9. A 4-year-old child has clusters of small, clear, tense vesicles with an erythematous base on one side of the mouth along the vermillion border, which are causing discomfort and difficulty eating. What will the primary care pediatric nurse practitioner recommend as treatment? a. Mupirocin ointment applied to lesions 3 times daily b. Oral acyclovir 20 to 40 mg/kg/dose for 7 to 10 days c. Topical acyclovir applied to lesions 4 times daily d. Topical diphenhydramine and magnesium hydroxide

ANS: D This child has lesions consistent with HSV-1. Topical anesthetics may be used for comfort and may be applied with cotton-tipped swabs. Mupirocin ointment is used for secondary bacterial infection. Oral acyclovir is used in more severe cases and most often with HSV-2. Topical acyclovir is useful for initial genital herpes infections.

25. A child has an area of inflammation on the neck that began after wearing a hand-knot woolen sweater. On examination, the skin appears chafed with mild erythematous patches. The lesions are not pruritic. What is an appropriate initial treatment? a. Application of a lanolin-based emollient b. Burow solution soaks and cool compresses c. Oral antihistamines given 4 times daily d. Topical corticosteroids applied 2 to 3 times daily

ANS: D Topical corticosteroids are useful for contact dermatitis. Lanolin-based emollients are contraindicated when inflammation is present. Burow solution soaks are useful for vesicular rashes. Oral antihistamines are not indicated unless itching and scratching occur.

10. A school-age child has several annular lesions on the abdomen characterized by central clearing with scaly, red borders. What is the first step in managing this condition? a. Fluoresce the lesions with a Wood's lamp. b. Obtain fungal cultures of the lesions. c. Perform KOH-treated scrapings of the lesion borders. d. Treat empirically with antifungal cream.

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