Burns Chapter 22, 31, 33, 26, 28, 7, 24, 19

The primary care pediatric nurse practitioner is evaluating an 11-month-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. "Although it is likely, based on family history, it is too soon to tell." b. "There is little reason to suspect that your infant has asthma." c. "With your infant's history of bronchiolitis, asthma is very likely." 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.

A 10-month-old infant who is new to the clinic has chronic hepatitis B infection. What will the primary care pediatric nurse practitioner do to manage this infant's disease? a. Consult a pediatric infectious disease specialist. b. Prescribe interferon-alfa. c. Provide supportive care. d. Consider use of lamivudine.

ANS: A A specialist in hepatitis B in children should be consulted for children with chronic hepatitis B infection because of the risk for developing hepatocellular carcinoma. Interferon-alfa and lamivudine are not used in infants. Supportive care only is not recommended.

The primary care pediatric nurse practitioner sees a child for follow-up care after hospitalization for acute rheumatic Fever (ARF). The child has polyarthritis but no cardiac involvement. What will the nurse practitioner teach the family about ongoing care for this child? a. Aspirin (ASA) is given for 2 weeks and then tapered to discontinue the medication. b. Prophylactic amoxicillin will need to be given for 5 years. c. Steroids will be necessary to prevent development of heart disease. 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.

A 12-year-old child is brought to the clinic with joint pain, a 3-week history of low-grade fever, and a facial rash. The primary care pediatric nurse practitioner palpates an enlarged liver 2 cm below the subcostal margin along with diffuse lymphadenopathy. An antinuclear antibody (ANA) test is positive. Which test may be ordered to confirm a diagnosis of systemic lupus erythematous (SLE)? a. Anti-double-strand DNA antibodies b. Anti-La antibodies c. Anti-Ro antibodies 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. Anti-SM antibodies are diagnostic of SLE but are only seen in 30% of patients with systemic lupus erythematous (SLE).

The primary care pediatric nurse practitioner is discussing fitness and exercise with the parents of a 5-year-old child who ask what kinds of activities are developmentally appropriate for their child. What will the nurse practitioner recommend? a. Bike riding b. Interactive play c. Martial arts d. Organized sports

ANS: A Bike riding away from traffic or with parents is a good activity for the preschool to early school-age child. Interactive play is recommended for toddlers. Martial arts and organized sports are recommended for school-age children.

Which lab value is most concerning in an infant with fever and a suspected bacterial infection? a. C-reactive protein of 11.5 mg/L b. Lymphocyte count of 8.7 c. Platelet count of 475 d. White blood cell count of 14

ANS: A CRP levels are non-specific acute phase indicators of inflammation with low diagnostic value except in predicting the likelihood of sepsis in infants, especially when the level is greater than 10 mg/L. Elevated lymphocyte, platelet, or WBC counts help with the differential diagnosis, but these values are not especially concerning.

The parent of a 14-year-old child asks the primary care pediatric nurse practitioner how to help the child prevent injuries when basketball tryouts begin later in the school year. Which recommendation will be of most benefit? a. Preseason conditioning b. Proper footwear c. Protective knee braces d. Stretching before practices

ANS: A Conditioning in the preseason is one of the most important things children can do to build muscle strength, to prevent sports injuries, and to learn how to make twisting, jumping, and landing movements safely. Proper footwear is also recommended but is not the most important. Protective knee braces may be worn but do not prevent injury. Stretching should be done after warming up to maintain flexibility.

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.

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. Order a CBC with differential and platelets and quantitative immunoglobulins. b. Order candida and pneumococcal skin tests and lymphocyte surface markers. c. Refer the infant to an immunologist for evaluation of immunodeficiency. 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.

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. Order an intranasal corticosteroid to begin 1 to 2 weeks prior to pollen season. b. Prescribe a decongestant medication as adjunct therapy during pollen season. c. Recommend adding diphenhydramine to the child's regimen for additional relief. 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 allergic rhinitis (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.

A 4-year-old child has just been released from the hospital after orthopedic surgery on one leg following a bicycle accident. The child is sitting quietly on the exam table. When asked to rate pain, the child points to the "1" on a faces rating pain scale. What will the primary care pediatric nurse practitioner do next? a. Assess the child's vital signs and ability to walk without pain. b. Refill the prescription for a narcotic analgesic medication. c. Suggest that the parents give acetaminophen for mild pain. d. Teach the parent to give analgesics based on the child's report of pain.

ANS: A Many children underreport pain because of fears of injections or of rehospitalization and other concerns, and reliance on self-report alone is insufficient. The PNP should evaluate other indications of pain as well before making a clinical decision. Parents should also be taught to assess a variety of factors when deciding when to give analgesics.

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.

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. Moisturizers b. Oral antihistamines c. Topical corticosteroids 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.

The primary care pediatric nurse practitioner is reviewing medical records for a newborn that is new to the clinic. The toddler's mother was found to be HIV positive during her pregnancy with this child and received antiretroviral therapy during pregnancy. The child was born by cesarean section, begun on anti-retroviral prophylaxis, and did not breastfeed. What is the correct management for this child? a. Consult with a pediatric HIV specialist. b. Discontinue cART after 4 weeks of age. c. Obtain a CD4+ cell count and HIV RNA levels. d. Reinforce the need to give cART for life.

ANS: A PNPs may manage infants exposed in utero to HIV but should do so in consultation with a pediatric HIV specialist. cART should be given for 6 weeks. Lab work is ordered according to protocol at the direction of the specialist. Many children who are treated according to the protocol do not become HIV positive.

The primary care pediatric nurse practitioner is performing a well child examination on a high school age adolescent who plays football who has hypercalciuria. Which dietary supplement will the nurse practitioner question the adolescent about? a. Protein supplements b. Salt tablets c. Sports drinks d. Vitamin C

ANS: A Protein supplements can cause hypercalciuria with calcium loss and dehydration if protein intake is too high. Salt tablets can cause hypernatremia and delayed gastric emptying. Sports drinks are high in sugar and electrolytes, which will not affect the calcium content of the urine. It is not necessary to take vitamin C.

The primary care pediatric nurse practitioner is discussing lifestyle changes with an adolescent who has hypertension. What will the nurse practitioner recommend about exercise for this client? a. Regular to vigorous activity initially with a combination of resistance and aerobic exercise to maintain lower blood pressure b. Moderate daily exercise such as walking for 20 minutes daily with increasing intensity as blood pressure drops c. Vigorous aerobic exercise combined with maximal strength training to lower blood pressure d. Vigorous aerobic exercise only to reduce blood pressure and then to maintain lowered blood pressure

ANS: A Regular to vigorous physical activity for 30 minute 3 days per week helps to lower blood pressure. Resistance training may be combined with aerobic exercise after blood pressure is lowered to help maintain lowered blood pressure. Strength training is contraindicated in children with hypertension.

An unimmunized school-age child whose mother is in her first trimester of pregnancy is diagnosed with rubella after a local outbreak. What will the primary care pediatric nurse practitioner recommend? a. Assessment of maternal rubella titers b. Intravenous immunoglobulin for the child c. MMR vaccine for the mother and child d. Possible termination of the pregnancy

ANS: A Reinfection or revaccination with rubella for pregnant women rarely results in congenital rubella syndrome, and these are not a reason for pregnancy termination. Maternal rubella antibody titers should be assessed. MMR vaccine is not given during pregnancy. IVIG is not indicated; rubella rarely has serious sequelae in children.

A pharmaceutical company has developed a new drug that was tested only on adults. The Federal Drug Administration (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.

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. Add a daily inhaled corticosteroid. b. Administer 3 SABA treatments. c. Continue the current treatment. 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%.

A child is brought to the clinic with a fever, headache, malaise, and a red, annular macule surrounded by an area of clearing and a larger, erythematous annular ring. The child complains of itching at the site. What will the primary care pediatric nurse practitioner do to determine the diagnosis? a. Ask about recent tick bites b. Obtain a skin culture c. Order blood cultures d. Perform serologic testing

ANS: A The presence of an erythema migrans rash with a positive history is diagnostic for Lyme disease, and no further testing is necessary. Because Borrelia burgdorferi is transmitted to humans through ticks, asking about recent tick bites is paramount to making this diagnosis. Skin and blood cultures are not indicated. Serology testing for IgG and IgM antibodies may be performed if the child is symptomatic without the characteristic EM rash.

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 Henoch-Schönlein Purpura (HSP). What ongoing evaluation will the nurse practitioner perform during the course of this disease? a. Antinuclear antibody (ANA)titers b. Blood pressure measurement c. Chest radiographs d. Liver function studies (LFTs)

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.

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 twice- daily 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 rules.

The primary care pediatric nurse practitioner is performing a pre-participation sports physical examination on a 14-year-old male who will be on the wrestling team at school. What will the nurse practitioner include when discussing healthy practices with this adolescent? a. Risks associated with repeatedly losing and gaining weight b. The need for an electrocardiogram or echocardiogram prior to participation c. The need to consume 20 to 30 grams of protein after exercise d. To consume water with CHO prior to activity lasting up to an hour

ANS: A Wrestlers often try to lose weight rapidly prior to wrestling matches to put themselves into a lower weight category. It is important to teach young athletes about the risks associated with repeated weight loss and gain. ECG and echocardiograms are not recommended as a requirement for all pre-participation physical exams unless there is an indication for doing so, such as with syncope or murmurs. Athletes do not need to consume 10 to 20 grams of protein after exercise; complex carbohydrates are recommended to improve muscle glycogen resynthesis. Plain water is recommended before, during, and after all activity lasting up to an hour.

1. What new vaccine delivery systems are being investigated? (Select all that apply.) a. Skin-patch b. Edible c. Nasal d. Rectal e. Topical

ANS: A, B, C New vaccine delivery systems are being investigated that include skin-patch vaccines, edible vaccines, additional applications for nasal delivery, and needle-free injections.

What reasons are commonly given by parents and caregivers for failing to have their children vaccinated? (Select all that apply.) a. Religious beliefs b. Distrust of government agencies c. Immunizations are too expensive d. Believed connection to the development of autism e. Inoculation is too physically and emotionally traumatic

ANS: A, B, D, E Parents commonly express concerns that vaccines are not safe and may cause autism, overload or are traumatic for children. Others distrust government agencies or have personal religious beliefs against immunization. Cost is not a commonly expressed concern.

What interventions does the primary provide for a child diagnosed with several complex health conditions? (Select all that apply.) a. Maintaining the child's routine vaccinations as well as a yearly flu shot b. Providing diagnosis and treatment for the child's acute onset of ear fullness and pain c. Providing an explanation regarding the use and care of the client's respiratory support equipment d. Referring the child to a respiratory specialist to deal with exacerbation of asthma symptomology e. Discussing the expected physical implications of puberty with the patient's parents

ANS: A, B, D, E Primary care is needed for routine vaccinations, common disease management, referrals, and family support and guidance Education regarding specialized equipment would be handled under the directive of tertiary care services.

Support for a child with complex health issues may require the use of what high level tech equipment? a. Urinary catheter b. Enteral feeding pump c. A handheld magnifier d. Crutches

ANS: B An enteral feeding pump is an example of a high level/complex tech equipment used to support a child with a complex medical history. All the other options, while helpful, are considered low tech because of their lack of significant technology.

The primary care pediatric nurse practitioner is managing care for a child who has been diagnosed with juvenile idiopathic arthritis (JIA) has a positive antinuclear antibody (ANA). Which specialty referral is critical for this child? a. Cardiology b. Ophthalmology c. Orthopedics 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.

A 10-year-old is hit in the head with a baseball during practice and is diagnosed with concussion, even though no loss of consciousness occurred. The primary care pediatric nurse practitioner is evaluating the child 2 weeks after the injury and learns that the child is still experiencing some sleepiness every day. The neurological exam is normal. The child and the parent are adamant that the child be allowed to return to play baseball. What will the nurse practitioner recommend? a. Continuation of cognitive rest only b. Continuation of physical and cognitive rest c. Continuation of physical rest only d. Returning to play

ANS: B Both physical and cognitive rest is indicated after diagnosis of concussion in youth, particularly if symptoms continue following injury. Cognitive recovery may lag behind physical recovery and is a key factor in return-to-play decisions. Only after all symptoms resolve may athletes progress through steps to gradually return to play.

The parent of a child who has asthma asks the primary care pediatric nurse practitioner about whether the child may engage in strenuous exercise. What will the nurse practitioner tell the parent? a. Children with asthma should be excluded from vigorous exercise and most strenuous sports. b. Children with asthma show improved aerobic and anaerobic fitness with moderate to vigorous/physical activity. c. Physical activity has been shown to improve overall pulmonary function in children with asthma. d. Vigorous exercise helps improve symptoms in children with poorly controlled asthma.

ANS: B Children with mild or well-controlled asthma may participate in moderate to vigorous sports and show benefits to aerobic and anaerobic fitness, which helps lung function and overall health outcomes. It is not necessary to exclude children with asthma from sports as long as symptoms are well controlled. Overall pulmonary function does not substantially improve with exercise. Children with poor control should not engage in sports until symptoms are under control.

A child with a history of a pustular rash at the site of a cat scratch on one arm now has warm, tender, swollen axillary lymph nodes on the affected side. The primary care pediatric nurse practitioner notes induration and erythema of these nodes. What will the nurse practitioner do? a. Obtain a complete blood count and C-reactive protein. b. Order an immunofluorescent assay (IFA) for serum antibodies. c. Perform a needle aspiration of the affected lymph nodes. d. Prescribe a 5-day course of azithromycin.

ANS: B IFA shows a good correlation with cat-scratch fever disease and is useful for a more definitive diagnosis. A complete blood count and C-reactive protein are non-specific indicators of disease. Needle aspiration is only necessary to determine whether local lymph nodes are infected. Antibiotics are not given unless nodes are infected.

The primary care pediatric nurse practitioner is examining a young child who has cerebral palsy. Which part of the family history raises concerns about potential child maltreatment? a. Child attends day care b. Limited financial resources c. Mother works outside the home d. No membership in a church

ANS: B Limited financial resources can put a strain on caring for a child with special needs whose medical needs are expensive. The fact that the mother works outside the home and the child attends day care may actually provide some respite from the strain of caring for a special needs child. Families may have strong spiritual values whether they attend church or not.

The primary care pediatric nurse practitioner is evaluating a heart murmur during a pre-participation examination of a high school athlete. Which finding would be a concern requiring referral to a cardiologist? a. A murmur that is louder when squatting and softer when standing b. A murmur that is quieter when squatting and louder with a Valsalva maneuver c. A murmur with narrow and variable splitting of S2 d. A systolic murmur that is grade 1 or 2

ANS: B Normally, squatting will increase venous return to the heart and cause murmurs to be louder, while standing or performing a Valsalva maneuver will cause murmurs to be quieter. If the reverse is true, then hypertrophic cardiomyopathy or mitral valve prolapse must be ruled out. A murmur with a wide or fixed splitting of S2 must be evaluated. A split S2 that is variable, particularly in synchrony with respirations, is common, and a narrow S2 split is of less concern but should be monitored over time. Systolic murmurs of grade 3 or greater must be evaluated by specialists; however, murmurs of grades 1 and 2 do not need to be evaluated by a cardiologist.

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 what form of juvenile idiopathic arthritis (JIA)? a. enthesitis-related JIA. b. oligoarticular JIA. c. polyarticular JIA. 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.

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. Complete remission occurs in some children at the age of puberty. b. Periods of remission may occur but there is no permanent cure. c. SLE can be cured with effective medication and treatment. 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.

Which complex health condition is the result of a chromosomal defect causing varied physical and emotional symptoms? a. Cerebral palsy b. Prader-Willi syndrome c. Cystic fibrosis d. Diabetes

ANS: B Prader-Willi syndrome is chronic, complex disorder that is a result of a chromosomal defect. Cerebral palsy is related to a neuromotor disorder. Cystic fibrosis is a respiratory disorder while diabetes is considered metabolic in mature.

The parent of a school-age child who is diagnosed with oligoarticular juvenile idiopathic arthritis (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. Running b. Swimming c. Weights d. Yoga

ANS: B Swimming is an excellent exercise for children with juvenile idiopathic arthritis (JIA) because water therapy and the use of heat or cold reduce pain and stiffness, unless they have severe anemia or cardiac involvement.

What is the criteria for Supplemental Security Income (SSI) approval? a. The existing impairment is chronic b. The impairment is life threatening c. The family is unable to cover health care costs d. The child is a ward of the state

ANS: B The Supplemental Security Income (SSI) program provides financial help with care costs if the child has severe functional limitations caused by a physical and/or cognitive impairment likely to last longer than one year or result in the child's death. None of the other options, while impactful, are criteria for SSI assistance.

A child who is immunocompromised has a fever and a rash consisting of macules, papules, and pustules. What will the primary care pediatric nurse practitioner do? a. Administer varicella immune globulin (VariZIG). b. Hospitalize the child for intravenous acyclovir. c. Order intravenous immunoglobulin as an outpatient. d. Prescribe oral acyclovir for the duration of the illness.

ANS: B The description of the rash the immunocompromised child has been exposed to is that of varicella. Intravenous acyclovir should be given to immunocompromised individuals. Immune globulin is not effective after the disease has progressed. Oral acyclovir is expensive and not routinely recommended for most children.

The primary care pediatric nurse practitioner is prescribing ibuprofen for a 25 kg child diagnosed with oligoarticular juvenile idiopathic arthritis (JIA. If the child will take 4 doses per day, what is the maximum amount the child will receive per dose? a. 200 mg b. 250 mg c. 400 mg 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.

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. Anti-DNase B test b. anti-streptolysin O (ASO) titer c. Rapid strep test 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 anti-DNase B test will also confirm a recent strep infection, but this doesn't peak until 6 to 8 weeks after the initial infection. A rapid strep test and throat culture do not differentiate the carrier state from a true infection.

A 3-year-old child is recovering from injuries sustained in a motor vehicle accident. How will the primary care pediatric nurse practitioner evaluate this child's pain? a. Ask the child to rate pain intensity on a 4- to 5-item pain discrimination scale. b. Have the child describe any pain as "no pain, a little pain, or a lot of pain." c. Question the child about the intensity and specific location of any pain. d. Rely on nonverbal responses such as facial expressions and limb movements.

ANS: B Three-year-olds can describe "no pain, a little pain, or a lot of pain" but cannot use a numeric pain rating scale or describe intensity or location of pain. Reliance on nonverbal responses is useful for infants and toddlers who cannot describe pain.

What is the greatest barrier to securing adequate home health care for the child with complex medical needs? a. Shortage of trained service providers b. Reimbursement for needed skilled nursing services c. Parent resistance to accepting such services d. Acquiring the necessary service related referral

ANS: B Unfortunately, reimbursement for home health is often difficult to obtain and often limited to eight hours a day. While the other options may be true in some situations, none are a consistent barrier to effective home health care.

The primary care pediatric nurse practitioner is preparing to perform a painful procedure on a 4-month-old infant. Besides providing local anesthesia, what other pain control method provides analgesic effects? a. Providing toys b. Singing or music c. Sucrose solution d. Swaddling or cuddling

ANS: C A 12% sucrose solution given 2 minutes prior to a procedure will have analgesic effects for 5 to 10 minutes and is useful for infants. The other methods are distraction techniques, which are not analgesic but help small children cope with or reduce the fear response to pain. These are generally more useful in older children and not infants.

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. Begin treatment with intravenous methyl prednisone. b. Consider IVIG therapy if symptoms persist one more week. c. Order a baseline echocardiogram today and another in 2 weeks. 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.

The primary care pediatric nurse practitioner is offering anticipatory guidance to the parents of a 6-year-old child who has Down syndrome. What will the nurse practitioner tell the parents about physical activity and sports in school? a. Children with Down syndrome get frustrated easily when engaging in sports. b. Children with Down syndrome should not participate in strenuous aerobic activity. c. Their child should have a cervical spine evaluation before participation in sports. d. Their child should only participate in sports sanctioned by the Special Olympics.

ANS: C Because up to 40% of children with Down syndrome have a hypermobility or instability between C1-C2 and up to 61% have occipito-atlantal hypermobility, they should undergo radiological evaluation of the cervical spine to be cleared for strenuous sports. Many children and adolescents with intellectual and developmental disabilities (including those with Down, fragile X, Turner, or Klinefelter syndromes or autism) are capable of performing exercise or strenuous activities. Special needs children should be encouraged to participate in sports to increase physical abilities and increase self-confidence. Children with Down syndrome may benefit from strenuous aerobic activity and may participate in any sports once cervical spine stability is evaluated, not just those sanctioned by the Special Olympics.

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 metered-dose inhaler 20 minutes before exercise but reports decreased effectiveness since beginning daily practice. What will the primary care pediatric nurse practitioner do? a. Counsel the adolescent to decrease the number of practices each week. b. Increase the albuterol to 4 puffs 20 minutes prior to exercise. c. Order a daily inhaled corticosteroid medication. 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 B2-agonist 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.

The parent of a 12-year-old child who has sickle cell trait (SCT) asks the primary care pediatric nurse practitioner whether the child may play football. What will the nurse practitioner tell this parent? a. Children with SCT should not play any contact sports. b. Children with SCT may not play for NCAA schools in college. c. Children with SCT should follow heat acclimatization guidelines. d. Children with SCT should not participate in organized sports.

ANS: C Children with SCT may play in sports as long as preventative measures, including heat acclimatization, are taken to prevent sickling crises. They may play contact sports and may play for NCAA teams as long as their sickle cell trait status is known.

The parent of a child newly diagnosed with epilepsy asks the primary care pediatric nurse practitioner if the child will ever be able to participate in gym or sports. What will the nurse practitioner recommend? a. Bicycle riding is not safe for children with seizures. b. Contact sports should be avoided. c. Direct supervision of some activities is necessary. d. Underwater sports are not recommended.

ANS: C Children with epilepsy may participate in most sports but may require direct supervision in some cases to reduce the risk of injury to self or others if a seizure should occur during sports. Bicycle riding, contact sports, and underwater sports may be engaged in, but certain precautions must be taken (e.g., supervision).

The primary care pediatric nurse practitioner diagnoses a high school basketball player with mononucleosis. The adolescent asks when she may resume play. What will the nurse practitioner tell her? a. After 3 weeks, she may begin lifting weights but not full sports. b. After 4 weeks, she may return to full play and practice. c. At 4 weeks, she must have an exam to determine fitness for play. d. She may engage in moderate exertion and practice after 3 weeks.

ANS: C Full return to play should be determined on a case-by-case basis and is generally considered safe at 4 weeks after symptom onset, assuming physical stamina has returned, all symptoms have resolved, and the sport does not increase intraabdominal pressure during play. Athletes should avoid any form of exertion, including all sports during the first 3 weeks at a minimum and should avoid anything with a risk of chest or abdominal contact or anything that involves increased intra-abdominal pressure. Splenic rupture can occur spontaneously (rare), but the risk of rupture increases when participating in a contact or collision sport or a sport in which there is an increase in intraabdominal pressure. The nurse practitioner should recommend an exam at 4 weeks to determine fitness for play.

An adolescent has a TB skin test prior to working as a volunteer in a hospital. The adolescent is healthy and has not travelled to or from a TB-endemic area or had close contact with anyone who has TB. The Mantoux skin test shows 10 mm of induration after 48 hours. What will the primary care pediatric nurse practitioner do? a. Ask the adolescent about exposure to homeless persons. b. Order a chest radiograph to rule out active TB. c. Reassure the adolescent that this is a negative screen. d. Refer the adolescent to an infectious disease specialist.

ANS: C In children 4 years and older without risk factors, induration must be at least 15 mm or greater to be considered to be a positive screen. It is not necessary to question the adolescent about possible exposures. Chest radiographs are ordered to evaluate for active TB in persons with a positive screen. Referral to an infectious disease specialist is done if active TB is present.

The primary care pediatric nurse practitioner suspects that the parent of a child who is doing poorly in school is being abused by a partner. What is a priority response by the nurse practitioner? a. Notifying the child's school counselor about this problem b. Referring the child and family to a social worker c. Reporting this according to any mandated reporting laws d. Suggesting that the parent avoid the abusive situation

ANS: C In most states, health care providers are mandated to report a child's exposure to Intimate partner violence since it is considered a form of emotional child abuse. The PNP should follow any state laws that mandate this as a priority. Once child protective services is involved, the PNP may assist with notification of school personnel, referrals to social workers, and suggestions to parents.

When reviewing a white blood cell (WBC) count, the primary care pediatric nurse practitioner suspects a viral infection when which WBC element is elevated? a. Bands b. Leukocytes c. Lymphocytes d. Neutrophils

ANS: C Lymphocytes are usually elevated during viral infections. Bands and neutrophils are generally elevated with bacterial infections. Leukocytes comprise all WBCs and are usually, although not always, elevated during bacterial infections.

Which PCP question, posed to a parent, best demonstrates participatory care when addressing the topic of childhood immunizations? a. "Do you want to hold your child while I give the shots due today?" b. "What are your feelings about childhood vaccinations?" c. "What shots do you want your child to receive at this visit?" d. "Do you have any questions about the shots that are due at this visit?"

ANS: C Providers who are presumptive (e.g., "these shots are due today") rather than participatory (e.g., "what shots do you want your child to receive today") in their discussion of childhood vaccines had fewer refusals by vaccine-hesitant parents even within the context of initial vaccine resistance on the part of the parent. The remaining options all present with the assumption that the vaccinations will be given.

A school-age child has fever of 104°F, sore throat, vomiting and malaise. The primary care pediatric nurse practitioner observes that the tonsils, oropharynx, and palate are erythematous and covered with exudate; the tongue is coated and red; and there is a red, sandpaper-like rash on the child's neck, trunk, and extremities. A rapid strep test is positive. What will the nurse practitioner do to manage this child's illness? a. Administer intramuscular ceftriaxone. b. Hospitalize for further diagnostic tests. c. Prescribe oral amoxicillin. d. Refer to a pediatric infectious disease specialist.

ANS: C Scarlatina is caused by erythrogenic toxin from Group A streptococcus. Treatment is the same as for Group A streptococcus unless complications occur. IM antibiotics are not indicated. The child does not need hospitalization or referral to a specialist.

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. Allergy testing b. Chest radiography c. Spirometry testing 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.

The primary care pediatric nurse practitioner prescribes a new medication for a child who develops a previously unknown adverse reaction. To report this, what action will the nurse practitioner take? 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: C The 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.

A 9-month-old infant has had a fever of 103°F for 2 days and now has a diffuse, maculopapular rash that blanches on pressure. The infant's immunizations are up-to-date. What will the primary care pediatric nurse practitioner do? a. Administer immunoglobulin G to prevent fulminant illness. b. Perform serologic testing for human herpes virus -6 and human herpes virus -7. c. Reassure the parent that this is a mild, self-limiting disease. d. Recommend avoiding contact with pregnant women.

ANS: C The infant has symptoms consistent with roseola infantum, which is a benign, self-limiting disease. It is not necessary to administer IgG or perform serologic testing or to avoid contact with pregnant women.

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.

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.

The parent of a school-age child with a chronic pain condition tells the primary care pediatric nurse practitioner that the child has requested to stay home from school more often in the past few months. The child's exam does not reveal any significant change in pathology, and a review of the child's medications indicates appropriate dosing of analgesic medications. What will the nurse practitioner recommend? a. Assessing the child's pain every day to determine changes b. Ensuring the child stays quiet in bed with videos when having pain c. Having the child do homework when staying home from school d. Requiring the child to go to school even during pain episodes

ANS: C To promote optimal coping with chronic pain in children, parents should not give excessive attention or special privileges when the child complains of pain and, if allowing the child to stay home, should require quiet, low-key activities and not video games or television, which may reinforce the child not wanting to go to school. Parents who focus on the child's pain only reinforce the child's behaviors. Parents should encourage normal activities but not necessarily require them.

The parent of a high school basketball player tells the primary care pediatric nurse practitioner that the adolescent becomes short of breath only when exercising. What will the nurse practitioner recommend? a. Permanent discontinuation of all strenuous and aerobic activities b. Enrollment in a conditioning program to improve performance c. Evaluation for underlying cardiac causes of this symptom d. Treatment for exercise-induced asthma with a bronchodilator

ANS: C While shortness of breath may indicate several more benign causes, athletes who exhibit this symptom should be evaluated for underlying cardiac causes to prevent sudden cardiac death. Once this is ruled out, other causes may be considered, such as EIA or poor conditioning.

The primary care pediatric nurse practitioner is examining a young child who was brought in by a grandmother for evaluation of a partial-thickness burn on one arm. The PNP suspects that this is an intentional injury, but the grandmother states that the parents are "just careless" and that the child is now living with her. What will the PNP do? a. Flag this as a concerning incident in the child's record. b. Reassure the grandmother that she is doing the right thing. c. Refer the child's parents to a parenting resource center. d. Report a suspicion of abuse to child protective services.

ANS: D All states have mandatory reporting laws that require health care professionals to report suspected or known abuse to appropriate agencies and provide both civil and criminal immunity to mandated reporters. The other options may be necessary once the case is investigated, but the priority is to report the suspicion of abuse.

An adolescent who has asthma and severe perennial allergies has poor asthma control in spite of appropriate use of a short-acting beta2-agonist (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. Consider daily oral corticosteroid administration. b. Order an anticholinergic medication in conjunction with the current regimen. c. Prescribe a LABA/inhaled corticosteroid combination medication. 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.

A school-age child who uses a short-acting beta2-agonist (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. Administer an oral corticosteroid and repeat the three treatments of the inhaled SABA. b. Admit the child to the hospital for every 2 hour inhaled SABA and intravenous steroids. c. Give the child 2 mg/kg of an oral corticosteroid and have the child taken to the emergency department. 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.

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. Evaluate the adolescent's pain using a numeric pain scale. b. Obtain ANA, CBC, liver function, and muscle enzymes tests. c. Reassure the adolescent that this condition is not life-threatening. 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.

An adolescent takes ibuprofen, acetaminophen, and a tricyclic antidepressant (TCA) to treat phantom limb pain and reports that the medications are no longer effective. What will the primary care pediatric nurse practitioner do? a. Change the TCA to a selective serotonin reuptake inhibitor. b. Evaluate the adolescent for drug-seeking behavior. c. Increase the TCA dose and reevaluate in 2 to 3 weeks. d. Refer the adolescent to a pain management specialist.

ANS: D Chronic pain management can include pharmacologic and non-pharmacologic measures. When medications are used, it is suggested that pain management specialists be consulted. An SSRI may be prescribed, but this drug has a black box warning and shouldn't be used unless necessary. An adolescent with a phantom limb pain condition is not likely to be engaging in drug-seeking behavior. TCA dosing is generally not managed in the primary setting.

A 15-year-old female basketball player who has secondary amenorrhea is evaluated by the primary care pediatric nurse practitioner who notes a BMI in the 3rd percentile. What will the nurse practitioner counsel this patient? a. That amenorrhea in female athletes is not concerning b. That she should begin a program of plyometrics and strength training c. To consider a different sport, such as volleyball d. To work with a dietician to improve healthy weight gain

ANS: D Female athletes who have amenorrhea have an increased risk of stress fractures. The adolescent should work to attain a healthy weight, which should allow normal periods to return and reduce this risk. Even though amenorrhea in female athletes is common, it is concerning. Plyometrics and volleyball can increase the risk of stress fractures since both involve jumping and thus not be suggested.

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 short-acting beta2-agonist (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. Have the parent administer all of the child's medications. b. Increase the ICS medication to a high-dose preparation. c. Reinforce teaching about the importance of using the SABA. 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 Inhaled corticosteroids (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.

The primary care pediatric nurse practitioner is evaluating a 12-year-old girl who reports penile penetration of her vagina by her mother's boyfriend the day before yesterday. The PNP reports this to the local child abuse hotline. What is the PNP's next action? a. Attaining a history of the abuse from the child b. Obtaining urethral specimens for STI testing c. Performing a colposcopic examination to evaluate for trauma d. Referring the child to the ED for forensic specimen collection

ANS: D If sexual abuse has occurred within 72 hours, it is required that appropriate forensic specimens be collected. Getting a history from the child is part of the child abuse evaluation and will be done by the child abuse team, as well as obtaining urethral specimens for STI. Colposcopic exams should be done by an expert in sexual abuse if trauma is suspected but is not performed by the PCPNP.

A child whose family has been camping in a region with endemic Lyme disease suffered several tick bites. The parents report removing the ticks but are not able to verify the type or the length of time the ticks were attached. The child is asymptomatic. What is the best course of action? a. Administer a prophylactic single dose of doxycycline. b. Perform serologic testing for IgG or IgM antibodies. c. Prescribe amoxicillin three times daily for 14 to 21 days. d. Teach the parents which signs and symptoms to report.

ANS: D Prophylaxis should not be given if the type of tick or the timeline for attachment cannot be verified; however, parents should be encouraged to report signs of Lyme disease if they occur. Prophylaxis is given if the tick is reliably identified as a nymph or adult Ixodes scapularis species. Serologic testing may be performed if symptoms occur. Amoxicillin tid for 2 to 3 weeks is indicated for early localized disease.

The primary care pediatric nurse practitioner is reviewing the rheumatology plan of care for a child who is diagnosed with systemic lupus erythematosus (SLE). Besides reinforcing information about prescribed medications, what will the nurse practitioner teach the family to help minimize flaring of episodes? a. Have the child rest between activities. b. Obtain regular ophthalmology exams. c. Participate in low-impact exercises. d. Use ultraviolet A (UVA) and ultraviolet B (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 juvenile idiopathic arthritis (JIA). Children should participate in low-impact activities, but this does not reduce the number of flares. Ophthalmology exams are recommended for children with juvenile idiopathic arthritis (JIA).

A 3-year-old child who attends day care has had a fever, nausea, and vomiting several weeks prior and now has darkened urine and constipation along with hepatomegaly and right upper quadrant tenderness. What treatment is warranted for this child? a. HAV vaccine b. Immunoglobulin G c. Interferon-alfa d. Supportive care

ANS: D The child has symptoms consistent with hepatitis A virus. HAV vaccine and IgG may be given within 2 weeks of exposure; otherwise supportive care is indicated. Interferon-alfa is used for hepatitis B virus.

A preschool-age child is brought to clinic for evaluation of a rash. The primary care pediatric nurse practitioner notes an intense red eruption on the child's cheeks and circumoral pallor. What will the nurse practitioner tell the parents about this rash? a. This rash may be a prodromal sign of rubella or roseola. b. The child will need immunization boosters to prevent serious disease. c. This is a benign rash with no known serious complications. d. Expect a lacy, maculopapular rash to develop on the trunk and extremities.

ANS: D This "slapped cheek" rash is consistent with fifth disease, or erythema infectiosum, and will be followed by a lacy, maculopapular all-over rash. It is not a prodrome of rubella or roseola, and immunizations are not indicated. Although it is mostly benign, there can be serious sequelae, especially for pregnant women.

Which statement is not supported by the ACIP general vaccination guidelines? a. If two live virus parenteral vaccines are given less than 28 days apart, the vaccine given second should be disregarded; repeat this second vaccine at least 4 weeks later. b. In some circumstances (e.g., imminent travel, country epidemics, delayed immunizations) an accelerated schedule is available from the ACIP. c. When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is preferred. d. While written, dated records are preferred, parent or guardian recollection of a child's immunization status may be accepted if source is considered reliable.

ANS: D Use only written, dated records. Parent or guardian recollection of a child's immunization status may not be reliable. All the other options are true statements.

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.

What intervention should the primary care provider (PCP) encourage all parents to implement to engage in the best management of potential serious child related injuries? a. Being aware of the causes of common childhood injuries b. Actively engaging in attentive parenting practices c. Actively supporting state and federal programs like Safe Kids USA d. Being proficient in basis pediatric life support techniques

ANS: D While all the options are appropriate parental interventions, the management of potential serious child related injuries is best served by parents and caregivers being familiar with and proficient in basic pediatric life support techniques.

The National Academy of Medicine has determined, after a comprehensive review, determined there is no substantiated evidence of a causal relationship between thimerosal-containing vaccines or measles, mumps, rubella (MMR) vaccine and what disorders? (Select all that apply.) a. Childhood schizophrenia b. Autism c. Asperger syndrome d. Attention-deficit/hyperactive disorder (AD/HD) e. Pett syndrome

B, E