peds - Chapter 15, 16, 17, 19 perception, sexuality, relationships, coping, values, stress,

Adolescent children are more likely to smoke cigarettes and drink alcohol if they live with a. cohabitating parents. b. grandparents. c. homosexual parents. d. single parents.

ANS: A Adolescents living in cohabitating households are more likely to smoke and drink in comparison with adolescents living in married or single parent households. Children living with homosexual parents and children living with grandparents do not have this increased risk.

The mother of a 15-year-old female expresses concerns that her daughter may be sexually active because she's had a steady boyfriend for over a year. The primary care pediatric nurse practitioner learns that the family is Catholic and that the mother had an abortion when she was 16 years old. What will the nurse practitioner do initially? a. Explore the mother's feelings about her own past experience. b. Offer to prescribe contraception to prevent pregnancy. c. Recommend that the mother discuss this with her daughter. d. Suggest that the mother talk to a priest about her daughter.

ANS: A An initial step when assisting families to manage ethical and behavioral issues is to assist parents and children in values clarification. Before offering other suggestions, the PNP should help the mother to clarify her own feelings. The other options may be necessary after values are clarified.

The primary care pediatric nurse practitioner is performing an examination on a 2-year-old child who has been placed in emergency foster care with a grandparent after the child's mother has been arrested for drug use. The child has a history of asthma with frequent exacerbations because of parental smoking. What is a priority for the nurse practitioner at this visit? a. Evaluation of financial resources, medical insurance, and access to health care and medications b. Providing a list of websites and community-based support groups for grandparents parenting grandchildren c. Referral to a social worker to help the child deal with emotional conflict related to separation from the parent d. Teaching the grandparent about the need for consistency in routines and discipline for the child

ANS: A A high percentage of grandparents who parent grandchildren have financial difficulties and most cannot claim grandchildren as dependents for health care. This child has a chronic disease and will need medication and possibly hospitalization, so the PNP should assess resources and access to care. The other options are important but are not a priority in the initial visit.

The parent of a school-age child is concerned that the child is going to be short like both parents and worries that he will have difficulty in school if he can't participate in a variety of sports. What will the primary care pediatric nurse practitioner do to counsel this parent? a. Encourage the child to engage in regular physical activity. b. Overlook his or her own feelings about this physical characteristic. c. Point out the accomplishments of other short people. d. Steer the child into other activities at school.

ANS: A Children should be encouraged to participate in all activities and to explore their own abilities and limitations without attributing "good" or "bad" to any of these experiences to improve self-esteem. Parents should be encouraged to explore their own feelings about their child's appearance to avoid subliminal messages of low self-worth. Pointing out the characteristic puts an unnecessary focus on the trait. Steering the child to specific activities is limiting.

A 14-year-old female comes to the clinic with amenorrhea for 3 months. A pregnancy test is negative. The adolescent's body weight is at 82% of expected for height and age. The mother reports that her daughter often throws up and refuses to eat most foods. Which condition does the primary care pediatric nurse practitioner suspect? a. Anorexia nervosa b. Bulimia nervosa c. Depression d. Substance abuse

ANS: A Children with anorexia nervosa are usually underweight. Refusal to maintain body weight at least 85% expected for age and height or failure to gain weight during growth periods so that weight drops below 85% expected is one of the diagnostic criteria of anorexia. Some may throw up frequently, but children with bulimia nervosa are generally average weight or overweight. Depression and substance abuse may be comorbidities, but these signs are consistent with anorexia nervosa.

The parent of a 15-year-old male is concerned that he refuses to eat meals with the family and consumes only protein drinks. The adolescent is on the track team at school and spends much of his time training and working out. The primary care pediatric nurse practitioner notes that his weight and BMI have dropped from the 20th percentile to the 3rd percentile in the past year. This child most likely has a problem with a. body image. b. personal identity. c. role performance. d. self-esteem.

ANS: A Children with disturbed body image may have concerns related to appearance, body size, function, or potential. Possible behaviors include eating disorders and a preoccupation with the perfect body. Children with body image problems become overly concerned with appearance and compare themselves to others. This child is losing weight and working out too often to try to change his body. Children with personal identity issues internalize negative perceptions of others and manifest feelings of inferiority. Children with role performance problems feel incompetent and are hesitant to try new things or become perfectionists to overcompensate. Children with poor self-esteem seek attention, importance, and security.

The parent of a school-age girl reports that the child has difficulty getting ready for school and is often late because of a need to check and recheck whether her teeth are clean and her room light has been turned off. What will the primary care pediatric nurse practitioner recommend to this parent? a. Cognitive-behavioral therapy b. Deferral of treatment until symptoms worsen c. Medication management with an SSRI d. Referral to a child psychiatrist

ANS: A Cognitive-behavioral therapy is used for mild to moderate symptoms of OCD. Children who have mild symptoms that do not interfere with their lives can defer treatment, but this is not the case in this situation. Medication and referral to a child psychiatrist are used for more severe symptoms.

The parent of a school-age child reports that the child becomes frustrated when unable to perform tasks well and often has temper tantrums and difficulty sleeping. Which disorder may be considered in this child? a. Generalized anxiety disorder (GAD) b. Obsessive-compulsive disorder (OCD) c. Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) d. Separation anxiety disorder (SAD)

ANS: A GAD is characterized by over-concern about competence, significant self-consciousness, irritability and tantrums, and poor sleep. OCD results in recurring thoughts, images, or impulses. Patients with PANDAS have OCD- and Tourette-like symptoms. SAD causes difficulties separating from caregivers and being away from home.

During a well child examination, a 15-year-old female tells the primary care pediatric nurse practitioner that some of her friends have begun having sex. She has a boyfriend but denies engaging in sex with him. What will the nurse practitioner do initially? a. Ask her for her definitions of "sex." b. Discuss the risks of sexually transmitted diseases. c. Find out if she is considering sexual relations. d. Give her information about contraception.

ANS: A Many adolescents do not equate oral or anal intercourse with sex, so it is important to find out how this patient defines sex. The other options also may be considered depending on the situation, however, clarity about the words used in the discussion are most important initially for the nurse practitioner to focus the subsequent conversation appropriately.

During a well child examination of a school-age child from a family who recently immigrated from Africa, the primary care pediatric nurse practitioner learns that the child has been involved in many arguments at school. The parents are concerned that their child will never fit in with classmates. How will the nurse practitioner address this situation? a. Assess the conditions in the country of origin prior to immigration. b. Recommend counseling to determine underlying causes of this behavior. c. Stress that this may be a normal response to feeling different at school. d. Suggest that the child may be responding to being bullied by others.

ANS: A Many children who exhibit signs of spiritual distress can express this by being angry or withdrawn. Trauma or violence to the self or to others can contribute to spiritual distress. The PNP should evaluate conditions in the country of origin since it is likely that the family may have escaped war or persecution prior to immigration. Once underlying conditions are known, the PNP can recommend options or try to explain the behavior to parents.

The primary care pediatric nurse practitioner is discussing newborn care with a mother who is pregnant with triplets. When counseling the mother about feeding issues, the nurse practitioner will recommend a. developing a plan to rotate breastfeeding for her infants. b. making sure that the triplets are on the same feeding schedule. c. pumping her breasts so she can feed breastmilk to all three. d. supplementing with formula to ensure adequate nutrition.

ANS: A Mothers of multiples can breastfeed their infants. With more than two infants, the mother should develop a rotation schedule. While it is recommended to attempt to get the babies on the same schedules for feeding and sleeping, this is not always possible and not necessary. Infant suckling is the best way to increase milk supply. Supplementation is not recommended unless her milk supply is inadequate.

The primary care pediatric nurse practitioner is assessing a special needs school-age child whose family has just moved to the area. What is a priority concern at this initial visit? a. Asking the parents to describe the child's illness, treatments, and unique needs b. Connecting the family to local support groups, school programs, and resources c. Gathering information about financial concerns related to the child's condition d. Providing expert information about the child's condition and its management

ANS: A Parents of children with special needs often become medical experts in their child's diagnosis, management, and idiosyncratic responses and expect to be treated seriously and respectfully in order to develop a trusting alliance with their health care providers. This family has experience caring for their child, and it is important to find out what that experience is and what works well for this child. The other options may be necessary after this collaborative relationship is established and when both parents and providers agree that these interventions are useful.

While the primary care pediatric nurse practitioner is discussing anticipatory guidance with the mother of a 12 month old, the child repeatedly pulls objects out of the mother's purse. Each time, the mother slaps the child's hands as she takes the objects away. What will the nurse practitioner recommend to help the mother manage this child's misbehavior in a developmentally appropriate manner? a. Keep her purse up high and out of the child's reach. b. Place acceptable objects in her purse for the child to find. c. Say "No!" instead of slapping the child's hands. d. Use timeout each time the child gets into the purse.

ANS: A Parents should provide a developmentally appropriate environment to minimize children's misbehavior. Children at this age who are naturally curious will explore the environment and will seek out objects within their reach. It is easier to put the purse up high than to have to repeatedly say "No." Putting acceptable objects in her purse only reinforces the undesired behavior.

The primary care pediatric nurse practitioner is counseling the parents of a 13-year-old female who has Down syndrome about sexual maturation. What will the nurse practitioner tell these parents? a. It is important to discuss and support healthy sexuality. b. Providing too much information about sexuality may be confusing given the child's cognitive level of understanding. c. Suppressing periods with contraceptives will lessen their daughter's distress. d. They should give her information about periods but not about sexuality.

ANS: A Persons with disabilities have the same desires to make decisions and foster fulfilling relationships with others as other people have. Unless healthy sexuality is taught and supported, unhealthy and abusive sexuality is more likely to occur. Parents should give information when it is desired and delivered in a manner appropriate to the child's level of understanding. Suppressing periods only ignores the issue but does not change the increased feelings that accompany puberty.

The parent of a school-age child reports that the child doesn't like being alone in rooms because of a fear of aliens hiding in closets. What will the primary care pediatric nurse practitioner tell the parent? a. "Fear of imaginary creatures does not usually occur at this age." b. "I may need to refer your child to a pediatric mental health specialist." c. "Your child is expressing normal fears for a school-age child." d. "Your child may be watching too much violence on television."

ANS: A Preschoolers tend to fear imaginary creatures but not school-age children. The PNP does not have enough information about the severity of the fear or its effects on behavior to refer the child to a mental health specialist. The PNP should evaluate the situation before attributing the fear to a cause such as television.

The parent of a 4-year-old child reports that the child seems to be having trouble adjusting to a new day care and reportedly is always engaging in solitary play when the parent arrives to pick up the child. What will the primary care pediatric nurse practitioner do? a. Ask the parent if the child is slow to warm up to other new situations. b. Reassure the parent that parallel play is common among preschool-age children. c. Recommend that the parent spend time encouraging the child to play with others. d. Suggest that the day care center may be neglecting the child.

ANS: A Shyness is a pattern of social inhibition with unfamiliar people, novel objects, or novel situations. If the child shows this pattern in other situations, shyness is most likely the cause of this behavior. Parallel play is common among toddlers and not preschoolers. Parent should be supportive and not push children to interact. Because this shyness is a common pattern in this age child, it is not necessary to suggest that neglect is occurring, unless there are other signs.

A newly divorced mother of a toddler reports that the child began having difficulty sleeping and nightmares along with exhibiting angry outbursts and tantrums 2 months prior. The primary care pediatric nurse practitioner learns that the child refuses to play with usual playmates and often spends time sitting quietly. What will the nurse practitioner do initially? a. Ask the mother about the child's relationship with the father. b. Consult with a child psychiatrist to prescribe medications. c. Recommend cognitive behavioral or psychodynamic therapy. d. Refer the family to a child behavioral specialist for counseling.

ANS: A The child exhibits signs of PTSD. Because the parents are newly divorced, the PNP should evaluate the child's previous interactions with the father to determine whether violence occurred. If PTSD is likely, referral to social service agencies may be warranted. Pediatric mental health specialists may be involved once a diagnosis is established and may order medications.

A 9-year-old child exhibits school refusal and a reluctance to attend sleepovers with classmates. The parent is concerned because the child has recently begun sleeping in the parents' bed. Which initial action by the primary care pediatric nurse practitioner is appropriate? a. Assess for environmental stress, parental dysfunction, and maternal depression. b. Ask about recent traumatic events that may have precipitated this behavior. c. Consider a possible pediatric autoimmune neuropsychiatric disorder cause. d. Recommend firm insistence on school and activity attendance.

ANS: A This child shows symptoms of separation anxiety disorder. Environmental stress, parental dysfunction, and maternal depression are risk factors for this disorder. Assessing for traumatic events is necessary if PTSD is suspected. Pediatric autoimmune neuropsychiatric disorder manifests with OCD- and Tourette-like symptoms. If the child does have separation anxiety disorder (SAD), treatment and not discipline is warranted.

The primary care pediatric nurse practitioner is performing a well baby examination on a newborn whose mother is 17 years old. The mother states that she is living with her parents and plans to finish high school. The maternal grandmother will care for the infant while she is in school. What will the nurse practitioner discuss with this mother at this visit? a. Early child intervention programs b. Her needs for socialization with peers c. Immunizations and well child visits d. Referral to a community health nurse

ANS: B Adolescent mothers face problems inherent when this major role is assumed before they are developmentally ready themselves. Their developmental needs may sometimes be in conflict with their children. Although this mother has support from her family, the PNP should assess her desires to socialize with her peers to evaluate her developmental needs. Early child intervention may be necessary when the child is preschool age and immunizations and well child visits should be discussed, but these do not take precedence over the need to evaluate a potential role conflict. Referrals to community health may be necessary if problems arise.

A middle-school-age child is skipping school frequently and getting poor grades since the child's father was killed while deployed in the military. How will the primary care pediatric nurse practitioner manage this situation? a. Prescribe short-term antidepressants for this situational depression. b. Refer the child to a mental health specialist for evaluation and treatment. c. Schedule extended appointments for counseling and mental health interventio. d. Suggest that the child have close follow-up by a school counselor.

ANS: B Children who are experiencing enduring problems, such as the loss of a parent, should be treated either in consultation with or by referral to a pediatric mental health specialist. Antidepressants and other pharmacotherapeutic agents should never be used without a thorough mental health evaluation. The PNP is not qualified to manage this in a primary care setting without consultation or referral, nor is a school counselor, although both may be part of the team of professionals who help to manage this child.

A parent who encourages competitiveness in a child who excels at a single sport but not in others may also encourage a sense of a. competence. b. insecurity. c. significance. d. worthiness.

ANS: B Children who gain praise for external measures, such as performance of a sport, may end up unduly comparing themselves with others and feel insecure, inferior, and inadequate, even as they continue to excel in this sport. Competence comes from feeling capable and confident and able to approach new tasks. Significance comes from having a sense of belonging and being accepted unconditionally; this child's self-worth is dependent on performance in a sport. Worthiness is based on an understanding of having a purpose in life and is also unconditional.

The parents of a 4-year-old boy are concerned because he has begun twisting and pulling out his hair, especially when he is tired or stressed. What will the primary care pediatric nurse practitioner recommend as part of an initial approach to treat this behavior? a. Consultation with a pediatric behavioral specialist b. Cutting his hair so that it is too short to pull c. Long-term anti-streptococcal prophylaxis d. Medication with risperidol or clonidine

ANS: B Children with mild to moderate tic disorders can be managed with cognitive-behavioral therapy ; part of this includes strategies to help distinguish the undesired behavior, such as cutting the hair so it cannot be pulled out. If this is not effective, consultation with a behavioral specialist and medications, prescribed following assessment by a qualified mental health specialist, may be needed.

A toddler has begun hitting and biting other children at a day care center and is exhibiting temper tantrums and bad language at home. The parent reports that these behaviors began shortly after a sibling was born. What will the primary care pediatric nurse practitioner do? a. Advise the parent that the child is exhibiting early symptoms of ADHD. b. Engage the parent in positive parenting strategies to facilitate appropriate child coping. c. Recommend evaluating the child for conduct or oppositional defiant disorder. d. Suggest putting the child in another day care center to ameliorate the problems.

ANS: B Children with social aggression may exhibit the behaviors described above. When social aggression is a response to acute stress, such as the birth of a sibling, the problem usually resolves if parents use positive parenting strategies and facilitate developmentally appropriate child coping efforts. These are not symptoms of ADHD. Conduct disorder (CD) symptoms usually manifest in the preschool age. Oppositional defiant disorder (ODD) is characterized by disobedience rather than aggressiveness. Moving the child to another day care or school does not solve the problem.

An adolescent is diagnosed with major depression, and the mental health specialist has prescribed fluoxetine. What other treatment is important to protect against suicide risk? a. Addition of risperidone therapy b. Cognitive-behavioral therapy c. Family therapy d. Hospitalization

ANS: B Cognitive-behavioral therapy appears to have a protective effect against suicide and the best treatment responses come from combinations of cognitive-behavioral therapy and SSRIs. Risperidone and other antipsychotics are used if psychosis is present to control those symptoms. Family therapy is useful but does not add protection from suicide. Hospitalization is not the first-line treatment and is used for severe exacerbations or suicide attempts.

The primary care pediatric nurse practitioner is examining an infant who has otitis media and learns that the mother and child are homeless. Besides assisting the mother to obtain medication to treat this illness, what is a priority during this visit? a. Assisting the mother to obtain transportation for health care needs b. Determining well child examination history and immunization status c. Making sure the family has access to WIC and food stamps resources d. Obtaining a tuberculosis skin test and scheduling a return office visit

ANS: B Even if a health care visit is in response to a crisis that cannot be denied, assessment of homeless patients should include well child care and immunizations on the operating principle that every child should receive the maximum health care possible. The other options may be part of ongoing assistance and evaluation of homeless families, but the initial response should be evaluation of well child needs.

The primary care pediatric nurse is performing a well child examination on an adolescent who was adopted as a toddler. The parent reports that the child had been removed from an abusive home at age 3 years. What will the nurse practitioner evaluate in light of possible long-term effects of this early situation? a. Cognitive and psychosocial development b. Mental health and suicide risk c. Moral development and conscience formation d. Spirituality, faith, and religious affiliation

ANS: B Findings of early research suggest that epigenetic changes may mediate the effect of prenatal and infant environment on mental health and disease in older children and adults. Adult suicide victims who were abused as children show decreased levels of a genetic marker of a stress reduction gene, suggesting that child abuse may have an epigenetic effect leading to prolonged stress and mental disorders.

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 sees a 6-year-old child after a hospitalization for injuries sustained in a motor vehicle accident (MVA) in which the child's grandfather was killed. The parent states that it is difficult to get the child to stop talking about the accident and is worried that the child will have permanent emotional scars. What will the nurse practitioner suggest? a. Assure the child that he is safe and this won't happen again. b. Encourage the child to express and examine feelings. c. Reassure the child that his grandfather is in heaven. d. Redirect these conversations to happier topics.

ANS: B Management goals when health crises occur should focus on helping children and families make sense of the events and to better understand what is happening to help regain control. Helping the child to express and examine feelings will help him to put what happened in perspective. Assuring the child that accidents won't happen again is false and can lead to even more distress in the future. Telling the child that the grandparent is in heaven doesn't address all his fears about the accident. Redirecting the conversation to happier topics minimizes the child's concerns.

The primary care pediatric nurse practitioner is performing a well child exam on an 8-year-old girl and notes the presence of breast buds. What will the nurse practitioner include when initiating anticipatory guidance for this patient? a. A discussion about the risks of pregnancy and sexually transmitted diseases b. Information about sexual maturity and menstrual periods c. Material about the human papillomavirus vaccine d. Sexual orientation and the nature of sexual relationships

ANS: B Since this child is 8 years old, it is early to discuss sexual behavior and reproduction given the level of the child's cognition and understanding. However, with these early changes in telearche marking the onset of puberty, it is wise to discuss menstruation in an age-appropriate manner before it occurs so that the child can be prepared. Since this child is showing signs of early puberty, this information can be included in anticipatory guidance.

The primary care pediatric nurse practitioner sees a 10-year-old child whose parent describes as a "class clown." The child denies having problems at school, but acknowledges poor grades by saying, "I'm not very smart, I guess." When counseling the parent about helping this child deal with this self-perception issue, the nurse practitioner will recommend which strategy? a. Empower the child to make decisions and assume more responsibilities. b. Help the child identify skills and activities that he is good at. c. Spend time each evening helping the child with homework to improve grades. d. Work with the teacher to set appropriate limits on school behavior.

ANS: B This child exhibits problems with personal identity and copes by clowning around to avoid dealing with problems of inferiority about school performance. The parent should work with the child to find areas of strength and help the child become accomplished in those things to improve self-esteem.

The parent of an adolescent female tells the primary care pediatric nurse practitioner that the child may be the victim of cyber-bullying at school but won't talk about it with her parents. What is the nurse practitioner's initial response? a. Ask about the adolescent's school performance and friends. b. Interview the adolescent separately from the parent. c. Reassure the parent that suicide is a rare response to bullying. d. Suggest that the parent discuss this with the school counselor.

ANS: B When bullying is suspected, it is ideal to interview the youth separately from the parent, even though it is necessary to get the history from both, since children are often reluctant to discuss bullying with their parents. Asking about school performance and friends is part of the history but not a priority. Reassuring the parent that suicide is rare minimizes the parent's concerns. Suggesting that the parent discuss this with the school shows an unwillingness to consider the problem as part of the child's overall health.

During a well child examination on a 4-month-old infant, the primary care pediatric nurse practitioner evaluates mental health issues. Which statement by the parent indicates a potential problem with the parent-infant relationship? a. "I can sense a difference in my baby's cries." b. "I let my baby cry a while to learn to be patient." c. "My baby prefers to nurse in a darkened room." d. "My baby seems very sensitive to loud noises."

ANS: B When parents respond promptly to their baby's needs, infants develop the ability to wait for care and typically provide less intense distress signals. Parents who are attentive to their babies' signals, preferences, and sensitivities are more in tune with their infants' needs.

The primary care pediatric nurse practitioner learns that a school-age child continues to hope that his parents will remarry 1 year after they have divorced. What will the nurse practitioner tell this child's parents? a. "If one of you remarries, he is more likely to understand that this is permanent." b. "This is a normal response and is an expression of hope that things will be OK." c. "You will need to help him accept the reality of the permanence of the divorce." d. "Your child is most likely blaming himself for your separation and divorce."

ANS: C Accepting the permanence of the divorce is one of the psychological tasks children of divorce must master in order to master normal developmental tasks. Parents need to focus on helping the child achieve these tasks. A remarriage does not necessarily help the child to achieve this task. It is a sign that the child cannot accept the reality of the situation, not of hope, and does not indicate self-blame.

An adolescent has recently begun doing poorly in school and has stopped participating in sports and other extracurricular activities. During the history interview, the adolescent reports feeling tired, having difficulty concentrating, and experiencing a loss of appetite for the past few weeks but cannot attribute these changes to any major life event. Which is an important next step in managing this patient? a. Administering a diagnostic rating scale for depression b. Considering a short-term trial of an antidepressant medication c. Determining suicidal ideation and risk of suicide d. Referring the adolescent to a mental health specialist

ANS: C Because this adolescent exhibits clear signs of depression, the first goals of management are to determine suicidal risk and to intervene to prevent suicide since the risk of suicide is greatest during the first 4 weeks of a depressive episode. A diagnostic rating scale may help in diagnosing the depression, but assessing suicide risk is a priority. Antidepressant medications may be useful but are best initiated by a mental health specialist. The initial response in adolescents should be to determine suicide risk to decide whether to admit to inpatient therapy or refer to a mental health specialist.

A school-age child enjoys playing basketball but doesn't make the intramural team. Which response by the child is characteristic of the concept of a growth mindset? a. "I didn't play well on the day of the tryouts." b. "I'll just have to find another sport I'm good at." c. "I'll need to work more on my outside shot." d. "I'm probably too short to be really good at this sport."

ANS: C Children who have a growth mindset have been taught to believe that hard work is key to success and that effort and practice contribute to growth. By not being discouraged and identifying something to work on, the child is exhibiting a growth mindset. Saying that he didn't play well is making excuses, while stating he needs to find something else he's good at or blaming his failure on a physical characteristic indicates a belief that success is dependent on fixed traits.

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.

During a well child assessment of a preschool-age child, the parent voices concerns that, because the child has behavior problems at school, the child may have a mental health disorder. Which initial approach will provide the best information? a. Ask the parent whether other caregivers have voiced similar concerns. b. Interview the child separately from the parent to encourage sharing of feelings. c. Take time to actively listen to the parent's and child's perceptions of the problem. d. Use a validated screening tool to ensure that all aspects of behaviors are evaluated.

ANS: C Providers can get a clearer picture of the situation by taking the time to sit down and actively listen to both the parent's and child's concerns about the issue. It is important to remember that many parents have been trying to cope with the problem for some time, so asking for validation from others may be viewed as belittling. School-age children and adolescents should be interviewed separately to encourage sharing of information. Validated screening tools may be used later, but allowing parents to voice concerns without restricting the history is the initial focus.

During a well child exam on a 13-year-old female, the primary care pediatric nurse practitioner notes that the child is at Tanner Stage 3. During the exam, when the nurse practitioner initiates a conversation about healthy sexuality education, the parent states that this topic is "off limits." What will the nurse practitioner do? a. Ask the adolescent whether she wishes to discuss these matters since she is becoming an adult. b. Separate the parent from the adolescent to discuss the adolescent's concerns in private. c. Spend private time with the parent to discuss how sexuality education reduces the risk of early sexual intercourse and risky sexual behaviors. d. Tell the parent that this information is a routine part of adolescent well child examinations and must be included.

ANS: C Research has shown that sexuality education leads to a reduction in early onset of sexual intercourse and risky sexual behaviors. It is important for the PNP to be sensitive to the values of the family but also to advocate for the child. The child should be told, especially when she shows an interest in sexual relationships, that she may seek care independently of her parent and that it will remain confidential. When possible, the parent's wishes should be taken into account and both the adolescent and the parent should be encouraged to begin an open dialogue about these matters.

The parent of an 8-year-old child tells the primary care pediatric nurse practitioner that the child has begun to ask questions about why a schoolmate has "2 daddies" and wonders how to talk to the child about this. What will the nurse practitioner recommend? a. Beginning a discussion about different types of sexual relationships and same-sex partners b. Discussing the issue with the child in terms of the parent's religious values and norms c. Explaining that not all families are the same and what is most important is that they love and care for their children d. Telling the child that some adult relationships are complicated and will be understood when the child is older

ANS: C School age is a good time for parents to reinforce the notion that there is diversity in families within which parents and adults love and care for their children. It is not necessary to be explicit but to establish a good history of communication and to explain complex issues to children at a level of the child's understanding. In this way, the child will know that parents are accessible and open to discussion of complex and/or puzzling issues.

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.

During a well child examination on an infant who has colic, the primary care pediatric nurse practitioner learns that the infant's mother is 17 years old and that the father, who is in the military, was deployed to wartime duty shortly after the baby was born. To determine the immediate risk of child maltreatment for this infant, the nurse practitioner will ask about : a. childrearing and parenting styles. b. role responsibilities of the parents. c. spiritual beliefs and religious practices. d. the location of extended family members.

ANS: D Assessment of resources, including the support of extended family members, is a key dimension of family functioning. In this case, the mother is young and alone and may lack the skills needed to cope with an infant with colic. Childrearing and parenting styles can affect the emotional and physical health of children who misbehave or who are learning how to behave in the world. An assessment of role responsibilities is important when there are disagreements about shared responsibilities. Assessing spiritual beliefs helps to determine the values ascribed to events. While all of these are important assessments, there is an urgent need to determine the level of support available to this mother.

The parent of a school-age child is concerned because the child has started to express anger about a grandparent's death even though this occurred when the child was a toddler. What will the primary care pediatric nurse practitioner tell the parent? a. Anger is an abnormal reaction to bereavement and loss in this age child. b. Counseling is needed since the child has had sufficient time to resolve this issue. c. Grief and bereavement lasting longer than a year may require medication. d. The significance of this loss must be reworked at each developmental level.

ANS: D At any given developmental stage, children resolve the effect of the death only at that developmental level and thus must rework the significance of the loss at each stage of development. Anger is a common reaction to loss in school-age children. Counseling and medication are not indicated since this is a normal response.

The primary care pediatric nurse practitioner is counseling a family whose parents are divorcing. To help support the children and reduce their stress through this process, the nurse practitioner will recommend a. allowing children to choose the custodial parent. b. being open about ongoing parental conflicts. c. establishing a single custody living arrangement. d. maintaining a civil relationship when discussing children.

ANS: D Children make more successful adjustments and suffer less stress when parents are able to develop a civil relationship that focuses on what is best for them. Custody arrangements vary and may change over time and should be determined by what is best for the children. Custody disputes and exposure to parental conflict place additional stress on children and can increase their feelings of insecurity

A 13-year-old child has exhibited symptoms of mild depression for several weeks. The parent reports feeling relieved that the symptoms have passed but concerned that the child now seems to have boundless energy and an inability to sit still. What will the primary care pediatric nurse practitioner do? a. Administer an ADHD diagnostic scale and consider an ADHD medication. b. Consult with a child psychiatrist to prescribe an antidepressant medication. c. Reassure the parent that this behavior is common after mild depressive symptoms d. Refer the child to a child psychiatrist for evaluation of bipolar disorder.

ANS: D Children who have ADHD symptoms and depression should be evaluated by a child psychiatrist for bipolar disorder. Medications are not appropriate until the disorder is correctly diagnosed. Stimulant medications are not effective in treating bipolar disorder. Antidepressants may potentiate manic responses. Providers should carefully evaluate and refer any child treated for ADHD who does not respond to therapy or who experiences a sudden worsening of agitation while using ADHD medications.

A child has a difficult temperament. What will the primary care pediatric nurse practitioner tell the parent about managing this child's behavior? a. A difficult temperament is its own risk factor for maladjustment disorders. b. Children with difficult temperaments need strict adherence to rules. c. Having a difficult temperament limits intelligence and emotional maturity d. It is important for the parent to learn to manage criticism and power struggles.

ANS: D Children with difficult temperaments tend to engender parental criticism and irritability, power struggles, and restrictive parenting, and this dynamic leads to difficulties with psychosocial adjustment. Parents of children with difficult temperaments must be aware of behavioral manifestations as temperament expressions in order to reframe their own responses to these behaviors. A difficult temperament alone is not a risk factor for maladjustment. Restrictive parenting only increases power struggles and maladaptive behaviors. Temperament is unrelated to IQ but does affect academic outcomes because of behavior issues in school.

The primary care pediatric nurse practitioner is evaluating a 16-year-old adolescent male who is on the high school wrestling team and whose weight fluctuates as much as 7 or 8 pounds before matches. The child is eager to talk about the various trophies he has won. When he expresses confidence that he will get a wrestling scholarship for college, his father remarks that his grades will never be good enough for college, causing him to blame his teachers. The nurse practitioner may identify potential problems with a. body image. b. personal identity. c. role performance. d. self-esteem.

ANS: D Children with poor self-esteem seek attention, importance, and security and may become self-absorbed with external markers of self-worth, such as performance in a sport. Another mark of insecurity is defensiveness, which this child exhibits by blaming his teachers for his poor grades. Children with body image problems become overly concerned with appearance and compare themselves to others. This child is losing and gaining weight to be better at wrestling, not to look different. Children with personal identity issues internalize negative perceptions of others and manifest feelings of inferiority. Children with role performance problems feel incompetent and are hesitant to try new things or become perfectionists to overcompensate.

The primary care pediatric nurse practitioner 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.

The primary care pediatric nurse practitioner is performing a well child examination on a 3-year-old. The child's parent reports that the child has recently begun masturbating. What will the nurse practitioner counsel this parent? a. To allow the behavior whenever it occurs, since it is normal b. To discuss sexuality with the child c. To explore whether the child is being abused d. To teach the child about privacy and hand hygiene

ANS: D Masturbation is normal at this age and children do this because it is pleasurable. Parents should be taught to discuss privacy and hygiene with the child and to encourage the child to limit the activity to a private place. At this age, the behavior is not associated with sexual fantasies, so a discussion of sexuality is not warranted. Masturbation at this age is common and is not usually an indication of abuse.

The mother of a 3-month-old male infant tells the primary care pediatric nurse practitioner that she occasionally notices he has a penile erection just after nursing. What will the nurse practitioner tell the mother? a. Infants should be prevented from masturbating. b. The infant is conscious of the pleasure associated with nursing. c. This is a form of infantile priapism. d. This is a normal, reflexive behavior at this age.

ANS: D Newborn infants are reflexive beings, and sexual reflexes, which are present prenatally, are easily stimulated. A penile erection may occur while nursing. Infants explore with their hands and may touch their own genitalia for pleasure and for the purpose of soothing, and this is normal. A penile erection at this young age is reflexive and not conscious and intentional. It is not a form of priapism.

The primary care pediatric nurse practitioner attempts to learn more about the emotional health of an 18-month-old child through which assessment strategy? a. Asking the child to tell a story using dolls and other props b. Asking the child to draw a picture of him- or herself and other family members c. Interviewing the child separately from caretakers and parents d. Observation of the child with caretakers in structured and unstructured situations

ANS: D The PNP can observe infants and toddlers with caretakers in both structured and unstructured situations to determine strengths and limitations of each partner in the interaction. Asking children to tell stories is more appropriate for older toddlers and preschoolers. Preschoolers may be asked to draw pictures. Interviewing children separately from caretakers is more appropriate with school-age children and adolescents.

The mother of two school-age children tells the primary care pediatric nurse practitioner that she and the children's father are divorcing and asks for advice to help the children cope with the situation. The nurse practitioner will counsel her to a. allow visitation only on weekends. b. maintain her own social life. c. notify the children's teachers. d. use a social support network.

ANS: D The availability of a social support system is a key factor in coping with divorce. Visitation patterns should be consistent and collaborative but not necessarily only on certain days. Although the mother should eventually maintain a social life, it is not a key early on to helping children cope with a divorce. Notifying teachers does not necessarily help children to cope.

The primary care pediatric nurse practitioner is providing anticipatory guidance to the parent of a school-age boy. The parent expresses concerns that the child prefers to play with dolls, is worried that the child will be a homosexual, and asks what can be done to prevent this from happening. What will the nurse practitioner tell this parent? a. Homosexual identity formation cannot be predicted by early childhood behavior. b. Masculinizing boys from an early age helps to determine heterosexual orientation. c. Sexual orientation identification begins late in adolescence and not in childhood. d. The development of sexual orientation is generally a multifaceted process.

ANS: D The etiology and age of preferred sexual orientation is unknown, and the sequential developmental signs are debated. The development of sexual orientation is most likely multifaceted and cannot be predicted by one phenomenon, such as playing with dolls alone. Early childhood behavior can predict homosexual orientation as girls may feel "unfeminine" and boys may exhibit feminine tendencies. It is clear that psychosocial components and parenting do not cause or prevent homosexuality.

The primary care pediatric nurse practitioner is performing a well child examination on a fussy toddler who has red hair. The child's parent tells the toddler to stop being fussy and says, "red hair gives him such a temper." Which common error that erodes self-esteem is this? a. Dwelling on negatives b. Expecting too much c. Negating the child's feelings d. Stereotyping and typecasting

ANS: D The parent is typecasting the child by associating having a temper with the trait of red hair, which can limit his sense of possibilities. Dwelling on negatives describes making critical remarks instead of positive remarks. A parent who expects too much creates pressures for behaviors that are beyond the reach of the child and makes the child feel inadequate. Negating feelings is a rejection of the child's emotions.

The parent of a preschool-age child reports that the child often appears anxious and nervous and that this is associated occasionally with a rapid heart rate and tremors. What is the best type of referral that the primary care pediatric nurse practitioner could recommend? a. Cognitive-behavioral therapy b. Family therapy c. Medication therapy d. Play therapy

ANS: D Toddlers and preschoolers who are experiencing anxiety often respond to play therapy. School-age children and adolescents benefit from cognitive-behavioral therapy. Family therapy may be a secondary choice. Medications are not indicated as first-line treatment for anxiety.

During a well child examination of a 6-year-old girl, the primary care pediatric nurse practitioner notes that the child becomes embarrassed and resists taking off her underwear for the exam. What should the nurse practitioner infer from this observation? a. The child has been sexually molested. b. The child is feeling violated by the examiner. c. The parent is exhibiting regressive behavior. d. This is a normal reaction in a child of this age.

ANS: D Young school-age children can be extremely modest and embarrassed and resist taking off their clothes for an examiner. Since this is normal, it does not indicate a history of sexual abuse unless other signs are present. Older school-age children more commonly feel violated during an exam, not younger children. This response of increased modesty is age-appropriate and not regressive.