Lower Respiratory Disorders

Question 1

A 4 wo presents in mid-January with a 1 week history of nasal congestion and occasional cough. On the evening prior she had a temp of 102, refused to breastfeed, had paroxysmal coughing, and noisy, labored breathing. You note an ill-appearing infant who is lethargic with tachypnea and intercostal retractions. She does not attend daycare, but has a 3 yo sib who is in daycare and who recently had a cold. Considering the clinical presentation, what is the most likely cause of illness?

a) mycoplasma pneumonia
b) RSV bronchiolitis
c) aspiration pneumonia
d) streptococcal infection of the pharynx

Answer 1

b) RSV bronchiolitis

Question 2

A 4 wo presents in mid-January with a 1 week history of nasal congestion and occasional cough. On the evening prior she had a temp of 102, refused to breastfeed, had paroxysmal coughing, and noisy, labored breathing. You note an ill-appearing infant who is lethargic with tachypnea and intercostal retractions. She does not attend daycare, but has a 3 yo sib who is in daycare and who recently had a cold. Considering the clinical presentation, what would be the treatment of choice?

a) antihistamine, decongestant, and cough suppressant
b) oral antibiotics and follow-up chest radiograph in 2 weeks
c) bronchoscopy with lavage, chest physiotherapy, and respiratory isolation
d) hospitalization, bronchodilators, supplemental oxygen, and nutritional support

Answer 2

d) hospitalization, bronchodilators, supplemental oxygen, and nutritional support

Question 3

Of the following children, which one should not have tuberculin skin testing?

a) a 14 yo whose uncle was recently granted parole after 5 years in prison and is now living with pt’s family
b) a 2 yo who was infected with RSV 3 months ago and is currently asymptomatic
c) a 3 mo whose family emigrated to the US from Cambodia 1 month ago
d) an 18 mo whose mother is infected with HIV

Answer 3

b) a 2 yo who was infected with RSV 3 months ago and is currently asymptomatic

Question 4

Which of the following clinical presentations least warrants sweat chloride testing?

a) a 10 yo female sib of a pt newly diagnosed with CF; sib is without pulmonary problems and growth parameters are at 50% for age
b) 2 yo male with recurrent pneumonia and growth parameters at 5% for age
c) 4 yo female with nocturnal cough, which resolves after treatment with bronchodilators and short-term steroids; growth parameters at 10% for age
d) 7 yo female with nasal polyps, mildly hyperexpanded lungs, growth parameters at 25% for age

Answer 4

c) 4 yo female with nocturnal cough, which resolves after treatment with bronchodilators and short-term steroids; growth parameters at 10% for age

Question 5

Of the following diagnostic findings, which one should be referred to a specialist immediately?

a) suspected foreign body aspiration
b) sweat chloride results of 30 mEq/L
c) pulmonary function tests of 85% predicted
d) chest radiograph with hyperexpansion

Answer 5

a) suspected foreign body aspiration

Question 6

What is the most common agent for nonviral pneumonia from older preschool to young adulthood?

a) Mycoplasma/ Chlamydia aureus
b) Staphylococcus aureus
c) Ureaplasma
d) Haemophilus influenza

Answer 6

a) Mycoplasma/ Chlamydia aureus

Question 7

Which one of the following diagnoses would not be part of the differential for recurrent lobar pneumonia in a 2 year old?

a) cystic fibrosis
b) foreign body aspiration
c) atelectasis
d) bronchitis

Answer 7

d) bronchitis

Question 8

The most common clinical presentation of pneumonia includes:

a) cough, fever, tachypnea, and abdominal pain
b) hemoptysis, putrid breath, and weight loss
c) sudden chest pain, cyanosis
d) retractions, stridor

Answer 8

a) cough, fever, tachypnea, and abdominal pain

Question 9

In addition to airway hyper-responsiveness and reversible airway obstruction, asthma is a chronic lung disease characterized by:

a) bronchiectasis
b) inflammation
c) pleural effusion
d) pulmonary edema

Answer 9

b) inflammation

Question 10

The most common trigger for an acute asthma episode in the very young child is:

a) respiratory infections
b) exercise
c) tobacco smoke
d) outdoor allergens

Answer 10

a) respiratory infections

Question 11

Appropriate daily medication for mild persistent asthma should include:

a) an inhaled low-dose corticosteroid
b) short-acting beta2 agonist
c) an oral systemic corticosteroid
d) a cough suppressant

Answer 11

a) an inhaled low-dose corticosteroid

Question 12

Which of the following is not a goal of appropriate asthma management:

a) limited activity and exercise
b) prevent recurrent exacerbations
c) prevent chronic troublesome symptoms
d) maintain near normal pulmonary function

Answer 12

a) limited activity and exercise

Question 13

A 4 yo male with a history of atopic dermatitis and recurrent pneumonias presents with a persistent nighttime cough. His most likely diagnosis is:

a) asthma
b) foreign body aspiration
c) croup
d) cystic fibrosis

Answer 13

a) asthma

Question 14

The most typical chest radiographic finding consistent with the diagnosis of asthma is:

a) normal chest film
b) diffuse airway edema
c) right upper lobe infiltrate
d) hyperinflation

Answer 14

d) hyperinflation

Question 15

When providing asthma education regarding the use of a long acting beta 2 agonist it is important to stress:

a) it should not be used as a quick relief medication
b) may be given every 30 minutes x 3 for rescue therapy
c) may be most beneficial for exercise-induced asthma
d) should never be taken while also using inhaled corticosteroids

Answer 15

a) it should not be used as a quick relief medication

Question 16

An 8 yo with moderate persistent asthma is still having a daily cough. She reports TID use of a short-acting beta 2 agonist and cromolyn sodium at her visit. Your managment plan should be altered to include:

a) broad-spectrum antibiotics and recheck 2 weeks
b) addition of systemic corticosteroids for 5 days
c) replace cromolyn sodium with inhaled corticosteroids
d) addition of an inhaled anticholinergic

Answer 16

c) replace cromolyn sodium with inhaled corticosteroids

Question 17

A 10 yo has recently been diagnosed with mild intermittent asthma. Which of the following is not a routine part of his clinic management?

a) spirometry
b) MDI technique demonstration
c) environmental triggers and control method review
d) school excuse not to participate in PE

Answer 17

d) school excuse not to participate in PE

Question 18

Major contributors to asthma morbidity and mortality are:

a) underdiagnosis and inappropriate treatment
b) an increase in indoor allergies
c) overuse of anti-inflammatory medications
d) an increase in air pollution

Answer 18

a) underdiagnosis and inappropriate treatment

Question 19

The primary treatment of bronchopulmonary dysplasia is:

a) pancreatic enzymes
b) surgical repair
c) adequate oxygenation
d) chest physiotherapy

Answer 19

c) adequate oxygenation

Question 20

The single most predictive factor in the development of bronchopulmonary dysplasia is:

a) birth weight
b) maternal weight
c) maternal education level
d) respiratory infections

Answer 20

a) birth weight

Question 21

The classic radiographic finding in croup is:

a) hyperinflation
b) perihilar lymphadenopathy
c) thumb sign
d) steeple sign

Answer 21

d) steeple sign

Question 22

Unilateral wheezing is a finding suggestive of:

a) croup
b) asthma
c) foreign body aspiration
d) cystic fibrosis

Answer 22

c) foreign body aspiration

Question 23

Which of the following is not characteristic of an apparent life-threatening event (ALTE):

a) change in muscle tone
b) fever
c) change in skin color
d) apnea

Answer 23

b) fever

Question 24

Following an ALTE management and treatment are based on findings from:

a) a thorough history and physical exam
b) an electroencephalogram
c) a chest radiograph
d) a sleep study

Answer 24

a) a thorough history and physical exam

Question 25

The predominant characteristic of a young infant with bronchopulmonary dysplasia is:

a) prolonged fevers
b) hypoxemia on room air
c) recurrent pneumonias
d) chronic hypoinflation

Answer 25

b) hypoxemia on room air

Question 26

The PNP is teaching a group of expectant parents about infant care and illness prevention. It is most important for the PNP to stress:

a) keeping all animals out of the house
b) keeping the infant away from cigarette smoke
c) keeping the infant well covered at night
d) keeping the infant away from crowds

Answer 26

b) keeping the infant away from cigarette smoke

Exposure to cigarette smoke has been associated with increased incidence of illnesses such as asthma, bronchiolitis, and OM in children.

Question 27

Which of the following does not place an infant at increased risk for SIDS?

a) Documented episodes of periodic breathing
b) Prematurity
c) Severe bronchopulmonary dysplasia
d) Apnea of prematurity

Answer 27

a) Documented episodes of periodic breathing

Infantile apnea or periodic breathing (periods of less than 15-20 seconds) without pallor, cyanosis, or limpness is normal and not related to SIDS.

Question 28

In the management of a child with bronchiolitis the early use of which of the following is likely to be the most beneficial?

a) antihistamines
b) broad spectrum antibiotics
c) fluids and nutritional support
d) bronchodilators

Answer 28

c) fluids and nutritional support

Medications are not routinely recommended. Bronchodilators and corticosteroids can be used in select infants.

Question 29

A NICU graduate with bronchopulmonary dysplasia (BPD) has been discharged home. A potential problem area that requires close monitoring is:

a) insufficient caloric intake
b) atrophy of abdominal muscles due to abdominal breathing patterns
c) lack of tactile stimuli due to restrictions on parental handling
d) the predisposition to development of nasal polyps

Answer 29

a) insufficient caloric intake

The pathophysiology of BPD is similar to chronic obstructive lung disease. Diuretic use and limitation of fluids is often part of the management plan. Limitation of fluids may make it difficult to provide adequate caloric intake.

Question 30

A 4 yo child with CF comes to the primary care office with complaints of runny nose, cough, congestion, and fever. You know that children with CF:

a) are more likely to have normal CXR and LFT findings
b) usually are poor eaters with accompanying poor growth
c) routinely take an oral mucolytic agent
d) warrant more liberal use of antibiotics for respiratory infections

Answer 30

d) warrant more liberal use of antibiotics for respiratory infections

Children with CF are more vulnerable to serious respiratory infection, so liberal use of antibiotics is the best course of action.

Question 31

To promote normal growth in the child with CF, dietary management should include:

a) limited fats and 50% more calories than usual daily allowances
b) liberal fats and 50% more calories than usual daily allowances
c) the usual number of calories as indicated by height and weight plus fat soluble vitamins
d) limited fat and sodium in moderation

Answer 31

b) liberal fats and 50% more calories than usual daily allowances

Because of steatorrhea and metabolic demands, the child with cystic fibrosis should receive 50% more calories than the usual daily allowance. Liberal fat should be allowed in the diet and may even be supplemented with MCT oil and polycose.

Question 32

A 10 day old is brought to the clinic due to a concern about his breathing. He often stops breathing for periods of about 10 seconds while feeding. History reveals that he eats well, has never appeared pale or cyanotic, and has never become limp during apnea episodes. Your management plan is based on which of the following?

a) This is a normal breathing pattern for an infant
b) these episodes likely indicate asperation of formula and should be evaluated
c) a variety of pathologic processes are associated with the episodes described.
d) Neurologic deficits in infants are often manifested by such episodes

Answer 32

a) This is a normal breathing pattern for an infant

Brief apnea episodes (less than 15-20 seconds) are normal in infants and are most frequent in preterm infants. These normal episodes are not associated with pallor, cyanosis, or hypotonia.

Question 33

A 4 yo female has a history of asthma. Her mother brings her to the clinic and states that pt has been coughing and wheezing severely for the past 10 hours. PE reveals a RR of 14. Respirations areshallow without wheezing and there are no retractions. What is the most likely reason that wheezing is not auscultated?

a) Pt is upset about something and has faked an asthma attack
b) Pt’s mother needs education regarding identification of wheezing
c) Pt’s condition has improved significantly
d) Wheezes are not being generated because breathing is shallow

Answer 33

d) Wheezes are not being generated because breathing is shallow

A RR of 14 breaths per minute for a 4 yo is slow and is an indicator that there is muscle fatigue or that the child is in extreme respiratory distress. When a wheezing child develops muscle fatigue, a wheeze may not be generated, even in the presence of severe obstruction.

Question 34

A 4 yo female has a history of asthma. Her mother brings her to the clinic and states that pt has been coughing and wheezing severely for the past 10 hours. PE reveals a RR of 14. Respirations areshallow without wheezing and there are no retractions. Appropriate initial management of pt’s condition is to:

a) talk with pt alone and ask what is upsetting her
b) educate the mother regarding identification of wheezing
c) tell pt’s mother to continue with treatment that has been effective in the past
d) administer a bronchodilator

Answer 34

d) administer a bronchodilator

When there are signs of muscle fatigue, and breathing is shallow in a known asthmatic, a bronchodilator should be given to help relieve airway obstruction.

Question 35

A 5 mo is brought to the clinic for coughing and clear rhinorrhea for the past 5 days. His mom tells you he has never been sick before. Family history is positive for allergies and you hear generalized wheezing. You may conclude that:

a) Pt has familial asthma
b) Pt has asthma exacerbated by a viral infection
c) Pt should be referred for allergy testing
d) Asthma should not be diagnosed at this stage

Answer 35

d) Asthma should not be diagnosed at this stage

Asthma is not diagnosed during a child’s first episode of wheezing but after a documented pattern of recurrent wheezing responsive to bronchodilator therapy. Differential diagnosis should include foreign body, congenital malformation, and bronchiolitis.

Question 36

When educating parents regarding transmission of RSV it is important to stress which of the following?

a) children with RSV should be totally isolated from other children
b) RSV can be spread by airborne droplets or from contact with a hard surface that has been contaminated
c) children who attend daycare centers should take prophylactic antibiotics early each fall
d) wiping hard surfaces with soap and water or disinfectant will not help the transmission of RSV transmission

Answer 36

b) RSV can be spread by airborne droplets or from contact with a hard surface that has been contaminated

The virus can be spread both directly and indirectly. One means of RSV transmission is by touching an RSV contaminated fomite, such as a counter or doorknob. Cleaning such environmental surfaces can be effective, as RSV can live for many hours on surfaces.

Question 37

In mild to moderate attacks of acute asthma, albuterol should be given every 3-4 hours and routine medications should be:

a) continued as usual
b) discontinued until albuterol treatments are deemed unnecessary
c) given only if the albuterol is ineffective
d) be decreased to the minimum recommended dose

Answer 37

a) continued as usual

Routine asthma medications should continue even when albuterol is needed. A review of routine medications may indicate a step-up in controller medications.

Question 38

A 5 yo presents to the clinic with inspiratory stridor, drooling, and a temperature of 105. He insists on sitting up during the clinical exam. This clinical picture is most consistent with a diagnosis of:

a) aspiration of foreign body
b) reactive airway disease
c) viral croup
d) epiglottitis

Answer 38

d) epiglottitis

Epiglottitis usually occurs in children ages 2-6 years, while croup usually occurs in children ages 3 months to 3 years. The child with epiglottitis runs a high fever, drools, and insists on sitting up, usually in the tripod position.

Question 39

A 5 yo presents to the clinic with inspiratory stridor, drooling, and a temperature of 105. He insists on sitting up during the clinical exam. Appropriate initial management of this pt includes:

a) high doses of an oral broad spectrum antibiotic and antipyretics
b) teaching the mother to administer racemic epinephrine by nebulization
c) teaching the mother how to administer loading and decreasing doses of prednisone
d) immediate hospitalization with IV antibiotics

Answer 39

d) immediate hospitalization with IV antibiotics

Epiglotittis progresses quickly and is a medical emergency. Initial therapy is hospitalization.

Question 40

A diagnosis of croup is substantiated by which radiographic finding?

a) ground glass appearance in the upper airway
b) sparse areas of atelectasis
c) thumb sign on lateral view
d) hourglass narrowing in the subglottic region

Answer 40

d) hourglass narrowing in the subglottic region

Inflammation in the subglottic region causes narrowing, resulting in an “hourglass” or “steeple” sign seen best on posteroanterior view.

Question 41

A lethargic appearing 18 mo child presents to the clinic with signs and symptoms of croup. PE reveals a RR of 20 and mild dehydration. Appropriate management includes:

a) Instructing the mother to force fluids and use a cool mist humidifier in the child’s room
b) Instructing the mother to liberally give fluids and encourage intake of solid foods
c) Prescribing an oral broad spectrum antibiotic and prednisone
d) Referring the child for hospitalization and IV fluids

Answer 41

d) Referring the child for hospitalization and IV fluids

A respiratory rate of 20 in an 18 mo child accompanied by lethargy and mild dehydration, likely indicates that he has become fatigued from the increased effort of breathing. The child should be hospitalized, given IV fluids to allow for rest and rehydration while respiratory status is closely monitored.

Question 42

A 6 mo boy is brought to the clinic because he has been coughing since yesterday. His mother states that he has never been sick before. She thinks he is febrile but is not sure. PE reveals a well developed baby with a RR of 50, mild retractions, wheezes, and a dry cough. CXR reveals diffuse hyperinflation and patchy areas of infiltration. These findings are most consistent with a diagnosis of:

a) laryngotracheobronchitis
b) cystic fibrosis
c) bronchiolitis
d) respiratory distress syndrome

Answer 42

c) bronchiolitis

The infant with bronciolitis typically presents with low-grade fever, cough, dyspnea, and wheezing. Chest radiograph reveals hyperinflation and perhaps patchy infiltrates.

Question 43

A 22 mo male has been brought to the clinic by his mother who says he has been coughing for 2 days and is now making a funny noise when he breaths. PE reveals a fussy child with a brassy cough and inspiratory stridor. Lips and nail beds are pink. Temp is 103 and RR is 50. The most likely diagnosis of this pt’s condition is:

a) laryngotracheobronchitis
b) bronchiolitis
c) respiratory distress syndrome
d) reactive airway disease

Answer 43

a) laryngotracheobronchitis

Laryngotracheobronchitis (croup) is the most common cause of stridor. Stridor is usually caused by an upper airway condition.

Question 44

A 22 mo male has been brought to the clinic by his mother who says he has been coughing for 2 days and is now making a funny noise when he breaths. PE reveals a fussy child with a brassy cough and inspiratory stridor. Lips and nail beds are pink. Temp is 103 and RR is 50. Which diagnostic test should be ordered first?

a) pulmonary function test
b) throat culture
c) radiograph of the upper airway
d) laryngoscopic examination

Answer 44

c) radiograph of the upper airway

Since stridor is usually caused by an upper-airway condition such as croup, epiglottitis, or foreign body aspiration, radiograph of the upper airway is helpful in diagnosing the cause of stridor.

Question 45

A 4 yo female stays with her great aunt during the day while her mom is at work. Her mom brings her to the clinic because the great aunt has just been diagnosed with TB. Pt’s Mantoux skin test is positive but there is no clinical or radiographic evidence of disease. Appropriate management includes:

a) reassuring pt’s mother that no treatment is needed
b) administering another skin test in 3 months
c) oral penicillin therapy
d) oral preventative isoniazid therapy

Answer 45

d) oral preventative isoniazid therapy

Isoniazid therapy is indicated if a child has a positive TB skin test and known exposure to TB even if there is no clinical or radiographic evidence of disease. Referral to a pediatric pulmonologist and reporting to the health department are also indicated.

Question 46

The mother of a 2 yo has brought her into the clinic with a bad cough. Onset was 4 days ago with clear rhinorrhea and coughing. Temperature has been as high as 103, currently 101. RR 56 with slight nasal flaring and intercostal, subcostal, and suprasternal retractions. the pharynx is red without tonsillar exudate. Chest auscultation reveals widespread rales and wheezing. The lips and nail beds are slightly pale but pink, skin turgor is good, and mucous membranes are moist. The most likely diagnosis is:

a) Viral pneumonia
b) Pneumococcal pneumonia
c) Streptococcal pneumonia
d) Haemophilus influenzae type b pneumonia

Answer 46

a) Viral pneumonia

Respiratory viruses (particularly RSV, adenovirus, parainfluenza virus types 1, 2, and 3), and enterovirus are the most common cause of pneumonia during the first several years of life. The condition is usually preceded by rhinitis and cough for several days. Temperatures with viral pneumonia are generally lower than with bacterial pneumonia. Rales and wheezing are common.

Question 47

The mother of a 2 yo has brought her into the clinic with a bad cough. Onset was 4 days ago with clear rhinorrhea and coughing. Temperature has been as high as 103, currently 101. RR 56 with slight nasal flaring and intercostal, subcostal, and suprasternal retractions. the pharynx is red without tonsillar exudate. Chest auscultation reveals widespread rales and wheezing. The lips and nail beds are slightly pale but pink, skin turgor is good, and mucous membranes are moist. Initially she should receive which diagnostic test?

a) sputum culture
b) sputum gram stain
c) chest radiograph
d) ESR

Answer 47

c) chest radiograph

Pneumonia is diagnosed by chest radiograph. An ESR will indicate inflammation, but not pneumonia.

Question 48

The mother of a 2 yo has brought her into the clinic with a bad cough. Onset was 4 days ago with clear rhinorrhea and coughing. Temperature has been as high as 103, currently 101. RR 56 with slight nasal flaring and intercostal, subcostal, and suprasternal retractions. the pharynx is red without tonsillar exudate. Chest auscultation reveals widespread rales and wheezing. The lips and nail beds are slightly pale but pink, skin turgor is good, and mucous membranes are moist. When deciding to treat at home or in the hospital it is most important to consider:

a) maximum temperature
b) frequency of coughing episodes
c) hydration status
d) total length of illness

Answer 48

c) hydration status

Children with viral pneumonia are usually treated at home with supportive measures unless they need IV fluids, oxygen, or assisted ventilation.

Question 49

Corticosteroid dosing for croup:

Answer 49

Dexamethasone 0.6mg/kg once, max dose 16mg

Question 50

Physical findings pneumonia:

Answer 50

1) fever (usually abrupt onset) with bacterial pneumonia
2) tachypnea (most consistent finding)
3) retractions
4) pallor
5) cyanosis/decreased O2 saturation
6) rales, crackles, wheezing (more common with viral), diminished breath sounds
7) chest pain, nausea/vomiting are common complaints

Question 51

First line treatment for bacterial pneumonia (outpatient):

Answer 51

4 mo-5 yr: Amoxicillin 90mg/kg/day
divided doses every 12 hours, max dose 4000mg/day

5 yr+: Azithromycin 10mg/kg once on day 1 (max dose 500mg) followed by 5mg/kg (max dose 250mg) once daily on days 2-5

Question 52

First line treatment for bacterial pneumonia (inpatient):

Answer 52

Birth-3 weeks: IV ampicillin and a third generation cephalosporin (ceftriaxone/Rocephin, cefdinir/Omnicef) x 10-21 days

3 weeks and up: IV cephalasporin with or without a macrolide x 10 days

Question 53

Role of PCP for patients with CF (3):

Answer 53

1) annual influenza vaccine
2) more liberal use of antibiotics for respiratory infections
3) be alert to signs of CF complications (small bowel obstruction, pancreatitis, CF related diabetes, salt loss syndromes)

Question 54

Pulmonary Function Testing (spirometry) is the gold standard for diagnosing asthma and begins at what age?

Answer 54

4-5 years old.

Question 55

What does spirometry reveal in a child with asthma?

Answer 55

Demonstrates obstruction and assesses reversibility:

1) Lower airway obstruction is indicated by reduction in the values for FEV1 (the forced expiratory in 1 second) and the FEV1/FVC (forced volume vital capacity) relative to predicted values.
2) Reversibility is demonstrated by an increase of FEV1 at least 12% from baseline or 10% from predicted after using a short-acting beta2 agonist.

Question 56

Management of bronchopulmonary dysplasia (BPD) (10):

Answer 56

1) maintain O2 sat at 92% or greater, wean as tolerated
2) nutritional supplementation with hypercaloric formulas (nutrition referral)
3) balance nutrition volume with fluid restriction when fluid sensitive
4) treat GER as needed
5) bronchodilators to decrease airway resistance
6) diuretics as needed
7) immunizations (including flu and RSV)
8) smoke free environment
9) good hand washing
10) close follow up (monthly) and refer as needed (pulmonology, cardiology, nephology, etc.)

Question 57

Apparent life threatening event (ALTE):

Answer 57

1) an episode that the observer believes is life threatening
2) includes some combination of apnea, change in skin color, marked change in muscle tone, choking or gagging, and requires significant intervention to restore normal breathing
3) more than 50% of episodes remain unexplained approximately half are associated with GI, followed by neuro and respiratory

Question 58

Positive TB skin test:

Answer 58

Reaction of 15mm or greater is considered positive in any population.
Reaction of 5-14mm may be considered positive if high-risk group.
Must report positive TB result to the health department.

Question 59

First line treatment for latent tuberculosis infection:

Answer 59

Isoniazid 10-20 mg/kg/day (max 300mg/day) once daily for 9 months