Miscellaneous

Question 1

When enlarged, which lymph nodes are most likely to be a sign of pathology (i.e., malignancy)?

Answer 1

Supraclavicular

Question 2

A congenital defect in the immune system of a 2-week-old infant may be suspected if:

Answer 2

the umbilical cord has not yet dropped off leukocyte adhesion defect (LAD) -AR defect in integrin beta2 -impaired chemotaxis -umbilical cord doesn’t fall off -severe immunodeficiency -death usu by age 5 -dx: monoclonal anti-CD11 (because the CD11 antigen is missing from the surface of the WBCs)

Question 3

When examining the skull of a 4-month-old baby, you should normally find closure of what fontanel?

Answer 3

closure of the posterior fontanel

Question 4

Gail is an 18-year-old high school student who comes to the clinic with headaches of six weeks duration. She tells the medical assistant about her heavy schedule, including part-time work and sport schedule. Her vital signs are normal. Which information is most appropriate to Gail’s history?

Answer 4

current medications

Question 5

During a head and neck assessment of a neonate, it is important to screen for: presence of torticollis signs and symptoms of cerebral palsy. uneven movement of the eyes. unilateral movement of the tongue

Answer 5

presence of torticollis

Question 6

Spasmodic muscular contractions of the head, face, or neck are called:

Answer 6

tics

Question 7

Term infants have a visual acuity of about:

Answer 7

20/200

Question 8

Which of the following findings, when seen in the infant, is more ominous? Difficulty tracking objects with the eyes Appearing to have better peripheral than central vision Blinking when bright light is directed at face White pupils on photographs

Answer 8

White pupils on photographs

Question 9

An allergy can cause the conjunctiva to have what kind of pattern?

Answer 9

cobblestone pattern.

Question 10

Bulging of an amber tympanic membrane without mobility is most often associated with?

Answer 10

middle ear effusion

Question 11

You should measure the child’s head circumference at every health visit until age ______ months?

Answer 11

24 months

Question 12

Which of the following situations poses the most concern? The child whose weight and height ratios have remained at the 50th percentile. The child whose weight and height ratios have stayed between the 90th and 95th percentiles. The child whose weight and height ratios have never been above the 50th percentile. The child whose weight and height ratios have dropped 15 percentiles in the last two visits.

Answer 12

The child whose weight and height ratios have dropped 15 percentiles in the last two visits.

Question 13

Healthy term babies generally double their birth weight by what age?

Answer 13

6 months

Question 14

Which of these primitive reflexes would you expect to see in an 8-month-old infant?

Answer 14

Plantar grasp

Question 15

You are doing a well child exam on Jane and note that she has no significant head lag when pulled from a supine to a sitting position. What is the expected age that this developmental task occurs?

Answer 15

Over 4 months

Question 16

Which components of the health maintenance visit are essential to each visit?

Answer 16

Immunization review

Question 17

A 4-year 5 month-old child presents for her preschool physical. The family is expecting a new baby in 2 months. The child’s history is significant for recurrent otitis media with effusion (OME). She is starting kindergarten in the fall and her mother has concerns about her adjustment to a new baby in the family. Additionally, she has been awakening with nightmares over the past 2 months. Her review of systems (ROS) in noncontributory and her physical exam is normal for her age. Among the following options, what is the best response to the family regarding the child’s sleep problems? “ Preschool children more often have night terrors than nightmares.” “It is abnormal for healthy preschool children to have nightmares.” “Preschool children more often have night terrors than nightmares.” “Nightmares are common during the preschool years and during times of stress.” None of the above

Answer 17

“Nightmares are common during the preschool years and during times of stress.”

Question 18

At what age is it recommended that a child begin dental check ups with a dentist?

Answer 18

1 year

Question 19

My 18-month-old isn’t eating as well as before, is this finding normal?

Answer 19

Yes

Question 20

A 3-year-old child can be expected to do all the following EXCEPT copy a square alternate feet when climbing stairs name one color speak in short sentences

Answer 20

copy a square

Question 21

Jaundice in the first 24 hours of life may be caused by all of the following except: ABO hemolytic disease Rh incmpatibility cytomegalic inclusion disease bacterial sepsis Correct breastfeeding

Answer 21

Correct breastfeeding

Question 22

For each set pf physical findings listed below, select the appoipriate Tanner sexual maturity rating A. Preadolscent penis and testes with no pubic hair B. Sparse, slightly pigmented pubic hair, breast and papilla elevated C. Coarse, curly pubic hair over the junction of the mons with aerola and papilla forming a secondary mound Slight enlargement of penis and scrotum with scanty pubic hair Mature breasts, adult feminine triangle of pubic hair A. Tanner stage 1 B. Tanner stage 2 C. Tanner stage 4 D. Tanner stage 2 E. Tanner stage 5

Answer 22

A. Tanner Stage 1 B. Tanner Stage 2 C. Tanner Stage 4 D. Tanner Stage 2 E. Tanner Stage 5

Question 23

At a routine well visit the mother of an 11 year old girl asks when the child will begin menstruating. The child is at Breast Stage 2 on the Sexual Maturity Rating scale. You reply that:

Answer 23

she will reach menarche in approximately 2 years

Question 24

Normal full-term newborns demonstrate each of the following reflex reactions EXCEPT stepping reflex palmar grasp placing reflex parachute reaction rooting reflex

Answer 24

parachute reaction

Question 25

Tim is a 13 year old and has told you that some of his friends smoke cigarettes. He has a crush on a girl in his class. In counseling him to avoid tobacco use, which rationale is MOST likely to appeal to him? Tobacco is linked to increased rates of lung cancer. Smoking cigarettes can stain his teeth and give him bad breath. Tobacco increases his risk of dying from a heart attack. Smoking cigarettes is expensive in the long run.

Answer 25

Smoking cigarettes can stain his teeth and give him bad breath.

Question 26

Which of the following teenagers is most likely to be interested in risk-taking behaviors? An 11-year-old girl who is Tanner 2. An 14-year-old girl who is Tanner 3. An 12-year-old boy who is Tanner 2. A 13 year old girl who is Tanner 5

Answer 26

A 13 year old girl who is Tanner 5

Question 27

A mother brings in her 4 day old infant to the clinic because she is concerned about a lump she felt on the left side of the baby’s neck. The infant holds her head tilted to the left and resists attempts to move her head to midline. The mass is soft, non-tender, and seems to be attached to the sternocleidomastoid muscle. The NP recommends: a sepsis workup two weeks of amoxicillin to treat cervical adendnitis A referal to a surgeon for biopsy of the mass and removal. A referral to physical therapy for exercises to treat torticollis.

Answer 27

A referral to physical therapy for exercises to treat torticollis.

Question 28

A 2 week old full term healthy infant comes to the clinic for her first visit. She is the youngest of four siblings. The mother is concerned about the infant’s belly button. She says, “it does not look like any of my other childrens: A moist white base at the umbilicus after the accompanying crusting has been removed is noted. What should the NP do? Suggest using gauze to be worn until all is healed. Apply silver nitrate to the area at the base of the umbilicus. Advise the mother to clean the area frequently and vigorously with alcohol for 10 more days. Have the mother place a coin over the area to prevent an “outie” belly button.

Answer 28

Apply silver nitrate to the area at the base of the umbilicus.

Question 29

The mother of a 1 week old infant calls because she is concerned about her infant’s bowel movement’s. She reports six to ten soft seedy stools each day. She denies fever in the infant, and states the baby is actively nursing. There are 10-12 wet diapers daily. Which of the following responses is the best approach to care for this neonate? I am concerned about the number of stools; we need to see this baby immediately. This sounds like a normal stool pattern for a breast fed infant, just continue to breast feed on demand. The baby may have a viral gastroenteritis. Dehydration is a major concern; I would feel best if you took the baby to the Emergency Department for evaluation. I would like for you to bring him daily for the next couple of days, for us to check his weight.

Answer 29

This sounds like a normal stool pattern for a breast fed infant, just continue to breast feed on demand.

Question 30

The female athlete triad includes?

Answer 30

osteoporosis anorexia amenorrhea

Question 31

Which of the following is the most likely source of lead intoxification in children in the US?

Answer 31

contaminated paint dust

Question 32

A preschooler is brought to the clinic with a history of an insect bite last evening. What presenting symptoms would be associated with the bite of a brown recluse spider? paresthesias in all extremities edematous, erythemic area with coalescing macules tissue sloughing in the bite area within 8-10 hours development of a central black eschar or “sinking infarct” in 6-12 hours

Answer 32

development of a central black eschar or “sinking infarct” in 6-12 hours

Question 33

The nurse practitioner understands that cat bites become infected more often than dog bites because dogs have a cleaner mouth than cats cat bites are often deep puncture wounds dog bites are usually on the face making them more suspectible to infection cat bites are usually associated with clawing and spreading of microorganisms

Answer 33

cat bites are often deep puncture wounds

Question 34

When do most bites/stings, from insects, spiders, snakes and bees most commonly occur?

Answer 34

Summer

Question 35

As adolescent was bitten on the face by a neighbor’s dog three days ago. He has developed an infection in the wound area. What would be appropriate management of this adolescent? prescribe amoxicillin-clauvulanate potassium (Augmentin) 500-875 mg PO bid for 10 days approximate the edges of the wound with suture prescribe cephalexin 500 mg PO qid for 10 days have the adolescent keep the wound clean with soap and water and return to the clinic for follow up in one week

Answer 35

prescribe amoxicillin-clauvulanate potassium (Augmentin) 500-875 mg PO bid for 10 days

Question 36

A school age child was bitten by a black widow spider while out in the yard. He is having a severe reaction: the nurse practitioner expects hypotension and shock localized pain, erythema, and edema in the area of the bite black eschar of sloughing tissue within 4 hours of the bite abdominal rigidity, nausea, and headache

Answer 36

abdominal rigidity, nausea, and headache

Question 37

Management of a brown recluse spider bite includes: warm, moist soaks to the area ice pack and elevation of the area active and passive range of motion avoiding antihistamines

Answer 37

ice pack and elevation of the area

Question 38

A pregnant teen is concerned about mercury exposure to her unborn child. Consumption of which poses the LEAST risk? shark steaks albacore tuna light canned tuna sword fish

Answer 38

light canned tuna

Question 39

Most pediatric cases of symptomatic lead poisoning in the US occur in children less than 6 months between 6 and 12 months between 1 and 3 years between 3 and 5 years

Answer 39

between 1 and 3 years

Question 40

In regard to screening programs, the concentration of whole-blood lead at which one should undertake watchful and continued medical evaluation of the child (no medications) 10ug/dL 1ug/dL 45ug/dL 60ug/dL

Answer 40

10ug/dL

Question 41

You have seen a seven-year-old female who has evidence of breast budding. True sexual precocity is most likely caused by: exogenous estrogrens a feminizing ovarian tumor a lesion of the central nervous system early onset “normal” puberty

Answer 41

early onset “normal” puberty

Question 42

The physical finding to differentiate pathological from normal gynecomastia is: unequal breast breast tenderness breast size greater than 3 cm evident in prepubescent boys

Answer 42

breast size greater than 3 cm

Question 43

A 15-year-old female has a mass in her neck. When determining whether this could be hypothyroidism versus hyperthyroidism what physical findings would indicate Graves disease? heat intolerance, tachycardia, lid lag cold intolerance, unexplained weight changes, dry skin heat intolerance, bradycardia, motor hyperactivity tremors, delayed maturation, impared cognition

Answer 43

heat intolerance, tachycardia, lid lag

Question 44

What single test can differentiate hypo- versus hyperthyroidism? TSH T3 T4 thyroid antibodies

Answer 44

TSH

Question 45

Hirsutism presenting in a young female with normal menstruation and normal plasma androgens is most likely: An ovarian tumor Cushing’s syndrome Idiopathic Polycystic ovary disease (POS)

Answer 45

Idiopathic

Question 46

A mother brings her school age child to the nurse practitioner and expresses her concern that her son is the shortest child in his class and asks if something is the matter with him. Initial differentiation of cause of the child’s short stature by the nurse practitioner would include: History and physical exam, including Tanner stage with possible skeletal maturation assessed by radiography, if indicated. History, physical exam, and trial tratment with growth hormone. Immediate referral to an endocrinologist. Physical exam and complete blood count, thyroid function panel, urinalysis, karotyping, chemistry profile, and insulin sensitivity tests.

Answer 46

History and physical exam, including Tanner stage with possible skeletal maturation assessed by radiography, if indicated.

Question 47

Which of the following findings would the nurse practitioner expect to find in a child with pubertal gynecomastia? Tanner stage II with testes

Answer 47

Breast tissue enlargement mainly glandular, moveable, and nonadherent to skin or underlying tissue.

Question 48

The nurse practitioner notes the following on physical examination of a 14-year-old adolescent who complains of amenorrhea: blood pressure 138/90, pulse 98, broad chest with widely spaced nipples, Tanner stage I, webbing of neck, low hairline, and prominent, anomalous ears. The nurse practitioner suspects: Klinefelter’s syndrome Marfan’s syndrome Fragile X syndrome Turner’s syndrome

Answer 48

Turner’s syndrome

Question 49

A 6-year-old with hypothyroidism diagnosed shortly after birth is seen by the nurse practitioner for a routine physical exam. His temperature is 96.8 degree F. and his pulse is 68. The mother states that she has noticed that the child has been constipated and seems to be more tired than usual. Based on the history of this child, the nurse practitioner should suspect: The child has been taking too much of the levothyroxine (Synthroid) and is exhibiting symptoms of toxicity. The child needs to add more fluids to his diet to correct his constipation. The child needs to have his dose of levothyroxine (Synthroid) increased because he is exhibiting signs of hypothyroidism. The child has “outgrown” his hypothyroidism and no longer needs levothyroxine (Synthroid).

Answer 49

The child needs to have his dose of levothyroxine (Synthroid) increased because he is exhibiting signs of hypothyroidism.

Question 50

In evaluating the laboratory values taken from a client with Graves’ disease, one should expect: TSH levels to be increased TSH levels to be decreased. TSH levels to be within normal levels. Thyroxine (T4) levels to be decreased

Answer 50

TSH levels to be decreased.

Question 51

While examining 8-year-old E.G.’s scalp you note three small patches of hair loss. Broken hair is present as is erythema and scaling. Based on this information, which of the following diagnoses is most likely? traction alopecia trichotillomania tinea capitis alopecia areata

Answer 51

tinea capitis

Question 52

A child presents with a history of a non-blanching purpuric rash with a centrifugal distribution and a fever. The nurse practitioner who examines this child should be highly suspicious of: rubella lyme disease meningococcemia roseola

Answer 52

meningococcemia

Question 53

A 6-year-old female presents with several dry, raised, periungual lesions on the two middle fingers of her left hand. She has a history of nail biting. The most likely diagnosis is: impetigo molluscum contagiosum common wart herpetic whitlow

Answer 53

common wart

Question 54

In infants, the lesions associated with atopic dermatitis are most likely to appear on the: wrist and ankles cheeks and forehead antecubital and popliteal fossae flexural surfaces

Answer 54

cheeks and forehead

Question 55

5-month-old has been irritable and not sleeping well. During the physical examination you note papular lesions on his feet and erythematous papules over his back. To confirm your suspicion of scabies you would order a: wood’s lamp examination microscopic skin scraping KOH preparation of skin scraping skin culture

Answer 55

microscopic skin scraping Skin scrapings are examined for scabies mites and eggs. It is important that we receive at least four cover slips with visible skin scrapings. Mites burrow and for the test to be accurate more than superficial surface skin needs to be examined.

Question 56

5-year-old J.D. presents at clinic with a single weepy lesion around his upper lip. Incorrect herpes simplex Answers: herpes simplex varicella nummular eczema impetigo

Answer 56

impetigo

Question 57

The characteristic that best differentiates psoriasis from other skin abnormalities is the: color of the scales. formation of tiny papules. general distribution over the body. recurrence.

Answer 57

color of the scales

Question 58

Painful vesicles are associated with: psoriasis. paronychia. herpes zoster. pityriasis rosea.

Answer 58

herpes zoster

Question 59

A 17-year-old student complains of a “rash for 3 days.” You note pale, erythematous oval plaques over the trunk. They have fine scales and are arranged in a fernlike pattern with parallel alignment. What is the nurse’s next action? Teach infectious control measures Inquire about another recent skin lesion. Inspect the palms and the soles. Inform the patient that this will resolve within a week

Answer 59

Inquire about another recent skin lesion.

Question 60

You are conducting a preschool examination on a 5-year-old child. Which injury would most likely raise your suspicion that the child was being abused? Recent bruising over both knees A healed laceration under the chin A bruise on the right shin with associated abrasion of tissue Bruises in various stages of resolution over posterior surfaces

Answer 60

Bruises in various stages of resolution over posterior surfaces

Question 61

A practice team that coordinates a person’s care across episodes and specialties?

Answer 61

a medical home

Question 62

Measurement for growth should be plotted on the Centers for Disease Control and Prevention (CDC) growth and BMI-for-age charts, looking for appropriate changes over time. Further investigation or anticipatory guidance for growth should occur when the child

Answer 62

begins to deviate from his/her normal percentiles.

Question 63

During a health supervision encounter, there are four activities that generally occur, including disease detection, health promotion, anticipatory guidance and

Answer 63

disease prevention

Question 64

Car safety is a critical area to address in a well child visit because many pediatric deaths are related to motor vehicle crashes when children are inadequately restrained. All children should ride in the backseat until 13-years of age and use a belt-positioning booster seat between the ages of

Answer 64

8-12 years old and 4’9” tall

Question 65

Young children lack the neurologic maturity, skills, and knowledge needed to safely cross the street. They have not developed neurologically to have the skills to see cars in their peripheral vision, localize sounds, and judge vehicle distance and speed, and, in general, are not ready to cross the street alone until they are at least

Answer 65

10 years of age

Question 66

What is the most common chronic disease in children? a. Asthma b. Allergic rhinitis c. Caries d. Diabetes mellitus

Answer 66

c. Caries

Question 67

What is the most serious complication from Pierre Robin syndrome? a. Airway obstruction b. Increased PaCO2 c. Poor weight gain d. Respiratory distress

Answer 67

a. Airway obstruction

Question 68

Carly is being evaluated during a 9-month well-child check. She is noted to have two lower central incisors erupted and is low-risk for dental caries. Anticipatory guidance during this visit includes a. brushing her teeth with a fluoridated toothpaste daily. b. brushing her teeth with a pea-sized amount of fluoride toothpaste twice daily. c. brushing her teeth with plain water twice daily. d. beginning visits with a dentist every 6 months.

Answer 68

c. brushing her teeth with plain water twice daily.

Question 69

What method is used to screen newborns for hearing? a. Acoustic reflectometry b. Audiometry c. Auditory brainstem response d. Evoked otoacoustic emission

Answer 69

d. Evoked otoacoustic emission

Question 70

The American Academy of Pediatrics, American Association of Certified Orthoptists, and the American Academy of Ophthalmologists recommends visual acuity screening starting at age: a. 2 years. b. 3 years. c. 4 years. d. 5 years.

Answer 70

b. 3 years

Question 71

H. O. is a 5-year-old Vietnamese child who has fallen off of his growth curve. The best intervention would be to: a. Suggest high-calorie breakfast drinks as supplements b. Incorporate traditional foods into a management plan that will provide increased calories and nutrients c. Educate the family on the need for increased calories and nutrients d. Refer family to growth clinic for evaluation

Answer 71

b. Incorporate traditional foods into a management plan that will provide increased calories and nutrients

Question 72

While taking the history of 6-monthold E. M., you learn that she is not sleeping through the night and will not fall back to sleep without the parents rocking or feeding her. This is an example of: a. Somnambulism b. Pavor nocturnus c. Learned behavior d. Delayed sleep phase

Answer 72

c. Learned behavior Learned behavior is a result of parents interfering with with the child’s attempt to return to sleep without stimulation from the parents.

Question 73

What is somnambulism?

Answer 73

Sleepwalking - a sleep disturbance

Question 74

What is pavor nocturnus?

Answer 74

night terrors - a sleep disturbance Sleep disturbances occur in school age and preschool age children.

Question 75

Which of the following scenarios is suggestive of a child who may not be ready to enter first grade? An inability to: a. Recognize six colors and remember one’s phone number b. Accurately use pronouns c. Empathize with others d. Count to five and draw a person with three parts

Answer 75

d. Count to five and draw a person with three parts. Children entering first grade should have the requisite skills to master the tasks they will encounter. This includes language, fine and gross motor skills, and personal and social skills. At this age the child should be able to draw a person with at least six parts and count to 10 or more.

Question 76

T. T. is a 9-week-old preterm infant whose birth weight was 2.3 kg. Mom was HBs Ag negative. He is seen today for the first time since discharge from the nursery. He has received no prior immunizations. The appropriate immunizations to give at this time would be: a. DTaP, Hib, IPV, rotavirus, Hep B-1, pneumococcal b. DTP, Hib, OPV, rotavirus, Hep B-1 c. DTaP, Hib, rotavirus, IPV, pneumococcal d. DTaP, Hib, IPV, pneumococcal

Answer 76

a. DTaP, Hib, IPV, rotavirus, Hep B-1, pneumococcal Preterm infants should be immunized at the usual chronologic age with the regular doses. IPV should be given to avoid nosocomial transmission of polio virus vaccine strain.

Question 77

While examining 10-year-old R. M.’s teeth you note that the upper incisors slightly overlap the lower incisors. The second and lower first molars are absent. Your assessment is: a. Malocclusion b. Delayed mandibular dentition c. Normal dentition d. Hyperdontia

Answer 77

b. Delayed mandibular dentition The mandibular (lower) molars usually erupt between ages 6 and 7. Even allowing for individual variation, this is a considerable delay. Hyperdontia refers to supernumerary teeth.

Question 78

The mother of 5-year-old D. W. is concerned that her son often cheats when playing board games with his older sister. What is the most appropriate response to D. W.’s behavior? a. Encourage the parent to use 5-minute time-outs when cheating occurs. b. Explain that D. W. is developmentally unable to comprehend rigid rules. c. Make sure that D. W. understands the rules before starting to play the game. d. Explain to D. W. that cheating is like lying and is not acceptable behavior.

Answer 78

b. Explain that D. W. is developmentally unable to comprehend rigid rules. Developmentally, the concept of cheating is not well understood until 7 years of age. The idea of playing fairly to assure everyone an equal chance occurs with maturity and the ability to differentiate among moral choices.

Question 79

Which of the following is not a sign of readiness to toilet train? a. Can sit for extended periods b. Can follow directions c. Occasional waking from naps with dry diapers d. Regularity of bowel movements

Answer 79

d. Regularity of bowel movements Regularity of bowel movements is established early in infancy but has nothing to do with voluntary sphincter control necessary for toilet training.

Question 80

Which of the following physical findings in a 2-month-old child warrants an immediate referral to a neurologist/ neurosurgeon? a. Head circumference growing faster than height and weight b. Unresolved cephalhematoma c. Rigid and immobile sagittal suture d. Snapping sensation when pressure is applied to parietal bone

Answer 80

c. Rigid and immobile sagittal suture Ridged and immobile sutures indicate premature fusing resulting in craniosynostosis. For proper brain growth, sutures need to approximate each other yet remain mobile.

Question 81

While listening to 2.5-year-old K. L. talk, you note that she frequently omits final consonants and her sentences are two to three words in length. The appropriate plan of care would be: a. Routine follow-up at next well-child visit b. Referring for hearing screen c. Assessing for developmental delays d. Referring to a speech pathologist

Answer 81

a. Routine follow-up at next well-child visit Children aged 2 to 3 years have several articulation disfluencies, among them is the dropping of final consonants. Two- to three-word sentences are normal for the 24- to 30-month-old child.

Question 82

The mother of 3-year-old G. W. reports that he has begun to stutter. Further probing reveals that the stuttering occurs frequently and lasts 1 to 2 seconds. G.W. does not seem bothered by the stuttering. The appropriate management would be: a. Referral to a speech pathologist b. Referral for an evaluation for an anxiety disorder c. Reassuring the mother that this is a mild problem d. Demonstrating to G. W. slow, deep breathing before talking

Answer 82

c. Reassuring the mother that this is a mild problem This represents a mild stuttering problem but does not warrant immediate referral unless the child or parent are increasingly concerned, or if it continues indefinitely.

Question 83

You would expect a school-age child to: a. Grow 1.5 inches per year b. Grow 0.5 inch per year c. Gain about 6 pounds per year d. Gain about 3 pounds per year

Answer 83

c. Gain about 6 pounds per year The recognized standard of physical growth of school-age children is to gain 5 to 7 pounds per year and grow about 2.5 inches per year.

Question 84

During 8-month-old L. B.’s physical examination, the father boasts that L. B. is going to be a left-handed batter since he prefers doing everything with his left hand. The appropriate response would be to: a. Ask if others in the family are left handed b. Suggest play activities that require using both hands c. Present toys more often to the right hand d. Perform a careful neurologic examination

Answer 84

d. Perform a careful neurologic examination Handedness before a year is cause for concern and may indicate cerebral palsy. A neurologic examination is indicated. The examiner should carefully assess for increase in deep tendon reflexes and tone.

Question 85

At 12 years old, Peter has been diagnosed with constitutional growth delay. Appropriate management would include: a. Starting low-dose testosterone therapy now b. Counseling regarding delayed onset of puberty c. Thyroxine replacement d. Nutritional counseling

Answer 85

b. Counseling regarding delayed onset of puberty Constitutional growth delay is considered a variant of normal marked by delayed onset of puberty, that is a delay in maturation. Laboratory studies are normal. Final growth is achieved later but is consistent with family genetics. Growth hormone r thyroxine is not recommended. Nutritional therapies will not change the outcome. Low-dose hormone therapy is appropriate for selected individuals with psychosocial concerns beginning at 14 years of age.

Question 86

Which of the following best describes behavior associated with Piaget’s concrete operations? a. Learning primarily by trial and error b. Interpreting events in relationship to themselves c. Categorizing information into lower to higher classes d. Drawing logical conclusions from observations

Answer 86

c. Categorizing information into lower to higher classes Concrete operations occur during the school-age years as children begin to understand the characteristics of things and objects. Classification is a thought process that develops during this time.

Question 87

Jeffrey, at 8 years of age, has been diagnosed with ADHD and is receiving stimulant medication. Which of the following interventions would be least helpful? a. Monthly height and weight checks b. Small frequent meals and snacks c. High-calorie supplemental drinks d. Elimination of refined sugar from diet

Answer 87

d. Elimination of refined sugar from diet Stimulant medication may decrease the appetite, so, careful monitoring of growth and a nutritional plan that encourages adequate calories is important. There is no sound evidence that sugar or artificial additives play a role in ADHD.

Question 88

The principle that growth and development becomes increasingly integrated is best demonstrated by: a. Gaining head control before raising the chest b. Bringing cup to mouth, tipping, and swallowing c. Rolling over before sitting d. Grasping with fist before using fingers

Answer 88

b. Bringing cup to mouth, tipping, and swallowing Infants must first develop hand–mouth coordination before incorporating tipping and swallowing, which is a more integrated function. Head control before raising the chest demonstrates the principle of cephalocaudal progression. Options “c” and “d” suggest proximal–distal progression.

Question 89

In males, Tanner Stage III can be distinguished from Tanner Stage II by: a. Fine, downy pubic hair at the base of penis b. Adultlike pubic hair not extending to thighs c. Penile growth in width d. Penile growth in length

Answer 89

d. Penile growth in length Most penile growth in Tanner Stage III is in length rather than width because of underdevelopment of the corpora cavernosa. Fine, downy pubic hair appears in Stage II and adultlike appearance occurs in Stage IV.

Question 90

T. J., 13 years old, reluctantly shares with you that his “chest hurts.” On physical examination, you note unilateral breast enlargement, which is tender to palpation. You suspect physiologic gynecomastia. Which Tanner stage would support that diagnosis? a. Tanner stage I b. Tanner stage III c. Tanner Stage IV d. Tanner Stage V

Answer 90

b. Tanner stage III Physiologic gynecomastia is a common clinical finding in young adolescent males. It is usually present during Tanner Stage III.

Question 91

During a physical examination of 10.5-year-old Melissa, you note the appearance of breast buds. You tell her that she can expect which of the following in approximately 2 years? a. Growth of pubic hair b. Peak height velocity c. Onset of menses d. Axillary hair

Answer 91

c. Onset of menses Understanding the sequencing of pubertal development is important, but it must be remembered that individual timing may differ. In the female patient, pubic hair, axillary hair, and the peak height velocity generally occur before menarche.

Question 92

Adolescents who engage in risky behavior, such as driving without a seat belt, are displaying: a. A type of egocentrism b. A need for independence c. Role experimentation d. Low self-esteem

Answer 92

a. A type of egocentrism The belief that one is immune from poor or bad outcomes (e.g., death, disease) is a form of egocentrism known as personal fable in which adolescents believe that the laws of nature do not apply to them.

Question 93

An increase in which of the following behaviors is seen more frequently in late, rather than in early, adolescence? a. Value conflict with parents b. Focus on physical appearance c. Peer group involvement d. Understanding inner motivations of others

Answer 93

d. Understanding inner motivations of others Late adolescence is characterized by increased autonomy and beginning to appreciate the complexities and motivations of other people’s behaviors.

Question 94

You detect a heart murmur while examining a 3-year-old child. In determining whether or not a referral is necessary, you determine it is an “innocent” heart murmur for which of the following reasons? a. It is best heard during diastole. b. It radiates to the axilla. c. The intensity is no greater than I or II/VI. d. There is no variation with change in child’s position.

Answer 94

c. The intensity is no greater than I or II/VI. Innocent murmurs usually have an intensity of no greater than I or II/VI, occur early in systole, are not likely to radiate over parts of the chest, and the presence and intensity vary with change in the child’s position.

Question 95

When providing anticipatory guidance

about infant development, you might

teach parents that a normal infant

could first transfer an object from hand

to hand at which age?

a. 2 months
b. 4 months
c. 7 months
d. 9 months

Answer 95

c. 7 months

A normal infant transfers objects

from hand to hand by 7 months of age.

Question 96

A 2-month-old infant at your clinic

received a combined DTaP/HepB/IPV

vaccine and the parents are in need of

teaching about possible side effects.

Which of the following is not an

adverse effect following administration

of the DTaP vaccination?

a. Local reaction
b. Fever
c. Increased fussiness
d. Transient morbilliform rash

Answer 96

d. Transient morbilliform rash

A transient morbilliform rash is

an adverse effect associated with the

MMR vaccine.

Question 97

When reviewing immunization protocols

at your clinic, you are aware that

the varicella vaccine can be administered

to susceptible children beginning

at what age?

a. 4 months
b. 6 months
c. 12 months
d. 15 months

Answer 97

c. 12 months

According to the recommended

Childhood Immunization Schedule

approved by the ACIP and AAP, the

varicella vaccine can be administered at

12 months of age.

Question 98

A 2-week-old infant is in the clinic for

a scheduled weight check. The best

indication that a 2-week-old infant is

receiving adequate breastmilk is that

the baby:

a. Passes at least four stools per day
b. Feeds every three hours
c. Voids four times a day
d. Has regained birthweight

Answer 98

d. Has regained birthweight

The newborn may lose 7 to 10% of

birthweight the first three days and then

should gain 0.5 to 1 ounce a day and

regain birthweight by 2 weeks of age.

Question 99

A mother of an 8-month-old infant

asks you for advice about continued

introduction of solids. Which of the following

food groups do you recommend

be introduced to the baby last?

a. Egg yolk
b. Egg white
c. Fruits
d. Vegetables

Answer 99

b. Egg white

Rice cereal, the least allergenic of

cereals, should be offered first, followed

by fruits and vegetables, meats,

egg yolk, and egg white.

Question 100

The mother of a 15-month-old child

informs you that she feeds the baby skim

milk. You advise the mother to change to

whole milk primarily because skim milk:

a. Is not as easily digested as whole milk
b. Contains an insufficient amount of

calcium

c. Contains too little protein
d. Provides an inadequate amount of

essential fatty acids

Answer 100

d. Provides an inadequate amount of

essential fatty acids

All milk (human and cow) is deficient

in iron. Skim milk should be

avoided until 2 years of age because it

provides too few calories, an excess of

protein, and an inadequate amount of

essential fatty acids.

Question 101

An adolescent is being evaluated for

childhood depression. Which behavior

or sign is least likely to be evident?

a. Evidence of hallucinations and

delusions

b. A history of recurrent “accidents”
c. A sense of guilt
d. The presence of eating disorders

Answer 101

a. Evidence of hallucinations and

delusions

Hallucinations and delusions are

uncommon in the presentation of adolescent

depression.

Question 102

A 12-year-old boy is brought into the

clinic for an urgent visit after having

ingested 10 diazepam tablets. Following

the initial emergent care and stabilization

of the child, the most important

aspect of your management is:

a. Referring the case to the social

services

b. Assessing the family supports available

to the child

c. Obtaining a psychiatric consultation
d. Reviewing the history for signs of

depression

Answer 102

c. Obtaining a psychiatric consultation

Every actively suicidal patient,

regardless of apparent seriousness,

requires psychiatric consultation and, in

some cases, hospitalization.

Question 103

You are seeing a 15-month-old boy

with leukemia for a check-up. If indicated,

this child may receive all of the

following vaccines except:

a. Inactivated polio vaccine (IPV)
b. H. influenzae type B (Hib)
c. Diphtheria, tetanus, acellular pertussis

(DTaP)

d. Varicella (VAR)

Answer 103

d. Varicella (VAR)

Children with cancer and children

receiving high-dose corticosteroids

or other immunosuppressive agents

should not be immunized with live

virus or live bacteria vaccines. MMR is a live vaccine.

Question 104

While conducting the Denver II developmental

screening test, the mother of

an 18-month-old child reports to you

that the toddler does not imitate activities.

You decide to assess the child’s

development further by giving him

tasks from which sector?

a. Personal–social
b. Fine motor–adaptive
c. Language
d. Gross motor

Answer 104

a. Personal–social

Imitating activities is considered to

be a personal–social task.

Question 105

You have ordered routine blood

screening for a 2-year-old girl who,

because of dietary habits, is at risk for

iron deficiency anemia. Which of the

following findings is not associated

with iron deficiency anemia?

a. Hypochromic RBC
b. Microcytic RBC
c. Low reticulocyte count
d. Low free erythrocyte protoporphyrin

(FEP) level

Answer 105

d. Low free erythrocyte protoporphyrin

(FEP) level

Iron deficiency anemia is a microcytic,

hypochromic anemia associated

with a low reticulocyte count and elevated

FEP level.

Question 106

During a prenatal visit, you review the

mother’s record for routine prenatal

screening results. While educating the

mother, you explain that the screening

of maternal serum for alpha-fetoprotein

(MSAFP) between the 15th and 21st

weeks of pregnancy is done primarily to

screen for:

a. Phenylketonuria
b. Galactosemia
c. Cystic fibrosis
d. Neural tube defects

Answer 106

d. Neural tube defects

The MSAFP is used primarily to

screen for neural tube defects. The other

diseases are usually screened for at birth.

Question 107

A tenderness is detected over the tibial

tuberosity of a 10-year-old boy during

a routine examination at a schoolbased

clinic. The PNP knows this may

be a sign of:

a. Osgood-Schlatter disease
b. Blount’s disease
c. Plantar fasciitis
d. Effusion in the joint space

Answer 107

a. Osgood-Schlatter disease

Tenderness over the tibial tubercle

may be a sign of Osgood-Schlatter

disease. Blount’s disease is characterized

by severe bowing of the legs,

and plantar fasciitis is associated with

painful heels.

Question 108

In the emergency room, you encounter a

toddler whose injuries are not consistent

with the history that is given. Which of

the following would be the best step a

provider could take in order to foster

communication with abusive parents?

a. Realize that abusive parents have

essentially different goals for their

children than other caregivers do

b. Understand that parental hostility

and resistance are potent symptoms

of fear and inadequacy

c. Consider referring the parents to a

substance abuse program

d. Be cautious when sharing the

results of medical findings

Answer 108

b. Understand that parental hostility

and resistance are potent symptoms

of fear and inadequacy

Parental fear and inadequacy

may be manifested as hostility.

Abusive parents generally have similar

goals for their children as others

and are not any more likely to be

substance abusers than nonabusive

parents. Medical findings should be

shared with the parents (without

necessarily promoting an etiologic

conclusion).

Question 109

You are preparing a drug prevention

program for middle school students.

Your educational approach is based on

the knowledge that the most common

substance of abuse in adolescence is:

a. Marijuana
b. Cocaine
c. Heroin
d. Alcohol

Answer 109

d. Alcohol

Alcohol is the most common

substance of abuse consumed by

teenagers.

Question 110

During a check-up of a 15-monthold

girl, you note that the child has

dropped significantly in percentile for

weight over the past few months. In

evaluating a child with failure to thrive,

the most important part of your assessment

involves:

a. The history
b. The physical examination
c. Laboratory studies
d. Observation of family interactions

Answer 110

a. The history

The two major causes of poor

growth, inadequate intake and social

problems, are detected through the

history.

Question 111

A 7-year-old child in your caseload has

recently been placed on methylphenidate

for behavioral concerns associated

with ADHD. Which of the following

side effects are not associated with this

drug?

a. Decreased appetite
b. Weight loss
c. Irritability
d. Decreased heart rate

Answer 111

d. Decreased heart rate

A common side effect of stimulants

is a small increase in heart rate or blood

pressure.

Question 112

The parents of an 8-year-old child are

concerned that their son does not

want to attend school. Which of the

following historical findings are not

usually associated with the diagnosis of

school phobia?

a. Sporadic school absence
b. Chronic medical illness
c. Vague physical symptoms
d. Depression and anxiety

Answer 112

b. Chronic medical illness

Children with chronic medical

illness typically strive actively to

remain in school. The findings listed

in the other answer choices are more

likely to be associated with school

phobia.

Question 113

A 17-year-old girl is referred to your

clinic by the school nurse to be assessed

for an eating disorder. Which of the

following dynamics is not characteristic

of anorexia nervosa?

a. Excessive eating followed by

purging

b. A pervasive sense of helplessness

and ineffectiveness

c. Weight loss that gives the patient a

sense of mastery and control

d. Low body temperature, pulse rate,

and blood pressure

Answer 113

a. Excessive eating followed by

purging

Excessive eating followed by

purging is a sign of bulimia.

Question 114

Following an episode of meningitis, it is

most important to assess the child for:

a. Hearing loss
b. Changes in taste
c. Cervical lymphadenopathy
d. Tinnitus

Answer 114

a. Hearing loss

Complications of meningitis include

hydrocephalus, deafness, and blindness.

Question 115

An 8-year-old boy has been brought

to the clinic with a chief complaint of

ear pain. When you grasp the pinna of

the ear, he says “that hurts real bad.”

These findings are consistent with a

diagnosis of:

a. Serous otitis media
b. Mastoiditis
c. Otitis externa
d. Cholesteatoma

Answer 115

c. Otitis externa

With otitis externa, exquisite tenderness

is noted when pressure is placed

on the tragus or pinna of the ear.

Question 116

Steven, at 10 years of age, has been

diagnosed with otitis externa twice this

year. Health teaching for Steven and

his mother should include:

a. Emphasis on consistent use of

low-dose prophylactic antibiotics

b. Sleeping with the affected ear in

the dependent position

c. Information on the use of decongestants

to open the eustachian

tube

d. Information on the use of acetic

acid after ear canal contact with

water

Answer 116

d. Information on the use of acetic

acid after ear canal contact with

water.

Otitis externa can be prevented by

instilling 2% acetic acid (half-strength

vinegar) in the external auditory canal

after ear canal contact with water. Half

isopropyl alcohol can also be used.

Question 117

Following tympanostomy tube insertion,

it is important that the tubes

remain patent. Which of the following

methods may be used to determine

patency?

a. Visual inspection
b. Impedance tympanometry
c. Valsalva maneuver
d. Instillation of an ototopical

suspension

Answer 117

a. Visual inspection

Visual inspection is used to determine

tube patency.

Question 118

The diagnosis of acute otitis media in a

1-year-old child is based on:

a. Abnormal findings when pneumatic

otoscopy and hearing test are

performed

b. Changes in the tympanic membrane’s

contour, color, and mobility

c. Presence of fever and color of the

tympanic membrane

d. Presence of fever, ear pain, and

tenderness of the pinna

Answer 118

b. Changes in the tympanic membrane’s

contour, color, and mobility

The diagnosis of acute otitis media

is based on changes in the contour,

color, and mobility of the tympanic

membrane. Redness of the tympanic

membrane alone can be caused by

crying and is not a reliable sign of

acute otitis media. Changes in contour,

mobility, and hearing may be caused by

nonsuppurative or serous otitis media.

Fever, ear pain, and tenderness of the

pinna may indicate otitis externa.

Question 119

Connor, 12 months of age, has been

treated five times for acute otitis

media. When planning Conner’s

follow-up care, it is most important to

evaluate for which of the following?

a. Otitis externa
b. Hearing loss
c. Enlarged tonsils
d. Shotty lymph nodes

Answer 119

b. Hearing loss

Hearing loss is the most common

complication of otitis media. Children

who have multiple infections should

have their hearing assessed. Tonsils

are normally large in young children.

Shotty lymph nodes are usually associated

with past infections and are not

clinically significant.

Question 120

Brian, who is 13 years old, presents to

the clinic with a sore throat. History

reveals that he had a sore throat a

couple of weeks ago and thought he

had gotten well. He now has severe

pharyngeal pain of 2 days duration and

says he has been sweating and thinks

he has fever. Physical examination

reveals a temperature of 102°F and

erythematous and edematous pharynx

and soft palate. The right tonsil is

swollen and inflamed without exudate

and the uvula is displaced to the left.

Right cervical nodes are tender. Lungs

are clear to auscultation. Brian’s signs

and symptoms are suggestive of:

a. Acute uvulitis
b. Viral pharyngitis
c. Epiglottitis
d. Peritonsillar abscess

Answer 120

d. Peritonsillar abscess

This presentation is classical for

peritonsillar abscess, which is generally

treated with incision and drainage and

antibiotics.

Question 121

Which of the following is an expected

finding after treatment of acute suppurative

otitis media?

a. Otitis externa
b. Central auditory dysfunction
c. Functional hearing loss
d. Middle ear effusion

Answer 121

d. Middle ear effusion

Middle ear effusion (serous otitis

media) is frequently seen after acute

otitis media. Central auditory dysfunction

is caused by the brain’s inability to use

sound properly. Functional hearing loss

means there is no disturbance with any

organ and may be psychiatric in origin.

Question 122

The mother of 2-year-old Shanda

has brought her to the clinic because

she thinks the child is having trouble

hearing. Your evaluation of the complaint

should start with:

a. Asking detailed questions related

to Shanda’s medical history

b. Examination of the ear
c. Tympanometry and hearing tests
d. Assuring the mother that transient

hearing loss in childhood is

common

Answer 122

a. Asking detailed questions related

to Shanda’s medical history

The investigation of all complaints

begins with exploration of the history.

Hearing loss in childhood is extremely

common. Specific historic risk factors

for hearing loss are family history of

congenital hearing loss, prenatal or

perinatal infection, birth trauma or

anoxia, and use of aminoglycosides.

Question 123

Assessment of the red reflex may be

used to rule out which of the following?

a. Opacities
b. Myopia or hyperopia
c. Decreased visual acuity
d. Blindness

Answer 123

a. Opacities

A normal red reflex rules out opacities,

intraocular tumor, and coloboma.

The red reflex does not assess visual

acuity. A nonvisible red reflex indicates

obstruction in the preretinal chambers.

Question 124

The mother of 2-year-old Bridget has

brought her to the clinic because “she got

bathroom cleanser in her eye.” History

reveals that about 30 minutes ago,

Bridget was sitting on the floor playing

with a squeeze bottle of bathroom

cleaner, when the bottle accidentally

opened and the liquid splashed into her

right eye. Physical examination reveals a

reddened right eye with an edematous

lid. Initial treatment should include:
a. Allowing the natural tearing

process to cleanse the eye

b. Performing a retinal fundoscopic

examination to assess for burns

c. Irrigating the eye with copious

amount of normal saline

d. Referring Bridget to an

ophthalmologist

Answer 124

c. Irrigating the eye with copious

amount of normal saline

Acid or alkali chemical eye injuries

are acute emergencies and require

copious normal saline. Overirrigation is

not a problem, but litmus paper can be

used to determine when the chemical

has been neutralized. The child should

be referred to an ophthalmologist after

irrigation of the eye.

Question 125

The mother of a 5-year-old boy has

brought him to the clinic because she thinks

he has pinkeye. Which of the following

would lead you to consider

a diagnosis

other than bacterial conjunctivitis?

a. Hyperemic conjunctiva
b. Scratchy sensation in the eye
c. Decreased corneal clarity
d. Copious tearing

Answer 125

c. Decreased corneal clarity

Bacterial conjunctivitis does not

affect corneal clarity. A more serious

condition should be suspected (such as

keratitis, corneal ulcer, or glaucoma) and

the child should be referred to an ophthalmologist

if the cornea is not clear.

Question 126

Julie, at 18 months of age, has been

brought to the clinic by her mother who

tells you that Julie has had a cold for

the past four days. There is no history of

cough and the mother is unsure whether

Julie has had fever. Physical examination

reveals greenish, blood-tinged mucus

with a strong, foul odor, draining from

the right nostril. This clinical picture is

most consistent with a diagnosis of:

a. Allergic rhinitis
b. Viral rhinitis
c. Acute sinusitis
d. Nasal foreign body

Answer 126

d. Nasal foreign body

Nasal foreign body is characterized

by unilateral purulent discharge that may

be blood tinged. Nasal discharge is very

foul smelling. Allergic rhinitis and viral

rhinitis usually cause clear bilateral nasal

secretions, while sinusitis usually produces

bilateral drainage with less odor.

Question 127

In a child with chronic sinusitis, the

most accurate method of identifying

sinus abnormalities is:

a. Dark room transillumination of

the sinuses

b. Percussion of the paranasal sinuses
c. AP, lateral, and occipitomental

sinus radiographs

d. CT scan of the sinuses

Answer 127

d. CT scan of the sinuses

CT scans are superior to sinus

radiographs in the identification of

abnormalities. A normal radiograph

suggests, but does not prove, that

sinuses are free of disease.

Question 128

Mike, at 10 years of age, has been brought

to the clinic with a cold. History reveals

that he has had a runny nose and cough

for about 10 days. There is no history of

frequent respiratory problems. Physical

examination reveals a temperature of

100° F and edematous cervical lymph

nodes. Eyes are without redness or swelling.

Examination of the nose is significant for

mucopurulent drainage from the middle meatus bilaterally. The pharynx is erythematous

without tonsillar enlargement or exudate. Breath is malodorous and lungs are clear to auscultation.

Mike’s management should include:

a. Culture of the nasal drainage
b. Radiograph of the sinuses
c. Measurement of erythrocyte

sedimentation

rate

d. Use of an antibiotic

Answer 128

d. Use of an antibiotic

The signs and symptoms, especially

mucopurulent drainage from the

middle meatus, are supportive of a

diagnosis of acute sinusitis. Sinus radiographs

are difficult to interpret and not

indicated at this time. Culture of nasal

drainage is not useful in the determination

of the causative organism in

sinusitis. There are no signs of complications,

and it is appropriate to treat

the condition with antibiotics.

Question 129

Mike, at 10 years of age, has been brought to the clinic with a cold. History reveals that he has had a runny nose and cough for about 10 days. There is no history of frequent respiratory problems. Physical examination reveals a temperature of 100° F and edematous cervical lymph nodes. Eyes are without redness or swelling. Examination of the nose is significant for mucopurulent drainage from the middle meatus bilaterally. The pharynx is erythematous without tonsillar enlargement or exudate. Breath is malodorous and lungs are clear to auscultation.

Two days after Mike’s first visit, his mother brings him back to the clinic because he has a “swollen eye.” Observation reveals redness and inflammation of the right eyelid with impaired extraocular movement. Which action is appropriate?

a. Reassure the mother that this is a common and usually benign condition
b. Treat Mike for bacterial conjunctivitis
c. Order anti-inflammatory eye drops
d. Refer Mike immediately to emergency

room

Answer 129

d. Refer Mike immediately to emergency

room

History of sinusitis often precedes

orbital cellulitis. Examination indicates

that Mike may have orbital cellulitis, a

medical emergency that requires hospitalization

and IV antibiotics. He should

be referred to the emergency room.

Question 130

The mother of 12-year-old Nathan

has brought him to the clinic because

he has had a runny nose for 2 weeks.

History reveals that Nathan has visited

the clinic three other times this year

for upper respiratory complaints.

Examination reveals slightly edematous

and erythematous eyes, pale nasal

mucosa with clear mucus, and pharynx

with thin secretions posteriorly. There

is no tonsillar swelling or exudate. Lips

and nail beds are pink. Lymph node

examination is significant for multiple

shotty nodes. Lungs are clear to auscultation.

Which action is appropriate

at this time?

a. Discuss symptomatic relief of the

common cold with Nathan and

his mother

b. Culture nasal drainage and delay

treatment until results are known

c. Order an antibiotic
d. Order an antihistamine

Answer 130

d. Order an antihistamine

Repeated episodes of upper respiratory illness, clear nasal secretions, and pale nasal mucosa are common in children with allergies. Antihistamines are used to treat seasonal and perennial allergies.

Question 131

A 1-week-old infant has been

diagnosed with nasolacrimal duct

obstruction. A typical initial therapy

includes:

a. Use of prophylactic oral antibiotics
b. Nasolacrimal sac massage
c. Surgical opening of obstructed ducts
d. Referral to an ophthalmologist

Answer 131

b. Nasolacrimal sac massage

Nasolacrimal sac massage using

downward strokes raises the pressure in

the nasolacrimal sac and may overcome

the obstruction. Topical ophthalmic

antibiotic may be indicated. Early

surgical opening of the ducts may be

performed to relieve parental anxiety,

but conservative treatment is successful

by 1 year of age in about 90% of cases.

Referral to an ophthalmologist is indicated

if the condition persists beyond 6

months or is frequently purulen

Question 132

Marie, at 4 years old, has been

brought to the clinic because she

“has something wrong with her

eye.” Marie and her mother report

that there has been no injury to the

eye and that it has been red since

yesterday. Examination reveals conjunctival

hyperemia and a copious

amount of purulent discharge bilaterally.

Vision, pupillary reflexes, and

corneal clarity are all normal. Which

treatment should be ordered?

a. Sodium sulfacetamide ophthalmic

solution

b. Gentamycin ophthalmic solution
c. Tobramycin ophthalmic solution
d. Cromolyn sodium ophthalmic

solution

Answer 132

a. Sodium sulfacetamide ophthalmic

solution

Marie’s presentation supports a

diagnosis of bacterial conjunctivitis.

Sodium sulfacetamide, erythromycin,

or polymixin B sulfate-trimethoprim

sulfate solution are appropriate firstline

treatments. Gentamycin and

tobramycin should be reserved for

suspected gram-negative bacterial conjunctivitis

or when justified by culture

results. Cromolyn sodium is used to

treat allergic conjunctivitis.

Question 133

During the routine examination of a

12-year-old boy, you detect a group of

hard, fixed, nontender lymph nodes, each

of which measure about 1 centimeter,

in the posterior cervical chain. You are

unable to detect any signs of infection.

Your management should include:

a. Recording the finding and reassessing

the nodes in 1 month

b. Ordering a 10-day course of a

broad spectrum antibiotic and

reevaluating the nodes in 2 weeks

c. Ordering a CBC, erythrocyte

sedimentation rate, and chest

radiograph

d. Referring the child to an allergist

Answer 133

c. Ordering a CBC, erythrocyte

sedimentation rate, and chest

radiograph

Nodes that are matted, hard, fixed,

and nontender are characteristic of

cancer. Lymph nodes associated with

Hodgkin’s disease usually begin in the

lower cervical area. A chest radiograph,

CBC, and erythrocyte sedimentation

rate should be obtained in any patient

with lymphadenopathy that is atypical

for infection.

Question 134

Which method might be used to assess

the vision of a 1-month-old child?

a. Check the vessel pattern of the

fundus of the eye

b. Watch to see if the infant turns his or

her head toward you when you speak

c. Observe the pattern of interaction

with the mother

d. Perform the Titmus test on the infant

Answer 134

c. Observe the pattern of interaction

with the mother

Nonquantitative, but clinically

helpful information may be gained

about the infant’s vision by observing

whether or not the infant fixates on and

attempts to follow the mother’s face.