Miscellaneous Flashcards
When enlarged, which lymph nodes are most likely to be a sign of pathology (i.e., malignancy)?
Supraclavicular
A congenital defect in the immune system of a 2-week-old infant may be suspected if:
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)
When examining the skull of a 4-month-old baby, you should normally find closure of what fontanel?
closure of the posterior fontanel
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?
current medications
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
presence of torticollis
Spasmodic muscular contractions of the head, face, or neck are called:
tics
Term infants have a visual acuity of about:
20/200
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
White pupils on photographs
An allergy can cause the conjunctiva to have what kind of pattern?
cobblestone pattern.
Bulging of an amber tympanic membrane without mobility is most often associated with?
middle ear effusion
You should measure the child’s head circumference at every health visit until age ______ months?
24 months
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.
The child whose weight and height ratios have dropped 15 percentiles in the last two visits.
Healthy term babies generally double their birth weight by what age?
6 months
Which of these primitive reflexes would you expect to see in an 8-month-old infant?
Plantar grasp
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?
Over 4 months
Which components of the health maintenance visit are essential to each visit?
Immunization review
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
“Nightmares are common during the preschool years and during times of stress.”
At what age is it recommended that a child begin dental check ups with a dentist?
1 year
My 18-month-old isn’t eating as well as before, is this finding normal?
Yes
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
copy a square
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
Correct breastfeeding
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
A. Tanner Stage 1 B. Tanner Stage 2 C. Tanner Stage 4 D. Tanner Stage 2 E. Tanner Stage 5
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:
she will reach menarche in approximately 2 years
Normal full-term newborns demonstrate each of the following reflex reactions EXCEPT stepping reflex palmar grasp placing reflex parachute reaction rooting reflex
parachute reaction
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.
Smoking cigarettes can stain his teeth and give him bad breath.
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
A 13 year old girl who is Tanner 5
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.
A referral to physical therapy for exercises to treat torticollis.
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.
Apply silver nitrate to the area at the base of the umbilicus.
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.
This sounds like a normal stool pattern for a breast fed infant, just continue to breast feed on demand.
The female athlete triad includes?
osteoporosis anorexia amenorrhea
Which of the following is the most likely source of lead intoxification in children in the US?
contaminated paint dust
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
development of a central black eschar or “sinking infarct” in 6-12 hours
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
cat bites are often deep puncture wounds
When do most bites/stings, from insects, spiders, snakes and bees most commonly occur?
Summer
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
prescribe amoxicillin-clauvulanate potassium (Augmentin) 500-875 mg PO bid for 10 days
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
abdominal rigidity, nausea, and headache
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
ice pack and elevation of the area
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
light canned tuna
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
between 1 and 3 years
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
10ug/dL
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
early onset “normal” puberty
The physical finding to differentiate pathological from normal gynecomastia is: unequal breast breast tenderness breast size greater than 3 cm evident in prepubescent boys
breast size greater than 3 cm
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
heat intolerance, tachycardia, lid lag
What single test can differentiate hypo- versus hyperthyroidism? TSH T3 T4 thyroid antibodies
TSH
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)
Idiopathic
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.
History and physical exam, including Tanner stage with possible skeletal maturation assessed by radiography, if indicated.
Which of the following findings would the nurse practitioner expect to find in a child with pubertal gynecomastia? Tanner stage II with testes
Breast tissue enlargement mainly glandular, moveable, and nonadherent to skin or underlying tissue.
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
Turner’s syndrome
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).
The child needs to have his dose of levothyroxine (Synthroid) increased because he is exhibiting signs of hypothyroidism.
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
TSH levels to be decreased.
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
tinea capitis
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
meningococcemia
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
common wart
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
cheeks and forehead
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
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.
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
impetigo
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.
color of the scales
Painful vesicles are associated with: psoriasis. paronychia. herpes zoster. pityriasis rosea.
herpes zoster
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
Inquire about another recent skin lesion.
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
Bruises in various stages of resolution over posterior surfaces
A practice team that coordinates a person’s care across episodes and specialties?
a medical home
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
begins to deviate from his/her normal percentiles.
During a health supervision encounter, there are four activities that generally occur, including disease detection, health promotion, anticipatory guidance and
disease prevention
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
8-12 years old and 4’9” tall
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
10 years of age
What is the most common chronic disease in children? a. Asthma b. Allergic rhinitis c. Caries d. Diabetes mellitus
c. Caries
What is the most serious complication from Pierre Robin syndrome? a. Airway obstruction b. Increased PaCO2 c. Poor weight gain d. Respiratory distress
a. Airway obstruction
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.
c. brushing her teeth with plain water twice daily.
What method is used to screen newborns for hearing? a. Acoustic reflectometry b. Audiometry c. Auditory brainstem response d. Evoked otoacoustic emission
d. Evoked otoacoustic emission
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.
b. 3 years
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
b. Incorporate traditional foods into a management plan that will provide increased calories and nutrients
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
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.
What is somnambulism?
Sleepwalking - a sleep disturbance
What is pavor nocturnus?
night terrors - a sleep disturbance Sleep disturbances occur in school age and preschool age children.
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
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.
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
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.
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
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.
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.
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
b. Tanner stage III Physiologic gynecomastia is a common clinical finding in young adolescent males. It is usually present during Tanner Stage III.
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
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.
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
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.
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
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.
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.
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.
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
c. 7 months
A normal infant transfers objects
from hand to hand by 7 months of age.
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
d. Transient morbilliform rash
A transient morbilliform rash is
an adverse effect associated with the
MMR vaccine.
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
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.
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
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.
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
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.
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
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.
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
a. Evidence of hallucinations and
delusions
Hallucinations and delusions are
uncommon in the presentation of adolescent
depression.
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
c. Obtaining a psychiatric consultation
Every actively suicidal patient,
regardless of apparent seriousness,
requires psychiatric consultation and, in
some cases, hospitalization.
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)
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.
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
a. Personal–social
Imitating activities is considered to
be a personal–social task.
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
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.
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
d. Neural tube defects
The MSAFP is used primarily to
screen for neural tube defects. The other
diseases are usually screened for at birth.
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
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.
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
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).
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
d. Alcohol
Alcohol is the most common
substance of abuse consumed by
teenagers.
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
a. The history
The two major causes of poor
growth, inadequate intake and social
problems, are detected through the
history.
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
d. Decreased heart rate
A common side effect of stimulants
is a small increase in heart rate or blood
pressure.
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
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.
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
a. Excessive eating followed by
purging
Excessive eating followed by
purging is a sign of bulimia.
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
a. Hearing loss
Complications of meningitis include
hydrocephalus, deafness, and blindness.
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
c. Otitis externa
With otitis externa, exquisite tenderness
is noted when pressure is placed
on the tragus or pinna of the ear.
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
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.
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
a. Visual inspection
Visual inspection is used to determine
tube patency.
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
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.
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
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.
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
d. Peritonsillar abscess
This presentation is classical for
peritonsillar abscess, which is generally
treated with incision and drainage and
antibiotics.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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
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
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.
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
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.
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
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.
