Week 11 Developmental Disabilities and Pedi Mental Health Flashcards
The primary care nurse practitioner is examining a 3-year-old child who speaks loudly, in a monotone, does not make eye contact, and prefers to sit on the exam room floor moving a toy truck back and forth in a repetitive manner. Which disorder does the nurse practitioner suspect?
A Executive function disorder
B Autism spectrum disorder
C Attention-deficit/hyperactivity disorder
D Sensory processing disorder
B Autism spectrum disorder
Autism spectrum disorder manifests in toddlers by alterations in socialization and speech as described above, along with repetitive behaviors. ADHD manifests with a lack of focus on activities and distractibility. Executive function disorders can manifest in a variety of ways but not with repetitive behaviors. Children with sensory processing disorders have altered responses to sensations.
Which of the following are associated with Turner Syndrome? Select all that apply.
A Short stature
B Ovarian dysfunction
C Low IQ
D Vision problems
E Heart defects
F High-arched palate
A Short stature
B Ovarian dysfunction
E Heart defects
Most common features of Turner’s are short stature and lack of ovarian function. 1/3 to 1/2 have heart defects such as coarctation of the aorta. IQ is normal.
Which clinical findings tend to support a diagnosis of Klinefelter syndrome? (Select all that apply.)
A Small penis
B Large testes
C Short arm span
D Scoliosis
E Gynecomastia
Klinefelter syndrome is characterized by tall stature with long arm spam, scoliosis, small penis and testes, and gynecomastia.
A Small penis
D Scoliosis
E Gynecomastia
The primary care nurse practitioner is performing an examination on a 5-year-old child who exhibits ritualistic behaviors, avoids contact with other children, and has limited speech. The parent reports having had concerns more than two years ago about autism, but was told that it was too early to diagnose. What will the nurse practitioner do first?
A Reassure the parent that if symptoms weren’t present earlier, the likelihood of autism is low
B Ask the parent to describe the child’s earlier behaviors from infancy through preschool
C Administer an M-CHAT screen to screen the child for communication and socialization delays
D Refer the child to a pediatric behavioral specialist to develop a plan of treatment and management
B Ask the parent to describe the child’s earlier behaviors from infancy through preschool
The DSM-5 criteria state that a patient must show symptoms from early childhood even if the symptoms are not recognized until later in life. The parent had noticed symptoms prior but was told not to worry; these symptoms should be evaluated in light of the current symptoms. The M-CHAT is used for infants and toddlers and not for school-age children. Autism symptoms are generally evident by age 3 years. The PNP should complete the assessment before making a referral.
Fragile X affects males and females. Females often have milder symptoms.
True or False
True
Fragile X affects males and female and is more common in males. Symptoms are milder in females. The average age of diagnosis for boys is 36 months and girls is 42 months.
The parent of a school-age child reports that the child becomes frustrated when unable to perform tasks well and often has temper tantrums and difficulty sleeping. Which disorder may be considered in this child?
A Generalized anxiety disorder (GAD)
B Separation anxiety disorder (SAD)
C Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS)
D Obsessive-compulsive disorder (OCD)
A Generalized anxiety disorder (GAD)
GAD is characterized by over-concern about competence, significant self-consciousness, irritability and tantrums, and poor sleep. OCD results in recurring thoughts, images, or impulses. Patients with PANDAS have OCD- and Tourette-like symptoms. SAD causes difficulties separating from caregivers and being away from home.
An adolescent has recently begun doing poorly in school and has stopped participating in sports and other extracurricular activities. During the history interview, the adolescent reports feeling tired, having difficulty concentrating, and experiencing a loss of appetite for the past few weeks but cannot attribute these changes to any major life event. Which is an important next step in the evaluation and management of this patient?
A Administering a diagnostic rating scale for depression
B Referring the adolescent to a mental health specialist
C Considering a short-term trial of an antidepressant medication
D Determining suicidal ideation and risk of suicide
D Determining suicidal ideation and risk of suicide
Because this adolescent exhibits clear signs of depression, the first goals of management are to determine suicidal risk and to intervene to prevent suicide since the risk of suicide is greatest during the first 4 weeks of a depressive episode. A diagnostic rating scale may help in diagnosing the depression, but assessing suicide risk is a priority. Antidepressant medications may be useful but are best initiated by a mental health specialist. The initial response in adolescents should be to determine suicide risk to decide whether to admit to inpatient therapy or refer to a mental health specialist.
The primary care nurse practitioner is conducting a follow-up examination on a child who has recently begun taking a low-dose stimulant medication to treat attention-deficit/hyperactivity disorder (ADHD). The child’s school performance and home behaviors have improved. The child’s parent reports noticing a few tics, such a twitching of the eyelids, but the child is unaware of them and isn’t bothered by them. What will the nurse practitioner recommend?
A Stopping the medication immediately
B Continuing the medication as prescribed
C Adding an alpha-agonist medication
D Changing to a non-stimulant medication
B Continuing the medication as prescribed
Tics may occur as a side effect of stimulant medications but do not need to be discontinued if there is a net benefit and the symptoms are not disturbing to the child. It is not necessary to add an alpha-agonist, change to a non-stimulant medication, or stop the medication.
The parent of a child diagnosed with attention-deficit/hyperactivity disorder (ADHD) tells the primary care pediatric nurse practitioner that the child gets overwhelmed by homework assignments, doesn’t seem to know which ones to do first, and then doesn’t do any assignments. The nurse practitioner tells the parent that this represents impairment in which executive function?
A Activation
B Emotion
C Focus
D Effort
A Activation
Activation is an executive function that helps individuals organize, prioritize, and begin activities. This child cannot prioritize a group of assignments and winds up not doing any of them, showing an inability to prioritize and begin activities. Effort is the function associated with sustaining effort and regulating awareness. Emotion is the function of managing frustration. Focus is associated with sustaining and shifting attention to a task.
An adolescent is diagnosed with major depression, and the mental health specialist has prescribed fluoxetine. What other treatment is important to protect against suicide risk?
A Cognitive-behavioral therapy
B Hospitalization
C Family therapy
D Addition of risperidone therapy
A Cognitive-behavioral therapy
Cognitive-behavioral therapy appears to have a protective effect against suicide and the best treatment responses come from combinations of cognitive-behavioral therapy and selective serotonin reuptake inhibitors (SSRIs). Risperidone and other antipsychotics are used if psychosis is present to control those symptoms. Family therapy is useful but does not add protection from suicide. Hospitalization is not the first-line treatment and is used for severe exacerbations or suicide attempts.
Your 9 yo male patient is a very active child with limited self-control. He is easily distracted and has difficulty concentrating, staying on task, and working toward a goal. You determine that he should have a neurodevelopmental evaluation because he is showing signs of
a. ADHD
b. Dyslexia
c. Autism
d. Impaired hearing
a. ADHD
ADHD is marked by inattention, impulsiveness, a low tolerance for frustration, and a great deal of inappropriate behavior. This can be exhausting for parents and teachers. In some cases, ADHD can be managed by medications, but the use of medications is controversial. A specialist should evaluate a child suspected of having ADHD.
Common medications for treating ADHD include
a. Aminophylline and antihistamines
b. Methylphenidate, amphetamine and their derivatives
c. Amphetamines and Accutane
d. Codeine and Valium
b. Methylphenidate, amphetamine and their derivatives
Amphetamine (Dexedrine, Adderall) and methylphenidate (Ritalin, Concerta, Methylin, Focalin, and so on) are preferred drugs for pediatric ADHD. Ritalin is a CNS stimulant that blocks the reuptake of norepinephrine and dopamine into the presynaptic neurons and increases the release of these monoamines into the extraneuronal space. Dexedrine probably causes the nerve endings to produce more norepinephrine at the synapse. Dysfunction in the actions of the neurotransmitters dopamine and norepinephrine may be key to the pathophysiological mechanisms of ADHD. These medications are likely effective in many cases of ADHD because they allow for these chemicals to be reabsorbed and recirculated.
While assessing the eyes of a newborn, you observe inner canthal folds and Brushfield spots. What is the primary differential diagnosis?
a. Trisomies
b. Turner syndrome
c. Down syndrome
d. Neurofibromatosis
c. Down syndrome
If you notice inner canthal folds and Brushfield spots, you should suspect Down syndrome. Slanted palpebral fissures are seen with other trisomies, blue sclera and osteogenesis imperfecta with Turner ’ s syndrome, and Lisch nodules with neurofibromatosis.
Which feature(s) of fragile X syndrome should be evaluated during well-child examinations?
a. Being easily overwhelmed by stimuli and language delays
b. Shorter linear growth
c. Increased frequency of ear infections
d. Difficulty swallowing
a. Being easily overwhelmed by stimuli and language delays
The behavioral features of fragile X syndrome include being easily overwhelmed by stimuli, excessive chewing on clothes, and frequent tantrums. Other features include hand biting, hand flapping, hyperactivity, mood instability, perseveration (repetition) and delays in speech, poor eye contact, short attention span, shyness, social anxiety, and tactile defensiveness. Linear growth, the incidence of ear infections, and difficulty swallowing are not affected by fragile X syndrome.
Julie, age 15, is 5 feet tall and weighs 85 lbs. You suspect anorexia and know that the best initial approach is to
a. Discuss proper nutrition
b. Tell Julie what she should weigh for her height and suggest a balanced diet
c. Speak to her parents before going any further
d. Confront Julie with the fact that you suspect an eating disorder
d. Confront Julie with the fact that you suspect an eating disorder
If you suspect anorexia, the best initial approach is to confront Julie with the fact that you suspect an eating disorder. Clients are usually aware that a problem exists but need the extra “push” that confrontation provides. Once they accept the diagnosis, proven treatments include medical monitoring, nutritional counseling, psychotherapy, including behavioral therapy, family counseling, and stress-reduction techniques, medications, and support groups.
Which statement about attention deficit hyperactivity disorder is correct?
a. This is more common in girls younger than age 9 years.
b. Family history does not play a role in this disorder
c. Hyperactivity must be present for this diagnosis
d. DSM V is used to diagnose a child with ADHD
d. DSM V is used to diagnose a child with ADHD
Anorexia nervosa is a steady, intentional loss
of weight with maintenance of that weight at an
extremely unhealthy low level. Which statement
is true regarding anorexia nervosa?
A. The poor eating habits result in diarrhea.
B. It may cause tachycardia.
C. It may occur from prepubescence into the
early 30s.
D. It may cause excessive bleeding during menses.
C. It may occur from prepubescence into the
early 30s.
Anorexia nervosa may occur from prepubescence into the early 30s and occurs most commonly from early to late adolescence. It occurs more frequently in women and may cause bradycardia, arrhythmias, and amenorrhea. Constipation is common in clients with anorexia because of their poor eating habits.
Which of the following criteria is not diagnostic for a child with attention deficit hyperactivity disorder (ADHD)?
A. The child frequently blurts out the answer to a question before the question is finished.
B. The child has difficulty following directions.
C. The child talks very little but is very restless.
D. The child often engages in physically dangerous activities
C. The child talks very little but is very restless.
C Diagnostic criteria for the child with ADHD include frequently blurting out answers before a question is finished, difficulty following directions, engaging in physically dangerous activities (often without thinking of the consequences of actions), tending to talk excessively, and often interrupting others. Behavior in which the child talks very little but is very restless is not indicative of ADHD.
Suzanne ’ s 8-year-old daughter, Natasha, has attention deficit-hyperactivity disorder (ADHD). She asks if Natasha will “ outgrow ”her ADHD. You respond,
A. “ Yes; when they become young adults, most children outgrow the problem. ”
B. “ No; unfortunately, Natasha will have this for the rest of her life. ”
C. “ No, but there are many treatments available that we need to start now. ”
D. “ About 50% or more of affected children will continue to have some difficulty as adolescents and adults. ”
D. “ About 50% or more of affected children will continue to have some difficulty as adolescents and adults. ”
Long-term studies have shown that school-age children and adolescents with attention deficithyperactivity disorder (ADHD) experience school failure, aggression, antisocial behavior, poor social skills, emotional immaturity, low self-esteem, and interpersonal conflicts. The same studies revealed that more than 50% of adults who had ADHD as children continue to exhibit anxiety, low selfesteem, personality disorders, alcohol and substance abuse, and interpersonal difficulties.
Fragile X syndrome is usually diagnosed when a child
A. is a newborn.
B. begins to walk.
C. is past the toddler stage.
D. begins puberty.
C. is past the toddler stage.
It is rare for a child to be diagnosed with fragile X syndrome during the first year of life. Although it is possible to detect the syndrome by amniocentesis, that screening is not routinely done unless there is a family history of the disorder. The child is often past the toddler stage when a diagnosis is made.
You suspect autism in the young child of a client of yours, but the client says the child is just shy. For a diagnosis of autism, you know the Diagnostic and Statistical Manual of Mental Disorders requires that three criteria be present. Which of these behaviors would lead the nurse practitioner to suspect autism in a young child?
A. Receiving immunizations that use thimerosal as adjuvants
B. Abnormal verbal and nonverbal communication
C. Reliance on an imaginary friend for all interactions by a preschooler
D. Inability of a newborn to track mother ’ s face from left to right
B. Abnormal verbal and nonverbal communication
The DSM-IV specifies the three core deficits of autism. These are impaired reciprocal social interactions, abnormal verbal and nonverbal communication, and a diminished repertoire of activities and interests, with the onset during infancy or childhood. Reliance on an imaginary friend for all interactions is not a diagnostic criterion of autism. There is no conclusive evidence supporting the increased incidence of autism in populations that receive immunizations containing mercury. The amount of thimerosal has been greatly reduced in vaccines. Neonates normally can follow an object or face to midline, not across midline
A 6-year-old has just been diagnosed with attention deficit hyperactivity disorder. His parents report that he is doing poorly in school and is often disruptive in the classroom. They ask what they can do. Your best response is:
A. “ Children usually outgrow a high activity level. ”
B. “ Use a consistent approach with behavioral ‘ cues ’ both at home and at school. ”
C. “ Medications are the only interventions that can help with ADHD. ”
D. “ You can have him tested for food and environmental allergies. ”
B. “ Use a consistent approach with behavioral ‘ cues ’ both at home and at school. ”
Studies have shown that a consistent approach with rewards and behavioral cues to remind the child when his behavior has exceeded acceptable limits is helpful to assist him in succeeding with schoolwork.
Jake, 8 years old, is brought in by his mother for evaluation of school problems. When he was 4 years old, his preschool teacher had expressed concern regarding his high activity level interfering with play with other children. Now, in third grade, he is underachieving in both math and reading. His teacher says that he constantly fidgets and bothers the other children. The school counselor has recommended that he be evaluated for attention deficit hyperactivity disorder (ADHD). Which question would provide important additional information regarding the possible diagnosis of ADHD?
A. “ How do you think his behavior compares to the other 8-year-olds you know? ”
B. “ How does his teacher handle his behavior in school?
C. “ What is he like at home? ”
D. “ Has anyone in your extended family had a diagnosis of ADHD? ”
C. “ What is he like at home? ”
ADHD is among the most common neurodevelopmental disorders in children. Its hallmarks are hyperactivity, impulsiveness, and inattention beyond the norm for the child ’ s age. Signs of ADHD are typically seen across settings rather than only in one setting or environment. Therefore, it is important to understand if the concerning behaviors are seen at home as well as at school. The diagnosis is reliable if made by a standardized approach
Janice, age 14, is markedly obese and has a poor self-image. How do you differentiate between compulsive eating and bulimia?
a. Bulimia results in irregular menstruation
b. A compulsive eater does not induce vomiting
c. A compulsive eater has tooth and gum erosion
d. A compulsive eater does compulsive exercising
b. A compulsive eater does not induce vomiting
Compulsive (binge) eating disorder and bulimia nervosa are two very serious types of eating disorders. There are overlapping criteria for the disorders, but the main difference in the presence of purging, which occurs in bulimia. Those with bulimia nervosa will engage in periods of binge-eating following by purging while those with compulsive eating disorder do not purge after a period of eating.