*NURSING > EXAM > Burns: Pediatric Primary Care, 6th Edition Chapter 25: Atopic, Rheumatic, and Immunodeficiency Disor (All)

Burns: Pediatric Primary Care, 6th Edition Chapter 25: Atopic, Rheumatic, and Immunodeficiency Disorders. Questions and Verified Answers. Nursing 6435 Test bank questions.

Document Content and Description Below

Burns: Pediatric Primary Care, 6th Edition Chapter 25: Atopic, Rheumatic, and Immunodeficiency Disorders Test Bank Multiple Choice 1. 1. The parent of a school-age child reports that the... child usually has allergic rhinitis symptoms beginning each fall and that non-sedating antihistamines are only marginally effective, especially for nasal obstruction symptoms. What will the primary care pediatric nurse practitioner do? a. a. Order an intranasal corticosteroid to begin 1 to 2 weeks prior to pollen season. b. b. Prescribe a decongestant medication as adjunct therapy during pollen season. c. c. Recommend adding diphenhydramine to the child’s regimen for additional relief. d. d. Suggest using an over-the-counter intranasal decongestant. Intranasal corticosteroids are a key component in long-term therapy to manage symptoms associated with AR. These should be begun 1 to 2 weeks prior to the beginning of pollen season. Decongestants are not recommended for long-term use because of side effects. Diphenhydramine causes daytime drowsiness. 1. 2. The primary care pediatric nurse practitioner sees a child for follow-up care after hospitalization for ARF. The child has polyarthritis but no cardiac involvement. What will the nurse practitioner teach the family about ongoing care for this child? a. a. Aspirin is given for 2 weeks and then tapered to discontinue the medication. b. b. Prophylactic amoxicillin will need to be given for 5 years. c. c. Steroids will be necessary to prevent development of heart disease. d. d. The child will need complete bedrest until all symptoms subside. ASA is given for arthritis for 2 weeks and then will be tapered. Children with ARF will need penicillin prophylaxis, not amoxicillin. Steroids are sometimes used for symptomatic relief but do not prevent chronic heart disease. Bed rest is indicated only when cardiac symptoms occur. 1. 3. A school-age child with asthma is seen for a well child checkup and, in spite of “feeling fine,” has pronounced expiratory wheezes, decreased breath sounds, and an FEV1 less than 70% of personal best. The primary care pediatric nurse practitioner learns that the child’s parent administers the daily medium-dose ICS but that the child is responsible for using the SABA. A treatment of 4 puffs of a SABA in clinic results in marked improvement in the child’s status. What will the nurse practitioner do? a. a. Have the parent administer all of the child’s medications. b. b. Increase the ICS medication to a high-dose preparation. c. c.Reinforce teaching about the importance of using the SABA. d. d. Teach the child and parent how to use home PEF monitoring. Home PEF monitoring is useful for children to identify when symptoms are worsening. This child does not appear to notice the presence of airway tightness or wheezing and so might benefit from PEF monitoring to know when to use the SABA. School-age children should be learning how to manage their chronic disease, so having the parent administer all medications is not the best choice, especially since use of the SABA is still dependent on the child’s report of symptoms. Since the child responded well to administration of the SABA, increasing the dose of ICS should not be done unless better management is not effective. Reinforcing the teaching is part of the plan but, unless the child is aware of symptoms, may not occur. 1. 4. A child has a fever and arthralgia. The primary care pediatric nurse practitioner learns that the child had a sore throat 3 weeks prior and auscultates a murmur in the clinic. Which test will the nurse practitioner order? a. a. Anti-DNase B test b. b. ASO titer c. c.Rapid strep test d. d. Throat culture This child has symptoms and a history consistent with ARF. The ASO titer peaks in 3 to 6 weeks and will confirm a recent strep infection. The anti-DNase B test will also confirm a recent strep infection, but this doesn’t peak until 6 to 8 weeks after the initial infection. A rapid strep test and throat culture do not differentiate the carrier state from a true infection. 1. 5. The primary care pediatric nurse practitioner is prescribing ibuprofen for a 25 kg child with JIA who has oligoarthitis. If the child will take 4 doses per day, what is the maximum amount the child will receive per dose? a. a. 200 mg b. b. 250 mg c. c.400 mg d. d. 450 mg The maximum dose is 40 mg/kg/day divided into 3 to 4 doses. 25 kg × 40 mg = 1000/4 = 250 mg. 1. 6. A school-age child who uses a SABA and an inhaled corticosteroid medication is seen in the clinic for an acute asthma exacerbation. After 4 puffs of an inhaled short-acting B2-agonist (SABA) every 20 minutes for three treatments, spirometry testing shows an FEV1 of 60% of the child’s personal best. What will the primary care pediatric nurse practitioner do next? a. a. Administer an oral corticosteroid and repeat the three treatments of the inhaled SABA. b. b. Admit the child to the hospital for every 2 hour inhaled SABA and intravenous steroids. c. c. Give the child 2 mg/kg of an oral corticosteroid and have the child taken to the emergency department. d. d. Order an oral corticosteroid, continue the SABA every 3 to 4 hours, and follow closely. Children with an incomplete response (FEV1 between 40% and 69% of personal best) should be given oral steroids and instructed to continue the SABA every 3 to 4 hours with close follow-up. Hospitalization is not necessary unless severe distress occurs. An FEV1 less than 40% after treatment indicates a need to be seen in the ED. 1. 7. An adolescent who has asthma and severe perennial allergies has poor asthma control in spite of appropriate use of a SABA and a daily high-dose inhaled corticosteroid. What will the primary care pediatric nurse practitioner do next to manage this child’s asthma? a. a. Consider daily oral corticosteroid administration. b. b. Order an anticholinergic medication in conjunction with the current regimen. c. c.Prescribe a LABA/inhaled corticosteroid combination medication. d. d. Refer to a pulmonologist for omalizumab therapy. Children older than 12 years who have moderate to severe allergy-related asthma and who react to perennial allergens may benefit from omalizumab as a second-line treatment when symptoms are not controlled by ICSs. The PNP should refer children to a pulmonologist for such treatment. Daily oral corticosteroid medications are not recommended because of the adverse effects caused by prolonged use of this route. Anticholinergic medications are generally used for acute exacerbations during in-patient stays or in the ED. A LABA/ICS combination will not produce different results. 1. 8. A 4-month-old infant has a history of reddened, dry, itchy skin. The primary care pediatric nurse practitioner notes fine papules on the extensor aspect of the infant’s arms, anterior thighs, and lateral aspects of the cheeks. What is the initial treatment? a. a. Moisturizers b. b. Oral antihistamines c. c.Topical corticosteroids d. d. Wet wrap therapy Moisturization is the first-line therapy to interrupt the itch-scratch-itch cycle. Oral antihistamines are used mostly to allow sleep during nighttime pruritus. Topical corticosteroids are used if moisturization is not effective. Wet wrap therapy is used to treat flares with recalcitrant disease. 1. 9. An 8-year-old child is diagnosed with systemic lupus erythematosus (SLE), and the child’s parent asks if there is a cure. What will the primary care pediatric nurse practitioner tell the parent? a. a. Complete remission occurs in some children at the age of puberty. b. b. Periods of remission may occur but there is no permanent cure. c. c.SLE can be cured with effective medication and treatment. d. d. The disease is always progressive with no cure and no remissions. Periods of remission do occur in some children with SLE for unknown reasons, but there is no permanent remission or cure. For some children with Juvenile Idiopathic Arthritis (JIA), complete remission occurs at puberty. 1. 10. The primary care pediatric nurse practitioner is examining a school-age child who has had several hospitalizations for bronchitis and wheezing. The parent reports that the child has several coughing episodes associated with chest tightness each week and gets relief with an albuterol metered-dose inhaler. What will the nurse practitioner order? a. a. Allergy testing b. b. Chest radiography c. c. Spirometry testing d. d. Sweat chloride test Spirometry testing is the gold standard for diagnosing asthma and is then used on a regular basis to monitor, evaluate, and manage asthma. Allergy testing should be considered but is not diagnostic of asthma. Chest radiography should not be routine. A sweat chloride test is used based on history. 1. 11. The primary care pediatric nurse practitioner examines a child who has had stiffness and warmth in the right knee and left ankle for 7 or 8 months but no back pain. The nurse practitioner will refer the child to a rheumatology specialist to evaluate for a. a. enthesitis-related JIA. b. b. oligoarticular JIA. c. c.polyarticular JIA. d. d. systemic JIA. Oligoarticular JIA is characterized by mild, painless asymmetric joint involvement without systemic symptoms. Enthesitis-related JIA involves arthritis of the lower limbs, especially the hips, intertarsal joints, and sacroiliac joints, with swelling, tenderness, and warmth. Polyarticular JIA involves 5 or more joints. Systemic JIA presents with systemic symptoms, such as fever. 1. 12. A child who has been diagnosed with asthma for several years has been using a short-acting B2-agonist (SABA) to control symptoms. The primary care pediatric nurse practitioner learns that the child has recently begun using the SABA two or three times each week to treat wheezing and shortness of breath. The child currently has clear breath sounds and an FEV1 of 75% of personal best. What will the nurse practitioner do next? a. a. Add a daily inhaled corticosteroid. b. b. Administer 3 SABA treatments. c. c.Continue the current treatment. d. d. Order an oral corticosteroid. The child is showing a need to step up treatment based on the frequency of symptoms, greater than twice each week. The PNP should order an inhaled corticosteroid maintenance medication to control symptoms and reduce the need for a SABA. The child is not having an acute exacerbation, so does not need 3 SABA treatments. Oral corticosteroids are given for moderate obstruction, <70%. 1. 13. The primary care pediatric nurse practitioner is evaluating an 11-month-old infant who has had three viral respiratory illnesses causing bronchiolitis. The child’s parents both have seasonal allergies and ask whether the infant may have asthma. What will the nurse practitioner tell the parents? a. a. “Although it is likely, based on family history, it is too soon to tell.” b. b. “There is little reason to suspect that your infant has asthma.” c. c.“With your infant’s history of bronchiolitis, asthma is very likely.” d. d. “Your infant has definitive symptoms consistent with a diagnosis of asthma.” A genetic predisposition for the development of an IgE -mediated response to aeroallergens is the strongest identifiable predisposing risk factor for asthma, but asthma is rarely diagnosed before age 12 months due to the high rate of viral-induced bronchiolitis. The PNP should be cautious about diagnosing asthma until wheezing without an association to viral illnesses occurs. This infant has clear risk factors for asthma; however, bronchiolitis is not a known risk factor. 1. 14. An 8-year-old boy has a recent history of an upper respiratory infection and comes to the clinic with a maculopapular rash on his lower extremities and swelling and tenderness in both ankles. The pediatric nurse practitioner performs a UA, which shows proteinuria and hematuria and diagnoses HSP. What ongoing evaluation will the nurse practitioner perform during the course of this disease? a. a. ANA titers b. b. Blood pressure measurement c. c.Chest radiographs d. d. Liver function studies Hypertension is a serious risk of HSP, so repeated BP measurement is indicated. ANA titers are not measured with HSP. Chest radiographs are performed only if indicated. LFTs are not indicated; the predominant risk is to the kidneys. 1. 15. A 12-year-old child is brought to the clinic with joint pain, a 3-week history of low-grade fever, and a facial rash. The primary care pediatric nurse practitioner palpates an enlarged liver 2 cm below the subcostal margin along with diffuse lymphadenopathy. An ANA test is positive. Which test may be ordered to confirm a diagnosis of SLE? a. a. Anti-double-strand DNA antibodies b. b. Anti-La antibodies c. c.Anti-Ro antibodies d. d. Anti-Sm antibodies Anti -double-strand DNA antibodies are present in most people with SLE and are generally exclusively seen in cases of SLE and not other diseases. Anti-SM antibodies are diagnostic of SLE but are only seen in 30% of patients with SLE. 1. 16. A 10-year-old child has a 1-week history of fever of 104°C that is unresponsive to antipyretics. The primary care pediatric nurse practitioner examines the child and notes bilateral conjunctival injection and a polymorphous exanthema, with no other symptoms. Lab tests show elevated ESR, CRP, and platelets. Cultures are all negative. What will the nurse practitioner do? a. a. Begin treatment with intravenous methyl prednisone. b. b. Consider IVIG therapy if symptoms persist one more week. c. c.Order a baseline echocardiogram today and another in 2 weeks. d. d. Reassure the child’s parents that this is a self-limiting disorder. An echocardiogram should be obtained as soon as the diagnosis of Kawasaki disease (KD) is established, as a baseline study, with subsequent studies in 2 weeks and in 6 to 8 weeks. This child has fever and only two other symptoms, which may be consistent with atypical KD. Atypical KD is more common in very young children and in children over 9 years of age, and coronary artery involvement is found more frequently in children with atypical KD. Methyl prednisone is given for children with IVIG-resistant disease. IVIG should be begun ideally in the first 10 days of the illness. Although KD is a self-limiting disorder, the risk of coronary artery involvement is high, so this must be evaluated and treated. 1. 17. The primary care pediatric nurse practitioner is reviewing the rheumatology plan of care for a child who is diagnosed with SLE. Besides reinforcing information about prescribed medications, what will the nurse practitioner teach the family to help minimize flaring of episodes? a. a. Have the child rest between activities. b. b. Obtain regular ophthalmology exams. c. c. Participate in low-impact exercises. d. d. Use UVA and UVB sunscreen daily. Sunlight is a known trigger of SLE so patients should be advised to use a UVA and UVB sunscreen both indoors and out. Resting between activities is recommended for children with JIA. Children should participate in low-impact activities, but this does not reduce the number of flares. Ophthalmology exams are recommended for children with JIA. 1. 18. The primary care pediatric nurse practitioner is performing a well-baby checkup on a 6-month-old infant and notes a candida diaper rash and oral thrush. The infant has had two ear infections in the past 2 months and is in the 3rd percentile for weight. What will the nurse practitioner do? a. a. Order a CBC with differential and platelets and quantitative immunoglobulins. b. b. Order candida and pneumococcal skin tests and lymphocyte surface markers. c. c. Refer the infant to an immunologist for evaluation of immunodeficiency. d. d. Refer the infant to an otolaryngologist to evaluate recurrent otitis media. Infants with warning signs of immunodeficiency, such as recurrent infections, skin infections, and oral thrush, should be evaluated. The initial step is to order a CBC with differential, platelets, and immunoglobulins. If this is not helpful, referral to an immunologist for further testing, such as candida and pneumococcal skin tests and lymphocyte surface markers, is warranted. Referral to an otolaryngologist is not indicated. 1. 19. An adolescent who has exercise-induced asthma (EIA) is on the high school track team and has recently begun to practice daily during the school week. The adolescent uses 2 puffs of albuterol via a metered-dose inhaler 20 minutes before exercise but reports decreased effectiveness since beginning daily practice. What will the primary care pediatric nurse practitioner do? a. a. Counsel the adolescent to decrease the number of practices each week. b. b. Increase the albuterol to 4 puffs 20 minutes prior to exercise. c. c. Order a daily inhaled corticosteroid medication. d. d. Prescribe cromolyn sodium in addition to the albuterol. Children with EIA should use 2 puffs of a B2-agonist and/or cromolyn MDI 15 to 30 minutes prior to exercise, but, since tolerance may develop if a B2-agonist is used more than a few times a week, it should not be used as a controller monotherapy. Those who exercise regularly should use an ICS as a controller medication. Patients with asthma should be encouraged to exercise to improve overall health. Increasing the albuterol dose will not overcome the tolerance. And ICS is a preferred controller medication. 1. 20. An adolescent female reports poor sleep, fatigue, muscle and joint paint, and anxiety lasting for several months. The primary care pediatric nurse practitioner notes point tenderness at several sites. What will the nurse practitioner do next? a. a. Evaluate the adolescent’s pain using a numeric pain scale. b. b. Obtain ANA, CBC, liver function, and muscle enzymes tests. c. c. Reassure the adolescent that this condition is not life-threatening. d. d. Refer the adolescent to a rheumatologist for further evaluation. Children with widespread musculoskeletal pain and painful point tenderness may have fibromyalgia and should be referred. The Widespread Pain Index is used to define the degree of pain. Laboratory studies are of little benefit when diagnosing fibromyalgia. Even though children need reassurance that this disease is not life-threatening, this is not the next action. 1. 21. The primary care pediatric nurse practitioner is managing care for a child who has JIA who has a positive ANA. Which specialty referral is critical for this child? a. a. Cardiology b. b. Ophthalmology c. c.Orthopedics d. d. Pain management An ophthalmology consultation is critical for children with JIA who have a positive ANA. Uveitis occurs in up to 35% of children with JIA who have a positive ANA. Other specialists may be consulted for specific symptoms. 1. 22. The parent of a school-age child who is diagnosed with oligoarticular JIA asks the primary care pediatric nurse practitioner what exercises the child may do to help reduce symptoms. What will the nurse practitioner recommend? a. a. Running b. b. Swimming c. c. Weights d. d. Yoga Swimming is an excellent exercise for children with JIA because water therapy and the use of heat or cold reduce pain and stiffness, unless they have severe anemia or cardiac involvement. Chapter 28: Neurologic Disorders Test Bank Multiple Choice 1. The parents of an 18-month-old child bring the child to the clinic after observing a brief seizure of less than 2 minutes in their child. In the clinic, the child has a temperature of 103.1°F, and the primary care pediatric nurse practitioner notes a left otitis media. The child is alert and responding normally. What will the nurse practitioner do? a. Order a lumbar puncture, complete blood count, and urinalysis. b. Prescribe an antibiotic for the ear infection and reassure the parents. c. Refer to a pediatric neurologist for anticonvulsant and antipyretic prophylaxis. d. Send the child to the emergency department for EEG and possible MRI. This child has symptoms of a simple febrile seizure with a focal site of infection and an otherwise normal exam. While this is very frightening to the family, the PNP should treat the infection and provide reassurance to the parents. Lumbar puncture may be performed in infants younger than 12 months. Prophylactic medications aren’t indicated for febrile seizures. Antipyretics aren’t useful, since most seizures occur when the temperature is either rising or falling. EEG and MRI are not indicated when focal neurological signs are not present. 2. A child who has sustained a head injury after falling on the playground is brought to the clinic. The parents report that the child cried immediately and was able to walk around after falling. The primary care pediatric nurse practitioner notes slight slurring of the child’s speech and the child has vomited twice in the exam room. Which course of action is warranted? a. Admit the child to the hospital for a neurology consult. b. Observe the child in the clinic for several hours. c. Order a head CT and observe the child at home. d. Send the child home with instructions for follow-up. Children with certain symptoms, such as vomiting or slurred speech after a head injury, should be admitted to the hospital for neurologic consultation. If the child had not exhibited these symptoms, any of the other options would be acceptable. 3. A female infant who was developing normally stops meeting developmental milestones at age 12 months and then begins losing previously acquired skills. What will the primary care pediatric nurse practitioner expect to tell the parents about this child’s prognosis? a. Cognitive development will be normal but motor skills will be lost. b. Physical and speech therapy will help the infant regain lost skills. c. The child’s intellectual development will not progress further. d. This is a temporary condition with full recovery expected. This child has symptoms of Rett syndrome, which affects females more than males and is characterized by a plateau of development with eventual loss of milestones. Intellectual development remains at the level of plateau. Physical therapy, occupational therapy, and speech therapy help to preserve functional abilities but do not improve skills. The condition is progressive, with variable life expectancy. 4. To evaluate brain tissue disorders in infants, which test is useful? a. Computerized tomography b. Head radiographs c. Magnetic resonance imaging d. Ultrasonography Ultrasonography is used to evaluate brain tissue in infants. CT scans expose patients to high levels of radiation, so they are not used unless indicated. Radiographs have relatively diagnostic value for the neurologic system. Magnetic resonance imaging is useful but is expensive and usually requires sedation. 5. A child who has had a single non-febrile seizure has a normal neurologic exam. Which diagnostic test is indicated? a. Computerized tomography (CT) b. Electroencephalogram (EEG) c. Magnetic resonance imaging (MRI) d. Polysomnography An EEG is standard for all children after a first non-febrile seizure. CT is not routinely used because of radiation exposure. MRI is used if cognitive changes or postictal focal dysfunction persists, if the seizure lasts longer than 15 minutes, if the child is younger than 6 months of age, and if any new onset of focal neurologic deficit has occurred. Polysomnography is used to assess nocturnal seizures. 6. During a well baby exam on a 9-month-old infant, the parent reports that the baby always uses the left hand to pick up objects and asks if the baby will be left-handed. What will the primary care pediatric nurse practitioner do? a. Explain that it is too soon to tell which hand the infant will prefer later. b. Perform a careful assessment of fine and gross motor skills. c. Teach the parent to encourage the infant to use both hands. d. Tell the parent that a hand preference usually develops between 6 and 12 months. Hand preference before 1 year of age is usually suspect for cerebral palsy and may indicate a lack of motor skills in the other hand. The PNP should perform a careful assessment of fine and gross motor skills. Infants should not exhibit a hand preference until after 1 year of age, so the correct response is to assess further. 7. Because of their inability to ambulate, children with cerebral palsy should be evaluated for which nutrients? a. Calcium and vitamin D b. Fat-soluble vitamins c. Iron and zinc d. Sodium and potassium Children who do not place weight on their bones are at risk for osteopenia and should have vitamin D and calcium levels monitored and supplemented if indicated. 8. A 14-year-old child has a headache, unilateral weakness, and blurred vision preceded by fever and nausea. The child’s parent reports a similar episode several months prior. The primary care pediatric nurse practitioner will consult with a pediatric neurologist to order a. a lumbar puncture. b. an electroencephalogram (EEG). c. neuroimaging with magnetic resonance imaging (MRI). d. positron emission tomography (PET) scan. Children who have MS exhibit the symptoms described above and are usually diagnosed with a gadolinium enhanced MRI. Lumbar puncture may be performed later to identify oligoclonal bands. An EEG is used to diagnose seizure activity. PET scans are used to detect tumors. 9. The pediatric nurse practitioner provides primary care for a 5-year-old child who has cerebral palsy who exhibits athetosis and poor weight gain in spite of receiving high-calorie formula to supplement intake. The child has had several episodes of pneumonia in the past year. Which specialty consultation is a priority for this child? a. Feeding clinic to manage caloric intake b. Neurology to assess medication needs c. Pulmonology for possible tracheotomy d. Surgery for possible fundoplication and gastrostomy Children with CP who have athetosis often have increased calorie needs up to 50% to 100% higher than others. This child is unable to gain adequate weight in spite of receiving extra calories. The child also has possible aspiration pneumonia, probably due to difficulty swallowing or GERD. A fundoplication and gastrostomy can help to prevent GERD and to provide nutrition that doesn’t involve swallowing. The feeding clinic would increase calories and nutrients but, without a gastrostomy, cannot increase actual intake. The child is not having seizures or drooling that contribute to this problem, so medications aren’t necessary. Unless there is an airway problem, tracheotomy is not indicated. 10. When performing a neurologic exam to assess for meningeal signs in an infant, the primary care pediatric nurse practitioner will attempt to elicit the Kernig sign by a. bending the infant at the waist to touch fingers to toes. b. extending the leg at the knee with the infant supine. c. flexing the infant’s neck to touch chin to chest. d. turning the infant’s head from side to side. In an infant, the Kernig sign is elicited by extending the leg at the knee with the infant in a supine position while observing for facial grimacing. Older children can bend at the waist to touch the toes to elicit the Kernig sign. The Brudzinski sign is elicited by passively flexing the neck to cause the patient to spontaneously flex the hip and knees. Turning the infant’s head from side to side is not done to elicit either sign. 11. The primary care pediatric nurse practitioner performs a well baby exam on a term 4-month-old infant and observes flattening of the left occiput, bossing of the right occiput, and anterior displacement of the left ear. The parents report performing various positioning maneuvers, but say that the baby’s head shape has worsened. What will the nurse practitioner recommend to correct this finding? a. Allow the infant to sleep on the tummy when the parents are in the room. b. Lay the infant in the “back to sleep” position, alternating the left and right occiput. c. Order a head CT to evaluate the infant for craniosynostosis. d. Refer the infant for orthotic cranial molding helmet therapy. This infant was term and likely has positional plagiocephaly, which has not responded to repositioning efforts, so a referral should be made for an orthotic helmet. Tummy time is performed when the infant is awake and the parents are present. The “back to sleep” position with alternation of left and right is a repositioning maneuver. Craniosynostosis is characterized by bossing and deformity that follow cranial suture lines. 12. A 4-year-old child who has previously met developmental milestones is not toiled trained. The primary care pediatric nurse practitioner notes decreased reflexes in the lower extremities and observe a dimple above the gluteal cleft. Which diagnosis may be considered for this child? a. Arnold-Chiari malformation b. Reye syndrome c. Spina bifida cystica d. Tethered cord Tethered cord occurs when the caudal end of the spinal cord, causing abnormal stretching and damage to nerve cells, fibers, and blood vessels. This can cause symptoms of neurologic deterioration such as incontinence of bladder and bowel and loss of reflexes and sensation in the legs. Arnold-Chiari malformation involves a downward herniation of the caudal end of the cerebellar vermis, which can cause brainstem and upper cervical cord compression. Reye syndrome involves swelling in the brain and signs of increased intracranial pressure. Spina bifida cystica is a myelomeningocele, with symptoms present at birth. A child with a recent history of URI reports tingling and pain in one ear followed by sagging of one side of the face. The primary care pediatric nurse practitioner observes that the child cannot close the eye or mo Burns: Pediatric Primary Care, 6th Edition Chapter 29: Eye Disorders Test Bank Multiple Choice 13. The primary care pediatric nurse practitioner is treating an infant with lacrimal duct obstruction who has developed bacterial conjunctivitis. After 2 weeks of treatment with topical antibiotics along with massage and frequent cleansing of secretions, the infant’s symptoms have not improved. Which action is correct? a. Perform massage more frequently. b. Prescribe an oral antibiotic. c. Recommend hot compresses. d. Refer to an ophthalmologist. Infants treated for a secondary bacterial conjunctivitis with lacrimal duct obstruction who do not improve after 1 to 2 weeks of topical antibiotic therapy must be referred to an ophthalmologist for possible lacrimal duct probe. Performing the massage more often or applying hot compresses will not help clear the infections. Oral antibiotics are not indicated. 14. The primary care pediatric nurse practitioner performs a well child examination on a 9-month-old infant who has a history of prematurity at 28 weeks’ gestation. The infant was treated for retinopathy of prematurity (ROP) and all symptoms have resolved. When will the infant need an ophthalmologic exam? a. At 12 months of age b. At 24 months of age c. At 48 months of age d. At 60 months of age Children who have a history of ROP requiring treatment, even if ROP has completely resolved, will need yearly ophthalmologic follow- up. Less frequent follow-up is required for children with ROP who did not require treatment. 15. A school-age child is hit in the face with a baseball bat and reports pain in one eye. The primary care pediatric nurse practitioner is able to see a dark red fluid level between the cornea and iris on gross examination, but the child resists any exam with a light. Which action is correct? a. Administer an oral analgesic medication. b. Apply a Fox shield and reevaluate the eye in 24 hours. c. Instill anesthetic eyedrops into the affected eye. d. Refer the child immediately to an ophthalmologist. This child has a traumatic injury with hyphema to the eye, and an ophthalmologist must examine the eye to rule out orbital hematoma or retinal detachment. Any further attempt to examine the child may result in further injury. A Fox shield is used once more serious injury is excluded. 16. During a well-baby assessment on a 1-week-old infant who had a normal exam when discharged from the newborn nursery 2 days prior, the primary care pediatric nurse practitioner notes moderate eyelid swelling, bulbar conjunctival injections, and moderate amounts of thick, purulent discharge. What is the likely diagnosis? a. Chemical-induced conjunctivitis b. Chlamydia trachomatis conjunctivitis c. Herpes simplex virus (HSV) conjunctivitis d. Neisseria gonorrhea conjunctivitis C. trachomatis conjunctivitis usually begins between 5 to 14 days of life and causes moderate eyelid swelling, palpebral or bulbar conjunctivitis, and moderate, thick, purulent discharge. Chemical-induced conjunctivitis manifests as nonpurulent discharge. HSV is characterized by serosanguinous discharge. N. gonorrhea causes acute conjunctival inflammation and excessive purulent discharge. 17. The primary care pediatric nurse practitioner applies fluorescein stain to a child’s eye. When examining the eye with a cobalt blue filter light, the entire cornea appears cloudy. What does this indicate? a. The cornea has not been damaged. b. There is too little stain on the cornea. c. There is damage to the cornea. d. There is too much stain on the cornea. When fluorescein stain is applied and the entire cornea appears cloudy, it means that there is too much of the stain. Damaged areas of the cornea should appear greenish after staining with fluorescein dye. 18. During a well child assessment of an African-American infant, the primary care pediatric nurse practitioner notes a dark red-brown light reflex in the left eye and a slightly brighter, red-orange light reflex in the right eye. The nurse practitioner will a. dilate the pupils and reassess the red reflex. b. order auto-refractor screening of the eyes. c. recheck the red reflex in 1 month. d. refer the infant to an ophthalmologist. Any asymmetry, dark or white spots, opacities, or leukokoria should be referred immediately to a pediatric ophthalmologist. The PNP does not dilate pupils or order auto-refractor exams; these are done by an ophthalmologist. Because retinoblastoma is a concern, any unusual finding should be immediately referred. 19. The primary care pediatric nurse practitioner performs a Hirschberg test to evaluate a. color vision. b. ocular alignment. c. peripheral vision. d. visual acuity. The Hirschberg test, or corneal light reflex, assesses ocular mobility and alignment by looking for symmetry of reflected light. Color vision testing is performed with Richmond pseudo-isochromatic plates. Peripheral vision is tested by watching the child’s response to objects as they are moved in and out of the visual fields. Visual acuity is performed using eye charts or visual-evoked potential readings. 20. The primary care pediatric nurse practitioner performs a well baby assessment of a 5-day-old infant and notes mild conjunctivitis, corneal opacity, and serosanguinous discharge in the right eye. Which course of action is correct? a. Administer intramuscular ceftriaxone 50 mg/kg. b. Admit the infant to the hospital immediately. c. Give oral erythromycin 30 to 50 mg/kg/day for 2 weeks. d. Teach the parent how to perform tear duct massage. The infant has symptoms consistent with HPV conjunctivitis and requires hospitalization for topical and systemic antiviral medications to prevent spread to the central nervous system, mouth, and skin. IM ceftriaxone is given for gonococcal conjunctivitis. Oral erythromycin is given for chlamydial conjunctivitis. Tear duct massage is performed for lacrimal duct obstruction. 21. The primary care pediatric nurse practitioner performs a vision screen on a 4-month-old infant and notes the presence of convergence and accommodation with mild esotropia of the left eye. What will the nurse practitioner do? a. Patch the right eye to improve coordination of the left eye. b. Reassure the parents that the infant will outgrow this. c. Recheck the infant’s eyes in 2 to 4 weeks. d. Refer the infant to a pediatric ophthalmologist. Esotropia that continues or occurs at 3 to 4 months of age is abnormal, so the infant should be referred to a pediatric ophthalmologist. The PNP does not determine whether an eye patch should be used. Because it is abnormal at this age, the PNP will not reassure the parents that the infant will outgrow this. Esotropia after 3 to 4 months of age must be evaluated by a specialist and not reevaluated in 2 to 4 weeks. 22. A toddler exhibits exotropia of the right eye during a cover-uncover screen. The primary care pediatric nurse practitioner will refer to a pediatric ophthalmologist to initiate which treatment? a. Botulinum toxin injection b. Corrective lenses c. Occluding the affected eye for 6 hours per day d. Patching of the unaffected eye for 2 hours each day Deviations are initially treated by patching the unaffected eye for 2 hours each day to force the affected eye to move correctly. Botulinum toxin injection may be used with some deviations but is not a first-line therapy. Corrective lenses alone improve amblyopia in 27% of patients. The unaffected eye is patched; 2 hours per day is as effective as 6 hours per day. 23. A preschool-age child is seen in the clinic after waking up a temperature of 102.2°F, swelling and erythema of the upper lid of one eye, and moderate pain when looking from side to side. Which course of treatment is correct? a. Admit to the hospital for intravenous antibiotics. b. Obtain a lumbar puncture and blood culture. c. Order warm compresses 4 times daily for 5 days. d. Prescribe a 10- to 14-day course of oral antibiotics. This child has periorbital cellulitis and must be hospitalized because of having pain with movement of the eye, indicating orbital involvement. LP is performed on infants under 1 year of age. Warm compresses are used for mild cases. Oral antibiotics are not indicated. 24. A preschool-age child who attends day care has a 2-day history of matted eyelids in the morning and burning and itching of the eyes. The primary care pediatric nurse practitioner notes yellow-green purulent discharge from both eyes, conjunctival erythema, and mild URI symptoms. Which action is correct? a. Culture the conjunctival discharge. b. Observe the child for several days. c. Order an oral antibiotic medication. d. Prescribe topical antibiotic drops. Young children with bacterial conjunctivitis may be treated with topical antibiotic drops. Culturing the eyes is not necessary unless there is no improvement. While most cases of bacterial conjunctivitis are self-limiting, using a topical antibiotic will hasten the return to day care. Oral antibiotics are not indicated. 25. The primary care pediatric nurse practitioner observes a tender, swollen red furuncle on the upper lid margin of a child’s eye. What treatment will the nurse practitioner recommend? a. Culture of the lesion to determine causative organism b. Referral to ophthalmology for incision and drainage c. Topical steroid medication d. Warm, moist compresses 3 to 4 times daily The child has symptoms of hordeolum, or stye. Although these often rupture spontaneously, warm, moist compresses may hasten this process. It is not necessary to culture the lesion unless symptoms do not resolve. Referral to ophthalmology is made if the hordeolum does not rupture on its own. Steroids are not indicated. 26. A school-age child is seen in the clinic after a fragment from a glass bottle flew into the eye. What will the primary care pediatric nurse practitioner do? a. Refer immediately to an ophthalmologist. b. Attempt to visualize the glass fragment. c. Irrigate the eye with sterile saline. d. Instill a topical anesthetic. The PNP should never attempt to remove an intraocular foreign body or any projectile object but should refer immediately to an ophthalmologist. Visualizing the object, irrigating the eye, or instilling drops may further injure the eye. 27. A 14-year-old child has a 2-week history of severe itching and tearing of both eyes. The primary care pediatric nurse practitioner notes redness and swelling of the eyelids along with stringy, mucoid discharge. What will the nurse practitioner prescribe? a. Saline solution or artificial tears b. Topical mast cell stabilizer c. Topical NSAID drops d. Topical vasoconstrictor drops This child has symptoms of allergic conjunctivitis. Topical NSAIDs work for acute symptoms to reduce inflammation and may be used in children over age 12 years. Saline solution or artificial tears are useful for milder symptoms. Topical mast cell stabilizers are useful for chronic symptoms and maintenance therapy. Topical vasoconstrictors should be avoided because of rebound hyperemia. 28. During a well child exam on a 4-year-old child, the primary care pediatric nurse practitioner notes that the clinic nurse recorded “20/50” for the child’s vision and noted that the child had difficulty cooperating with the exam. What will the nurse practitioner recommend? a. Follow up with a visual acuity screen in 6 months. b. Refer to a pediatric ophthalmologist. c. Re-test the child in 1 year. d. Test the child’s vision in 1 month. Children age 4 years and older who have difficulty cooperating with a vision screen should be retested in 1 month; if they continue to have difficulty cooperating, they should be referred for a formal examination. Children who are 3 years old should be re-evaluated in 6 months. Burns: Pediatric Primary Care, 6th Edition Chapter 27: Hematologic Disorders Test Bank Multiple Choice 29. The primary care pediatric nurse practitioner sees a 12-month-old infant who is being fed goat’s milk and a vegetarian diet. The child is pale and has a beefy-red, sore tongue and oral mucous membranes. Which tests will the nurse practitioner order to evaluate this child’s condition? a. Hemoglobin electrophoresis b. RBC folate, iron, and B12 levels c. Reticulocyte levels d. Serum lead levels Infants and children who are fed goat’s milk or who are on a strict vegetarian diet are at risk for folic acid and vitamin B12 deficiency. These should be evaluated, along with iron, to rule out IDA. Hemoglobin electrophoresis is used to evaluate diseases associated with altered hemoglobin, such as beta-thalassemia and sickle cell anemia, neither of which is indicated by this child’s history. Reticulocyte levels are evaluated to evaluate transient erythroblastopenia of childhood, a condition that frequently follows a viral infection. Serum lead levels are not indicated based on this history. 30. A 2-year-old child who has SCA comes to the clinic with a cough and a fever of 101.5°C. The child currently takes penicillin V prophylaxis 125 mg orally twice daily. What will the primary care pediatric nurse practitioner do? a. Admit the child to the hospital to evaluate for sepsis. b. Give intravenous fluids and antibiotics in clinic. c. Increase the penicillin V dose to 250 mg. d. Order a chest radiograph to rule out pneumonia. Fever and pulmonary symptoms are two conditions warranting referral or emergency admission to the hospital to rule out sepsis and acute chest syndrome. Increasing the dose of penicillin V or giving IV antibiotics is not indicated. 31. The primary care pediatric nurse practitioner evaluates a 5-year-old child who presents with pallor and obtains labs revealing a hemoglobin of 8.5 g/dL and a hematocrit of 31%. How will the nurse practitioner manage this patient? a. Prescribe elemental iron and recheck labs in 1 month. b. Reassure the parent that this represents mild anemia. c. Recommend a diet high in iron-rich foods. d. Refer to a hematologist for further evaluation. The child has mild to moderate iron-deficiency anemia and will need iron supplementation. The hemoglobin, hematocrit, and reticulocytes should be reevaluated in 4 weeks after initiation of treatment. The child needs iron supplementation, so reassurance alone is not indicated. It is difficult to get iron from foods, so supplementation will be needed. Children with hemoglobin levels less than 4 g/dL and some children with hemoglobin levels less than 7 g/dL must be referred. 32. The primary care pediatric nurse practitioner is examining a 5-year-old child who has had recurrent fevers, bone pain, and a recent loss of weight. The physical exam reveals scattered petechiae, lymphadenopathy, and bruising. A complete blood count shows thrombocytopenia, anemia, and an elevated white cell blood count. The nurse practitioner will refer this child to a specialist for a. bone marrow biopsy. b. corticosteroids and IVIG. c. hemoglobin electrophoresis. d. immunoglobulin testing. This child has symptoms and initial lab tests consistent with leukemia and should be referred to a pediatric hematologist-oncologist for a bone marrow biopsy for a definitive diagnosis. Corticosteroids and IVIG are given for severe ITP. Hgb electrophoresis is used to diagnose SCA. Immunoglobulins are evaluated when immune deficiency syndromes are suspected. 33. The pediatric nurse practitioner provides primary care for a 30-month-old child who has sickle cell anemia who has had one dose of 23-valent pneumococcal vaccine. Which is an appropriate action for health maintenance in this child? a. Administer an initial meningococcal vaccine. b. Begin folic acid dietary supplementation. c. Decrease the dose of penicillin V prophylaxis. d. Give a second dose of 23-valent pneumococcal vaccine. Invasive bacterial infection is the leading cause of death in young children with SCA. Meningococcal vaccine should be given initially for all children over the age of 2 years and a booster dose given every 5 years after that. Folic acid supplementation is often used for adults but not for children unless there is a documented deficiency. Penicillin V prophylaxis is started at 2 months of age, with the dose increased at age 3 years. The 23-valent pneumococcal polysaccharide second dose is given 5 years after the first. 34. The primary care pediatric nurse practitioner reviews hematology reports on a child with beta-thalassemia minor and notes an Hgb level of 8 g/dL. What will the nurse practitioner do? a. Evaluate serum ferritin. b. Order Hgb electrophoresis. c. Prescribe supplemental iron. d. Refer for RBC transfusions. Children with beta-thalassemia minor may have low hemoglobin without iron deficiency so, before prescribing iron, the PNP should measure serum iron levels or serum ferritin. Hgb electrophoresis is indicated in a child whose diagnosis is unknown to diagnose this disorder. Supplemental iron should only be ordered when there is documented iron deficiency. RBC transfusions are controversial and used only for more severe iron deficiency. 35. A school-age child comes to the clinic for evaluation of excessive bruising. The primary care pediatric nurse practitioner notes a history of an upper respiratory infection 2 weeks prior. The physical exam is negative for hepatosplenomegaly and lymphadenopathy. Blood work reveals a platelet count of 60,000/mm3 with normal PT and aPTT. How will the nurse practitioner manage this child’s condition? a. Admit to the hospital for IVIG therapy. b. Begin a short course of corticosteroid therapy. c. Refer to a pediatric hematologist. d. Teach to avoid NSAIDs and contact sports. This child has symptoms, a history, and lab work that indicate idiopathic thrombocytopenic purpura. Since platelets are greater than 20,000/mm3, management without specific therapy may be done on an outpatient basis by teaching the family to avoid things that contribute to bleeding. IVIG therapy is used for children with active, severe bleeding. Corticosteroids are given for platelet counts less than 20,000/mm3. Referral to a hematologist is necessary for more severe cases. 36. A toddler who presents with anemia and reticulocytopenia has a history of a gradual decrease in energy and increase in pallor beginning after a recent viral infection. How will the primary care pediatric nurse practitioner treat this child? a. Closely observe the child’s symptoms and lab values. b. Consult with a pediatric hematologist. c. Prescribe supplemental iron for 4 to 6 months. d. Refer for transfusions to correct the anemia. This child has symptoms and a history consistent with transient erythroblastopenia of childhood (TEC), which is usually self-limited. The PNP should monitor the child closely without treatment unless the anemia gets worse. Any of the other options may be necessary if the child’s condition worsens. 37. The primary care pediatric nurse practitioner is managing care for a child diagnosed with iron-deficiency anemia who had an initial hemoglobin of 8.8 g/dL and hematocrit of 32% who has been receiving ferrous sulfate as 3 mg/kg/day of elemental iron for 4 weeks. The child’s current lab work reveals elevations in Hgb/Hct and reticulocytes with a hemoglobin of 10.5 g/dL and a hematocrit of 36%. What is the next step in management of this patient? a. Continue the current dose of ferrous sulfate and recheck labs in 1 to 2 months. b. Discontinue the supplemental iron and encourage an iron-enriched diet. c. Increase the ferrous sulfate dose to 4 to 6 mg/kg/day of elemental iron. d. Refer the child to a pediatric hematologist to further evaluate the anemia. This child has mild to moderate anemia and is showing a good response to the current dose of iron. Ferrous sulfate should be continued for at least 2 to 3 months to normalize hemoglobin, and then continue for 2 to 4 months to replace depleted iron stores. There is no need to increase the dose, since the child is responding appropriately to the current dose. Children with hemoglobin levels less than 4 g/dL should be referred. 38. The primary care pediatric nurse practitioner is performing a well child examination on a school-age child who has a history of cancer treated with cranial irradiation. What will the nurse practitioner monitor in this child? a. Cardiomyopathy and arrhythmias b. Leukoencephalopathy c. Obesity and gonadal dysfunction d. Peripheral neuropathy and hearing loss Leukoencephalopathy is a late effect of cancer treatment associated with cranial irradiation. Cardiomyopathy and arrhythmias are related to anthracycline use. Obesity and gonadal dysfunction result from neuroendocrine effects of chemotherapeutic agents. Peripheral neuropathy and hearing loss occur after cisplatin use. 39. A complete blood count on a 12-month-old infant reveals microcytic, hypochromic anemia with a hemoglobin of 9.5 g/dL. The infant has mild pallor with no hepatosplenomegaly. The primary care pediatric nurse practitioner suspects a. hereditary spherocytosis. b. iron-deficiency anemia. c. lead intoxication. d. sickle-cell anemia. Iron-deficiency anemia is the most common type of anemia in infants and children, accounting for approximately 90% of cases. It is characterized by decreased hemoglobin, with microcytic, hypochromic RBCs. Hereditary spherocytosis is characterized by pallor and jaundice with splenomegaly. Lead intoxication is accompanied by neurobehavioral problems. Sickle-cell anemia involves the presence of HgbS. 40. The primary care pediatric nurse practitioner performs a well baby examination on a 4-month-old infant who is exclusively breastfed and whose mother plans to introduce only small amounts of fruits and vegetables in addition to breastfeeding. To ensure that the infant gets adequate amounts of iron, what will the nurse practitioner recommend? a. Elemental iron supplementation of 1 mg/kg/day until cereals are added b. Elemental iron supplementation of 3 mg/kg/day for the duration of breastfeeding c. Monitoring the infant’s hemoglobin and hematocrit at every well-baby checkup d. Offering iron-fortified formula to ensure adequate iron intake Infants who are exclusively breastfeeding or who receive more than half of their diet from breast milk should be given 1 mg/kg/day of supplemental iron until iron-containing foods are added to the diet. It is not necessary to monitor Hgb/Hct regularly unless the child has symptoms. Formula is not necessary for breastfeeding infants. 41. The primary care pediatric nurse practitioner reviews a child’s complete blood count with differential white blood cell values and recognizes a “left shift” because of a. a decreased eosinophil count. b. a decreased lymphocyte count. c. an elevated monocyte count. d. an elevated neutrophil count. A left shift occurs when there is an increase in the number of circulating immature neutrophils and indicates a bacterial infection or an inflammatory disorder. Eosinophils are associated with an antigen-antibody response and are elevated with exposure to allergens, inflammation of skin, or parasites. Lymphocytes are non-granulocytes that are elevated with viral infections. Monocytes are non-granulocytes and are elevated in infections and inflammation and some leukemias; elevations of non-granulocytes are referred to as a “right shift.” Burns: Pediatric Primary Care, 6th Edition Chapter 22: Prescribing Medications in Pediatrics Test Bank Multiple Choice 42. The single mother of a 4-year-old who attends day care tells the primary care pediatric nurse practitioner that she had difficulty giving her child a twice-daily amoxicillin for 10 days to treat otitis media during a previous episode several months earlier because she works two jobs and is too busy. The child has an ear infection in the clinic today. What will the nurse practitioner do? a. Administer an intramuscular antibiotic. b. Order twice-daily amoxicillin for 5 days. c. Prescribe azithromycin once daily for 5 days. d. Reinforce the need to adhere to the plan of care. To improve adherence, the PNP should shorten the length of treatment, if possible and, if possible, reduce the number of times per day that a medication is given. This mother indicated that she had difficulty giving two doses per day, so a once daily for 5 days medication is ideal. It is not necessary to give an IM injection unless the child refuses to take the medication. Reinforcing the need to adhere to the plan is important but does not address the underlying difficulty associated with scheduling. 43. The primary care pediatric nurse practitioner is considering use of a relatively new drug for a 15-month-old child. The drug is metabolized by the liver, so the nurse practitioner will consult a pharmacologist to discuss giving the drug: a. less often or at a lower dose. b. more often or at a higher dose. c. via a parenteral route. d. via the oral route. Infants metabolize drugs more slowly than older children due to decreased levels of oxidases and conjugating enzymes produced in the immature liver, so they may need drugs given less often or at lower doses to avoid toxicity. The route does not necessarily play a role in this case. 44. The parent of a school-age child who has asthma tells the primary care pediatric nurse practitioner that the child often comes home from school with severe wheezing after gym class and needs to use his metered-dose inhaler right away. What will the nurse practitioner do? a. Recommend that the child go to the school nurse when symptoms start. b. Review the child’s asthma action plan and possibly increase his steroid dose. c. Suggest asking the school to excuse the child from gym class. d. Write the prescription for two metered-dose inhalers with spacers. When children have to take a medication at school or day care, the PNP should dispense two units of the medication so that one can remain at school and one at home to avoid missed doses. The school nurse will not be able to order a medication that the child does not have available. The child is missing his rescue medication and just needs access to his inhaler. It is not necessary to excuse the child from gym class if his symptoms can be controlled. 45. A pharmaceutical company has developed a new drug that was tested only on adults. The FDA has declared this drug to have potential benefits for ill children. According to the Pediatric Research Equity Act (PREA), what may the pharmaceutical company be required to do? a. Conduct pediatric drug studies to determine whether the drug is safe and effective in children. b. Provide labeling stating that the safety and efficacy of the drug is not established for children. c. Receive a patent extension for conducting pediatric studies to determine use in children. d. Survey existing data about the drug to determine potential use in the pediatric population. The PREA gives the FDA more leverage over the types of new drugs developed for children and can require pharmaceutical companies to conduct pediatric drug trials if the FDA declares a drug as possibly useful to ill children or one that might be used by a substantial number of children. The Food and Drug Administration Modernization Act (FDAMA) allowed labeling that “safety and effectiveness in pediatric patients have not been established” on drugs with insufficient evidence to support pediatric indications. The Best Pharmaceuticals of Children Act (BPCA) grants a patent extension when a drug company voluntarily studies a known or new drug in children. The FDAMA also requires pharmaceutical companies to survey existing data and determine potential drug use and indications in pediatric populations. 46. The primary care pediatric nurse practitioner is considering using a drug for an “off-label” use in a child. The nurse practitioner has used the drug in a similar situation previously, has consulted a pharmacology resource and the FDA website, and has determined that there are no significant contraindications and warnings for this child. What else must the nurse practitioner do when prescribing this drug? a. Discuss recommendations with the parents and document their consent. b. Document anecdotal reports of previous use of the drug by other providers. c. Follow up daily with the parents to determine safe administration of the drug. d. Report this use to the FDA Medwatch website for tracking purposes. Many prescriptions are written for “off -label” uses for children because the drug doesn’t have enough substantial evidence for FDA approval. The PNP should make sure to discuss the drug and this use with the family and document the decision-making process and their consent for this use. It is not enough to base a decision solely on what someone else has done. Unless the drug is experimental or has many serious adverse effects, close daily monitoring is not necessary. The PNP is not required to report off-label drug use to the FDA. 47. The primary care pediatric nurse practitioner prescribes a new medication for a child who develops a previously unknown adverse reaction. To report this, the nurse practitioner will : a. access the BPCA website. b. call the PREA hotline. c. log onto the FDA Medwatch website. d. use the AAP online PediaLink program. The FDA Medwatch website is available for reporting of drug-related adverse effects, and all providers are encouraged to report these here. BPCA and PREA are legislative acts and do not have a hotline or website for adverse effects reporting. The AAP PediaLink program is a source for labeling changes of drugs. 48. The primary care pediatric nurse practitioner is treating a toddler who has a lower respiratory tract illness with a low- grade fever. The child is eating and taking fluids well and has normal oxygen saturations in the clinic. The nurse practitioner suspects that the child has a viral pneumonia and will : a. order an anti-viral medication and schedule a follow-up appointment. b. prescribe a broad-spectrum antibiotic until the lab results are received. c. teach the parents symptomatic care and order labs to help with the diagnosis. d. write a prescription for an antibiotic to be given if the child’s condition worsens. To decrease antibiotic overuse and resistance, the PNP should order an antibiotic only if laboratory data confirm a bacterial infection. This child is mildly ill and can be treated symptomatically. It is not necessary to treat with an anti-viral medication. A broad-spectrum antibiotic will only increase the risk of antibiotic resistance. Writing a prescription for the parents to fill if needed is not recommended; parents may give an antibiotic believing that it is indicated when it is not. 49. The primary care pediatric nurse practitioner is counseling an adolescent who was recently hospitalized for an asthma exacerbation and learns that the child usually forgets to use twice- daily inhaled corticosteroid medications that are supposed to be given at 0800 and 2000 each day. Which strategy may be useful in this case to improve adherence? a. Ask the adolescent to identify two times each day that may work better. b. Consider having the school nurse supervise medication administration. c. Prescribing a daily oral corticosteroid medication instead. d. Suggest that the parent enforce the medication regimen each day. When working with adolescents who take medication, it is important to allow the adolescent to have input into dosing schedules and what works for them. Having the school nurse supervise does not allow autonomy and creates continued dependency. Daily oral corticosteroids are not used for maintenance. The PNP should assist the family with transitioning the adolescent from parent to teen administration and not suggest that parents enforce medication rule Burns: Pediatric Primary Care, 6th Edition Chapter 41: Genetic Disorders Test Bank Multiple Choice 50. Which diagnostic study may be ordered when the provider wishes to detect the presence of additional genetic material on a chromosome? a. Chromosomal microarray b. FISH c. Karyotype d. Molecular testing Fluorescence in-situ hybridization is used to locate and detect a specific area of a particular chromosome, including subtle missing, additional, or rearranged chromosomal material. Chromosomal microarray is used to detect micro-deletions or duplications in any of the chromosomes but not specific gene mutations. Karyotype testing is used to identify and evaluate the size, shape, and number of chromosomes. Molecular testing is used to detect specific single gene mutations. 51. What is an important responsibility of the primary care pediatric nurse practitioner to help determine genetic risk factors in families? a. Assessing physical characteristics of genetic disorders b. Knowing which genetic screening tests to perform c. Making appropriate referrals to pediatric geneticists d. Obtaining a three-generation pedigree for each family In primary care practice, taking the time to collect a child’s family health history and pedigree can be just as important as information from a laboratory test and gives useful information about possible genetic disorders present in a family. The other skills are necessary if there is concern that a genetic disorder exists. 52. Which type of mutation is responsible for many single-gene genetic disorders? a. Copy number variations b. Nucleotide repeat expansions c. Point mutations d. Single nucleotide polymorphisms (SNP) Point mutations are single base pair changes capable of changing the function of a gene or gene product. Copy number variations involve larger areas of chromosomes beyond point mutations and provide the genetic basis for many psycho-behavioral diseases. Nucleotide repeat expansions occur beyond single point changes; genetic changes occur when the number of repeats increases beyond the tolerated limit. SNPs are alterations that contribute to multifactorial disorders. 53. Cystic fibrosis is a recessive disease requiring the presence of a gene mutation on both alleles inherited from the parents. Which type of genetic disorder is this? a. Chromosome b. Mitochondrial c. Monogenetic d. Multifactorial Monogenetic disorders occur when the mutation affects a single gene; recessive diseases are one type of monogenetic disorder. Chromosome disorders occur with changes in the number or structure of an entire chromosome or large segments of it. Mitochondrial disorders are rare and are related to mutations in the genetic material found in the mitochondria and not the chromosomes. Multifactorial disorders are caused by mutations that may have inherited and environmental causes. 54. Which type of testing will the primary care pediatric nurse practitioner recommend for a couple concerned about the potential for having children with cystic fibrosis? a. Biochemical testing b. Carrier testing c. FISH testing d. Karyotype testing Carrier testing is used to detect the presence of a carrier state by detecting whether each has one copy of a gene mutation known to cause a specific disorder caused when two copies are present. Biochemical testing is used to study the amount, activity level, or structure of proteins and enzymes that result from gene mutations. FISH testing is used to locate and detect a specific area of a particular chromosome, including subtle missing, additional, or rearranged chromosomal material. Karyotype testing is used to identify and evaluate the size, shape, and number of chromosomes. 55. A family medical history conducted during a well baby exam for a newborn girl reveals that hemophilia A, an X-linked recessive disorder, is present in males in three previous generations in the mother’s family, whose father had the disease. What will the primary care pediatric nurse practitioner tell the parents about the risk of this disease in their children? a. All of their sons will be affected by the disease. b. Any sons they have will not be affected by the disease. c. Daughters have a 50% chance of being carriers of the disease. d. Their daughter has a 25% chance of having the disease. If a father is affected by an X- linked recessive disease, all of his daughters will be carriers and will have a 50% chance of having sons who are affected. Daughters have a 50% chance of being a carrier, but are not affected, since they receive normal X chromosomes from their father. 56. What is true about haploid cells? a. Each contains 23 paired chromosomes. b. Each one contains 23 chromosomes. c. Replication produces two identical cells. d. They replicate via the process of mitosis. Haploid cells each contain only 23 chromosomes, while diploid cells contain 23 paired chromosomes. Diploid cells replicate via the process of mitosis, producing two identical daughter cells. 57. A child has a recessive genetic disorder that is homozygous for that mutation. What is most likely about this child’s parents? a. Neither parent has a copy of that gene mutation. b. Only the mother has a copy of that gene mutation. c. Only the father has a copy of that gene mutation. d. Each parent has one copy of that gene mutation. When a child has a recessive genetic mutation that is homozygous, the child has two copies of the mutation, each donated by the parents. Since it is recessive, parents may be carriers of the gene, having only one copy, and pass the disorder to the child when the child inherits two copies. Both parents have to donate this mutation to the child. 58. The primary care pediatric nurse practitioner is counseling a couple about genetic risks and learns that one parent has neurofibromatosis, an autosomal dominant disorder, and the other parent does not. What will the nurse practitioner include when discussing this disorder and its transmission? a. Children must inherit a gene from both parents to develop the disease. b. Each child born to this couple will have a 50% risk of having the disease. c. This type of disorder characteristically skips generations. d. Unaffected offspring may still pass on the disease to their offspring. With this type of disorder, the gene mutation is passed on from only one parent, who has a single copy of the gene. The unaffected partner does not carry the genes. Each pregnancy carries a 50% risk from the probability that the affected parent will either donate an affected gene or not. Only one gene is necessary to produce disease. This type of disorder usually does not skip generations. Unaffected offspring will not have the gene and cannot pass on the disease to their offspring. 59. What does the following genetic notation symbol mean 47,XX,6q-? a. Male with deletion of chromosome 6 b. Female with deletion of chromosome 6 c. Male with deletion on the long arm of chromosome 6 d. Female with deletion on the long arm of chromosome 6 “XX” is a female. “q” indicates the long arm of a chromosome. “-” indicates a deletion. Burns: Pediatric Primary Care, 6th Edition Chapter 21: Introduction to Disease Management Test Bank Multiple Choice 60. The parent of a child with complex health care needs tells the primary care pediatric nurse practitioner that the child has had difficulty breathing the past two nights but can’t articulate specific symptoms. The child has normal oxygen saturations and a normal respiratory rate with clear breath sounds. What will the nurse practitioner do? a. Admit the child to the hospital for close observation and monitoring of respiratory status. b. Encourage the parent to call when concerned and schedule a follow-up appointment the next day. c. Perform a complete blood count, blood cultures, and a chest radiograph to evaluate symptoms. d. Reassure the parent that the child has a normal exam and is most likely not ill. Most parents are alert to subtle changes in their children, so it is important to listen attentively when they voice their concerns. Children who have special health care needs merit closer observation and follow-up than the average, thriving child. The child has a normal exam, so does not need labs or X-rays or hospitalization, but the PNP should make sure the parent is able to reach the provider when needed and should schedule an office follow-up to evaluate changes in the child’s status. Reassuring the parent that things are fine only minimizes the parent’s concerns. 61. The parent of a toddler who has special health care needs is resistant to a suggestion that her child needs a gastrostomy tube for nutrition. The toddler has fallen from the 10th percentile to the 5th percentile in the past few months and resists taking in appropriate amounts of food by mouth even with assistance from occupational therapy. What will the primary care pediatric nurse practitioner do? a. Inform the mother that, since other options have failed, the gastrostomy tube is the only option. b. Refer the child to a dietician to teach the mother the importance of adequate nutrition. c. Set weight gain and food intake goals with the mother and schedule regular visits to monitor weight. d. Suggest that the gastrostomy tube may be tried temporarily and removed once the child gains weight. This child is still at an acceptable weight, so it is not urgent to place a gastrostomy tube for feeding. Health care management for Children and youth with special health care needs includes empowering families through education, counseling, and support, and it is vitally important to listen to families and ask them for input. Allowing the mother to set goals and make attempts to achieve appropriate weight gain may help her see that a gastrostomy tube may be necessary. If the child’s weight loss becomes more acute, it may be necessary to tell the mother that there is no other option. Referring the child to a dietician may be part of the overall plan but still needs to be decided in collaboration with the mother. Generally, when gastrostomy tubes are inserted, they are permanent, and giving false hope is not ethical. 62. A parent brings a 4-month-old infant to the clinic who has had a low-grade fever for 24 hours. The primary care nurse practitioner notes that the infant has a weak cry, slightly dry oral mucosa, mottled skin, and a respiratory rate of 65 breaths per minute and sleeps unless stimulated by the examiner,. What will the nurse practitioner do? a. Administer oral fluids in the clinic. b. Admit the infant to the hospital. c. Order outpatient laboratory tests. d. Send the infant home with close follow-up. This infant has several signs indicating severe impairment and should be hospitalized. 63. The parent of an 18-month-old child calls the clinic to report that the child has a rectal temperature of 100.4°F (38°C). The child is playing normally, taking fluids well, and has a slightly reduced appetite. What will the primary care pediatric nurse practitioner recommend? a. Administering an antipyretic medication b. Bringing the child to the clinic for evaluation c. Offering extra fluids and calling if symptoms change d. Ordering outpatient lab work such as a CBC Fever management depends on the degree of temperature and the symptoms exhibited by the child. This child has a low elevation in temperature and is acting normally. Antipyretics are only necessary for comfort or to prevent cellular damage that occurs with very high fevers. This child can be managed with extra fluids and monitoring for changes in status. It is not necessary to give an antipyretic, bring the child to the clinic, or perform lab tests. 64. The primary care pediatric nurse practitioner is assessing an ill 2-month-old infant who is febrile and refusing most fluids. The preliminary blood work indicates a viral infection and shows that the infant is hydrated. The infant is alert. The infant’s parents are attentive and live close by. What will the nurse practitioner do? a. Administer a parenteral antibiotic and antipyretic and send the infant home. b. Admit the infant to an inpatient hospital unit for overnight monitoring. c. Give the parents sick care instructions and follow up in the clinic in the morning. d. Send the infant to the urgent care center for intravenous fluids. Management of an acute illness in a 1- to 2-month-old infant depends on the results of diagnostic studies, the appearance of the infant, and whether the infant can be followed up within 24 hours. This infant does not appear to have a bacterial infection, is alert, and has parents who can provide appropriate care and can bring the infant to the clinic in the morning for follow-up. Unless a bacterial infection is suspected, antibiotics are not indicated. It is not necessary to admit the infant to the hospital. The infant is hydrated and does not need intravenous fluids. 65. The primary care pediatric nurse practitioner is performing a well baby examination on a 2-week-old infant who was recently discharged home from the neonatal intensive care unit. The mother reports that the infant was born at 26 weeks’ gestation and states she was told that her baby will probably have developmental delays. What is the most important aspect of long-term management for this infant? a. Careful monitoring of attainment of developmental milestones b. Familiarizing the parent with laws that mandate educational support c. Providing genetic counseling to the infant’s parents d. Referral to social services for assistance with resources Early identification of conditions and diseases that contribute to special health care needs is of paramount importance, and the primary care provider should ensure that the child is followed closely to determine developmental deficits so that services can be provided in a timely manner. The other options may be done as part of the course of managing any potential deficits, but, until these are known, these are not the priority action. 66. A toddler swallowed a coin several days prior. The child’s parent has not found the coin in the child’s stool. Which imaging test will the primary care pediatric nurse practitioner employ to evaluate this ingestion? a. Abdominal ultrasound b. Computed tomography c. Conventional radiograph d. Magnetic resonance imaging The conventional radiograph is the least expensive test and will identify a foreign body. Even though it involves radiation, it does not require sedation or anesthesia. An ultrasound is highly dependent on operator experience but is not usually used for a quick location of a foreign body. The CT scan is expensive and has a relatively large radiation exposure and is more useful for identifying calcifications and fresh blood, along with abnormalities of blood vessels. The MRI is expensive and requires sedation or anesthesia and is used to identify soft tissue lesions. 67. The parent of a preschool-age child calls the clinic to report that the child has clear, watery drainage from both eyes, mild erythema of the conjunctiva, and no fever or other symptoms. What will the primary care pediatric nurse practitioner recommend? a. Allow the child to go to preschool. b. Bring the child to the clinic for a culture. c. Keep the child home for 2 days. d. Use antibiotic eyedrops for 3 days.. Children with nonpurulent conjunctivitis without fever or behavioral change may attend day care. It is not necessary to keep the child home, perform a culture, or use antibiotic eyedrops. 68. Which characteristic is the key criterion that identifies a child has having special needs? a. Cognitive function b. Emotional health c. Health service requirements d. Medical diagnosis Children and youth with special health care needs (CYSHCN) are those with one or more chronic physical, developmental, behavioral, or emotional conditions that require health and related services of a type or amount greater than the average child. The need for services, rather than the medical diagnosis, is the key factor. 69. The primary care pediatric nurse practitioner diagnoses a 5-year-old child with asthma and prescribes an oral steroid and a short-acting beta-adrenergic medication via a metered-dose inhaler to manage acute symptoms. Along with education about the prescribed medications, what information is important to give the child’s family at this visit? a. An asthma action plan b. Effects and side effects of current medications c. Information about spirometry testing d. Instructions for medications at school It is important to consider where the patient and family are in the trajectory of disease diagnosis and management when providing education. They do not need all information in one visit. Once the acute symptoms are managed, education for long-term management can begin, including an asthma action plan, spirometry testing, and school management. 70. A toddler is prescribed a liquid oral medication. The parent tells the primary care pediatric nurse practitioner that the child refuses to take medications and usually spits them out. What will the nurse practitioner do? a. Demonstrate oral medication administration with the toddler in the office. b. Instruct the parent to hide the medication in a favorite food or beverage. c. Order the medication to be given via another route if possible. d. Tell the parent to offer the child a reward each time the medication is taken. Demonstration and return demonstration can be useful when teaching parents how to administer oral medications to infants and young children. Since most outpatient medications for children are oral suspensions, it is best to teach parents how to administer these and for children to learn how to take them. Hiding the medication in food or fluids often results in the medication not being taken if the child refuses the food or fluid. Giving the medication via another route does not teach the child or parent how to use liquid oral medications. Offering a reward is not usually recommended for something that the child is expected to do. 71. The primary care pediatric nurse practitioner uses a shared decision-making (SDM) model when working with families of children with chronic health conditions. When using this model, the nurse practitioner can expect a. considerably more time in each encounter. b. improved patient health outcomes. c. less PNP involvement in health care decisions. d. lower provider and higher patient satisfaction. Patients who feel that they have been an active participant in the SDM process have improved health outcomes. SDM does not require significantly more time per encounter. The PNP remains actively involved in this collaborative process and will have improved satisfaction along with the patients and families. 72. The primary care pediatric nurse practitioner orders a pulmonology consult for a child who has severe asthma. The nurse practitioner writes “child with asthma refractory to conventional treatments needs suggestions for alternative treatments.” The nurse practitioner expects the pulmonologist to a. confirm the medical diagnosis for the child’s parents. b. make recommendations for disease management. c. stress the importance of adherence to the medication regimen. d. take over management of this child’s chronic illness. A consult implies that the person being consulted will make recommendations for disease management but that the primary care provider will continue to manage the patient’s care. The consult in this case is not to confirm the diagnosis but to determine other treatment options. There is no indication that nonadherence is the issue. The PNP has not asked the pulmonologist to assume care for this child. 73. The primary care pediatric nurse practitioner is preparing to perform a well child examination on a 5-year-old child who has multiple developmental and cognitive delays. The child’s mother is angry and tells the nurse practitioner that her friends’ children are all preparing for kindergarten. The nurse practitioner will : a. allow the mother to express her feelings, understanding that she is experiencing grief. b. reassure the mother that special educational opportunities are available for her child. c. suggest that the mother find a support group with other children with special needs. d. tell her that most schools provide services for children with special health care needs. The mother is experiencing chronic sorrow, which involves feelings of anger, sadness, guilt, or failure and which may be experienced at various times during her child’s life. The PNP should be understanding about the mother’s anger and allow her to express her feelings. The other options do not acknowledge her feelings or remove her sorrow. 74. What is the most important role of the primary care pediatric nurse practitioner who provides care for a child with special health care needs who sees several specialists and receives community and school-based services? a. Assessing the parent’s ability to perform home care tasks b. Coordinating services to ensure continuity of care c. Monitoring the family’s adherence to the health care plan d. Ordering medications and other prescribed treatments Children and youth with special health care needs should receive care in a medical home, and the PNP’s main role is to coordinate care across specialties and disciplines to ensure continuity of care. The other options describe tasks that may be performed by other members of the child’s health care team and are not the primary role of the PNP. 75. The primary care pediatric nurse practitioner cares for several families with chronically ill children who text status updates about their children to a mobile device that has an encryption- protection platform installed. If the nurse practitioner misplaces the mobile device, it is important to : a. disconnect the user from the system to avoid a data breach. b. notify the families that their messages may be read by others. c. obtain a new device as soon as possible to resume communication. d. upload the messages from another remote device. To avoid a data breach if a mobile device is lost, the user must disconnect from the device. It is not enough to notify the families, since the information is still on the device Burns: Pediatric Primary Care, 6th Edition Chapter 20: Cognitive-Perceptual Disorders Test Bank Multiple Choice 76. The parent of a 4-year-old child reports that the child gets upset when the hall light is left on at night and won’t leave the house unless both shoes are tied equally tight. The primary care pediatric nurse practitioner recognizes that this child likely has which type of sensory processing disorder? a. Dyspraxia b. Over-responder c. Sensory seeker d. Under-responder Children who are over-responders have difficulties with clothing, physical contact, light, sounds, and food. Dyspraxia refers to difficulty recognizing and distinguishing shapes and textures. Sensory seekers are on perpetual overdrive and often in trouble. Under-responders have little or no reaction to stimulation, pain, and extreme hot or cold. 77. The primary care pediatric nurse practitioner is considering medication options for a school-age child recently diagnosed with ADHD who has a primarily hyperactive presentation. Which medication will the nurse practitioner select initially? a. Low-dose stimulant b. Moderate -dose stimulant c. Low-dose non-stimulant d. Moderate -dose non-stimulant Stimulants are generally the first-line medication for ADHD, with non-stimulants recommended for non-responders. Moderate- to high-dose stimulants are recommended for children with primarily hyperactive presentations. 78. The parent of a preschool-age child who is diagnosed with a sensory processing disorder (SPD) asks the primary care pediatric nurse practitioner how to help the child manage the symptoms. What will the nurse practitioner recommend? a. Establishing a reward system for acceptable behaviors b. Introducing the child to a variety of new experiences c. Maintaining predictable routines as much as possible d. Providing frequent contact, such as hugs and cuddling Children with SPD do best with an environment that is predictable and routine and the same from day to day. Discipline and/or a reward system is not effective. Children with SPD can become overwhelmed by new experiences or frequent touch. 79. The primary care pediatric 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. Attention-deficit/hyperactivity disorder b. Autism spectrum disorder c. Executive function disorder d. Sensory processing 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. 80. The primary care pediatric nurse practitioner cares for a preschool-age child who was exposed to drugs prenatally. The child bites other children and has tantrums when asked to stop but is able to state later why this behavior is wrong. This child most likely has a disorder of a. executive function. b. information processing. c. sensory processing. d. social cognition. Children with prenatal drug or alcohol exposure often have executive function disorders, characterized by an inability to stop or delay a response or interrupt an inappropriate behavior and an inability to modify emotional expression appropriately. Information processing refers to thinking and problem-solving ability. Sensory processing has to do with the ability to take in information through senses and to process it appropriately. Social cognition refers to the ability to interpret behavior and emotions of the self and others. 81. A child who has attention-deficit/hyperactivity disorder (ADHD) has difficulty stopping activities to begin other activities at school. The primary care pediatric nurse practitioner understands that this is due to difficulty with the self-regulation component of a. emotional control. b. flexibility. c. inhibition. d. problem-solving. Flexibility is a component of self-regulation, which is under the control of executive functions in the cerebral cortex and is the ability to shift or transition between activities or thoughts. Emotional control is the ability to modify emotional expression to the most adaptive expression. Inhibition refers to the ability to stop or delay an initial response. Problem solving is a component of metacognition. 82. The primary care pediatric nurse practitioner is selecting a medication for a 12-year-old child who is newly diagnosed with ADHD. The child is overweight, has a history of an atrial septal defect at birth, and reports mild shortness of breath during exercise. What will the nurse practitioner prescribe? a. A low-dose stimulant medication b. A non-stimulant medication c. Behavioral therapy only d. Cardiovascular pre-screening Children with potential heart problems with symptoms such as previously detected cardiac abnormalities and shortness of breath with exercise should have a cardiovascular evaluation by a cardiologist prior to initiating treatment. If the screening and assessment are normal, a stimulant medication may be prescribed. 83. The primary care pediatric nurse practitioner is evaluating a school-age child who has been diagnosed with ADHD. Which plan will the nurse practitioner recommend asking the child’s school about to help with academic performance? a. 504 b. FAPE c. IDEA d. IEP The Section 504 plan specifies “reasonable accommodations” to help children with disabilities, such as physical or mental conditions, to benefit from their education. Many children with ADHD with learning disabilities but not cognitive deficits are eligible for this plan. FAPE, or free and appropriate public education, is a part of the special education system and lays out regulations for providing special education. IDEA is the Individuals with Disabilities Education Act, which provides mandates for providing education for children with disabilities. An IEP, or Individualized Education Plan, is a written plan defining disabilities, educational needs, and specific annual goals for meeting these needs. It is not generally used for children who do not have cognitive deficits, such as those with ADHD. 84. The primary care pediatric nurse practitioner is conducting a follow-up examination on a child who has recently begun taking a low-dose stimulant medication to treat 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. Adding an alpha-agonist medication b. Changing to a non-stimulant medication c. Continuing the medication as prescribed d. Stopping the medication immediately 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. 85. The primary care pediatric nurse practitioner uses the Neurodevelopmental Learning Framework to assess cognition and learning in an adolescent. When evaluating social cognition, the nurse practitioner will ask the adolescent a. about friends and activities at school. b. if balancing sports and homework is difficult. c. to interpret material from a pie chart. d. to restate the content of something just read. Social cognition is one construct of the Neurodevelopmental Learning Framework and is the ability to know what to discuss when, with whom, and for how long as well as the ability to work and play with others in a cooperative manner. Asking about friends will tell the PNP something about this ability. Determining the ability to manage a schedule assesses temporal-sequential ordering ability. Evaluating interpretation of material presented in a chart format assesses spatial ordering skills or visual thinking. Asking the adolescent to restate something in his or her own words assesses language and verbal skills. 86. The parent of a child diagnosed with 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. Effort c. Emotion d. Focus 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. 87. The primary care pediatric 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 2 years ago about autism, but was told that it was too early to diagnose. What will the nurse practitioner do first? a. Administer an M-CHAT screen to screen the child for communication and socialization delays. b. Ask the parent to describe the child’s earlier behaviors from infancy through preschool. c. Reassure the parent that if symptoms weren’t present earlier, the likelihood of autism is low. d. Refer the child to a pediatric behavioral specialist to develop a plan of treatment and management. 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. Burns: Pediatric Primary Care, 6th Edition Chapter 24: Infectious Diseases and Immunizations Test Bank Multiple Choice 1. A 10-month-old infant who is new to the clinic has chronic hepatitis B infection. What will the primary care pediatric nurse practitioner do to manage this infant’s disease? a. Consult a pediatric infectious disease specialist. b. Prescribe interferon-alfa. c. Provide supportive care. d. Consider use of lamivudine. A specialist in hepatitis B in children should be consulted for children with chronic hepatitis B infection because of the risk for developing hepatocellular carcinoma. Interferon-alfa and lamivudine are not used in infants. Supportive care only is not recommended. 2. The primary care pediatric nurse practitioner is performing an initial well child exam on a 3-year-old child recently adopted from Africa. The adoptive parent has a record of immunizations indicating that the child is fully vaccinated. What will the nurse practitioner do? a. Administer a booster dose of each vaccine to ensure immunity. b. Find out whether the vaccines were provided by reliable suppliers. c. Perform antibody titers and reimmunize the child. d. Record the vaccines in the child’s electronic medical record. Even though suppliers of vaccines worldwide produce vaccines that are of adequate quality, vaccine handling can be suspect. The PNP should perform titers and reimmunize if in doubt. If the child has not been adequately vaccinated, the PNP will need to administer each series based on catch-up dosing for age. If the child has been adequately immunized, boosters are not indicated. Performing titers is the best way to assess full immunity, since suppliers can be suspect. 3. A 3-year-old child who attends day care has had a fever, nausea, and vomiting several weeks prior and now has darkened urine and constipation along with hepatomegaly and right upper quadrant tenderness. What treatment is warranted for this child? a. HAV vaccine b. Immunoglobulin G c. Interferon-alfa d. Supportive care The child has symptoms consistent with hepatitis A virus. HAV vaccine and IgG may be given within 2 weeks of exposure; otherwise supportive care is indicated. Interferon-alfa is used for hepatitis B virus. 4. A 10-month-old infant has an erythematous, fluctuant, non-draining abscess on the right buttock after 10 days of treatment with amoxicillin for impetigo. What is the next step in managing this infant’s care? a. Consultation with a pediatric infectious disease specialist b. Culture of any superficial open surface wounds c. Empiric treatment with clindamycin d. Incision and drainage of the abscess with culture Non-draining, fluctuant abscesses should be incised, drained, and cultured to determine the causative organism. Consultation with an infectious disease specialist is necessary for seriously ill children, those who are immunocompromised, or those who have an increased risk for myocarditis. Superficial wounds should not be cultured because of the chance of sample contamination. Empiric treatment may be considered for severe infection, but many mild abscesses may not need antibiotic therapy after I&D. 5. An unimmunized school-age child whose mother is in her first trimester of pregnancy is diagnosed with rubella after a local outbreak. What will the primary care pediatric nurse practitioner recommend? a. Assessment of maternal rubella titers b. Intravenous immunoglobulin for the child c. MMR vaccine for the mother and child d. Possible termination of the pregnancy Reinfection or revaccination with rubella for pregnant women rarely results in congenital rubella syndrome, and these are not a reason for pregnancy termination. Maternal rubella antibody titers should be assessed. MMR vaccine is not given during pregnancy. IVIG is not indicated; rubella rarely has serious sequelae in children. 6. A 2-month-old infant has a staccato cough and fever. Which aspect of the history is most important in determining the diagnosis? a. Day care attendance b. Immunization history c. Medication history d. Past medical history A staccato cough may be present with pertussis, which is a vaccine-preventable disease. Careful assessment of immunization history is important when this is suspected. Day care attendance is an important aspect of determining exposure and may be considered, but it is not the most important part of the history in this case. Medication and past medical history are probably not relevant in this case since it is less likely that a 2-month-old infant has been taking medications or has a chronic or recurrent illness. 7. The parent of a 2-month-old infant is reluctant to have the baby vaccinated. What is an initial step in responding to these concerns? a. Inform the parent that all vaccines may be given without thimerosol. b. Providing Vaccine Information Statements for the parent to review. c. Question the parent’s reasons for concern about immunizations. d. Remind the parent that the infant is exposed to thousands of germs each day. PNPs should question and listen carefully to parents’ concerns about vaccines. Once concerns are identified and understood, the PNP can address the issues. The presence of thimerosol in vaccines is just one concern and should be addressed if that is identified. Providing a Vaccine Information Statement (VIS) should be done as part of the discussion to provide information to the parent. Unless the parent expresses concerns that vaccines will overwhelm the child’s immune system, it is not necessary to bring up this possibility . 8. Which lab value is most concerning in an infant with fever and a suspected bacterial infection? a. C-reactive protein of 11.5 mg/L b. Lymphocyte count of 8.7 c. Platelet count of 475 d. White blood cell count of 14 CRP levels are non-specific acute phase indicators of inflammation with low diagnostic value except in predicting the likelihood of sepsis in infants, especially when the level is greater than 10 mg/L. Elevated lymphocyte, platelet, or WBC counts help with the differential diagnosis, but these values are not especially concerning. 9. An adolescent has a TB skin test prior to working as a volunteer in a hospital. The adolescent is healthy and has not travelled to or from a TB-endemic area or had close contact with anyone who has TB. The Mantoux skin test shows 10 mm of induration after 48 hours. What will the primary care pediatric nurse practitioner do? a. Ask the adolescent about exposure to homeless persons. b. Order a chest radiograph to rule out active TB. c. Reassure the adolescent that this is a negative screen. d. Refer the adolescent to an infectious disease specialist. In children 4 years and older without risk factors, induration must be at least 15 mm or greater to be considered to be a positive screen. It is not necessary to question the adolescent about possible exposures. Chest radiographs are ordered to evaluate for active TB in persons with a positive screen. Referral to an infectious disease specialist is done if active TB is present. 10. A parent is concerned about vaccine adverse reactions. Based on an Institute of Medicine report, what will the primary care pediatric nurse practitioner tell the parent? a. Administering multiple vaccines may trigger the development of type 1 diabetes. b. The MMR may be linked to febrile seizures in immunocompromised children. c. There is some risk of CNS disorders associated with the hepatitis B vaccine. d. Vaccines containing thimerosol are linked to pervasive developmental disorders. The IOM report found that febrile seizures and measles inclusion body encephalitis can occur in immunocompromised children. The IOM found no substantiated evidence that multiple vaccines trigger type 1 diabetes, hepatitis B vaccine is associated with increased risk of CNS disorders, or thimerosol-containing vaccines are linked to pervasive developmental disorders. 11. An adolescent female who is sexually active and who has not had the HPV vaccine asks if she may have it. What will the primary care pediatric nurse practitioner tell her? a. Getting the vaccine now will still protect her from HPV oncogenic types even if already exposed b. Receiving the HPV vaccine series will replace the need for regular cervical cancer screening c. She will need to have Papanicolaou and pregnancy screening prior to receiving the vaccine d. The vaccine will not protect her from any HPV oncogenic types acquired previously There is no protection for HPV oncogenic types acquired prior to the vaccine. The vaccine does not eliminate the need for cervical cancer screening. It is not necessary to perform PAP or pregnancy testing prior to vaccine administration. 12. A child with a history of a pustular rash at the site of a cat scratch on one arm now has warm, tender, swollen axillary lymph nodes on the affected side. The primary care pediatric nurse practitioner notes induration and erythema of these nodes. What will the nurse practitioner do? a. Obtain a complete blood count and C-reactive protein. b. Order an immunofluorescent assay (IFA) for serum antibodies. c. Perform a needle aspiration of the affected lymph nodes. d. Prescribe a 5-day course of azithromycin. IFA shows a good correlation with cat-scratch fever disease and is useful for a more definitive diagnosis. A complete blood count and C-reactive protein are non-specific indicators of disease. Needle aspiration is only necessary to determine whether local lymph nodes are infected. Antibiotics are not given unless nodes are infected. 13. An 18-month-old child has bronchopulmonary dysplasia. To help prevent pneumococcal disease, which vaccine will be ordered? a. PCV7 b. PCV13 c. PCV23 d. PCV33 PCV13 is recommended for all children under age 5 years. PCV7 was replaced by PCV13 in 2010. PCV23 is used in children over age 2 years who are at higher risk of pneumococcal disease; this child will be eligible for the PCV23 at age 2; children younger than 2 years have shown poor immunogenicity to PCV23. PCV33 does not exist. 14. A child whose parents have refused vaccines has been exposed to chickenpox, and the parents ask whether the child may attend day care. What will the primary care pediatric nurse practitioner tell them? a. The child may attend day care as long as no rash is present even with mild fever or other symptoms. b. The child should remain home and receive oral acyclovir for 5 days to prevent onset of symptoms. c. The child should stay home until the 21-day incubation period has passed even if symptom free. d. The child should stay home if any symptoms occur and may return in 1 week if no rash develops. Exposed children can attend school for about a week but should be kept out of school if any symptoms develop for 1 week and may return if no rash develops. Any symptomatic child should be kept home for 1 week. Oral acyclovir is not effective in preventing disease onset. It is not necessary to remain home for the duration of the incubation period. 15. The primary care pediatric nurse practitioner reviews the immunization records of an 18-month-old child and notes that the child received an MMR immunization 2 days prior to the first birthday. What will the nurse practitioner do? a. Administer a reduced dose of MMR to ensure adequate immunity. b. Obtain mumps, measles, and rubella titers to determine immunity. c. Recommend the next dose of MMR vaccine at 4 to 5 years of age. d. Repeat the MMR vaccine since the first dose was given too soon Vaccine doses may be given 4 days prior to or later than minimum intervals or ages to provide schedule flexibility. The next dose will be given at age 4 to 5, so this child may remain on schedule. It is never recommended to give reduced doses for any reason; reimmunization if in doubt is not harmful. Titers are not indicated unless the vaccine quality or storage is in doubt. 16. The primary care pediatric nurse practitioner performs a well child examination on a 1-month-old. The infant was recently discharged from the neonatal intensive care unit after treatment with parenteral acyclovir for a neonatal herpetic infection and is currently taking oral acyclovir. What will the nurse practitioner do to manage this infant’s care? a. Obtain regular absolute neutrophil counts. b. Perform routine skin cultures for herpes simplex virus. c. Reinforce the need to give acyclovir indefinitely. d. Stop the oral acyclovir at 2 months of age. Infants treated with parenteral acyclovir for neonatal herpetic infections should remain on oral acyclovir for 6 months. The PNP should obtain regular ANC levels and temporarily discontinue acyclovir if neutropenia occurs until the neutrophil count recovers. New lesions should be cultured, but routine skin cultures are not indicated. Oral acyclovir suppressive therapy for 6 months after parenteral treatment of any classification of acute neonatal disease has been shown to reduce the recurrences of mucocutaneous lesions and improve neuro-developmental outcomes. 17. A child whose family has been camping in a region with endemic Lyme disease suffered several tick bites. The parents report removing the ticks but are not able to verify the type or the length of time the ticks were attached. The child is asymptomatic. What is the best course of action? a. Administer a prophylactic single dose of doxycycline. b. Perform serologic testing for IgG or IgM antibodies. c. Prescribe amoxicillin three times daily for 14 to 21 days. d. Teach the parents which signs and symptoms to report. Prophylaxis should not be given if the type of tick or the timeline for attachment cannot be verified; however, parents should be encouraged to report signs of Lyme disease if they occur. Prophylaxis is given if the tick is reliably identified as a nymph or adult Ixodes scapularis species. Serologic testing may be performed if symptoms occur. Amoxicillin tid for 2 to 3 weeks is indicated for early localized disease. 18. A child who is immunocompromised has a fever and a rash consisting of macules, papules, and pustules. What will the primary care pediatric nurse practitioner do? a. Administer varicella immune globulin (VariZIG). b. Hospitalize the child for intravenous acyclovir. c. Order intravenous immunoglobulin as an outpatient. d. Prescribe oral acyclovir for the duration of the illness. The description of the rash the immunocompromised child has been exposed to is that of varicella. Intravenous acyclovir should be given to immunocompromised individuals. Immune globulin is not effective after the disease has progressed. Oral acyclovir is expensive and not routinely recommended for most children. 19. A preschool-age child is brought to clinic for evaluation of a rash. The primary care pediatric nurse practitioner notes an intense red eruption on the child’s cheeks and circumoral pallor. What will the nurse practitioner tell the parents about this rash? a. This rash may be a prodromal sign of rubella or roseola. b. The child will need immunization boosters to prevent serious disease. c. This is a benign rash with no known serious complications. d. Expect a lacy, maculopapular rash to develop on the trunk and extremities. This “slapped cheek” rash is consistent with fifth disease, or erythema infectiosum, and will be followed by a lacy, maculopapular all- over rash. It is not a prodrome of rubella or roseola, and immunizations are not indicated. Although it is mostly benign, there can be serious sequelae, especially for pregnant women. 20. The primary care pediatric nurse practitioner is examining a 2-month-old infant with fever and cough. A WBC is 14,000/mm3 and a chest radiograph is normal. The infant is nursing well and having normal stools. What would be an appropriate next step? a. Admitting the infant to the hospital for LP and IV antibiotics b. Obtaining a blood culture, erythrocyte sedimentation rate, and C-reactive protein c. Performing a catheterized urinalysis to screen for leukocytes and nitrites d. Prescribing empiric, broad-spectrum antibiotics with close follow-up A catheterized urinalysis to rule out UTI is appropriate to help determine the cause of infection. The infant has a reassuring WBC and chest X-ray, so it is not necessary to admit to the hospital or to perform blood cultures. Antibiotics are indicated only if bacterial infection is suspected. 21. A 2-month-old infant will receive initial immunizations, and the parent asks about giving medications to increase the infant’s comfort and minimize fever. What will the primary care pediatric nurse practitioner recommend? a. Administering ibuprofen or acetaminophen as needed b. Avoiding antipyretics if possible to attain better immunity c. Giving ibuprofen and acetaminophen only after the vaccines d. Pre-treating the infant with both ibuprofen and acetaminophen Although some studies have detected lower antibody responses in infants and children who were given antipyretics before or after routine vaccinations, the lowered response did not influence persistent immunological memory and did not cause a decrease in vaccine protection. Parents may administer acetaminophen or ibuprofen before or after vaccines as needed. There is no evidence that a combination of acetaminophen and ibuprofen is more effective. 22. According to recent research, which populations may have higher rates of under-immunization than others? a. Those with higher rates of Asians b. Those with higher rates of graduate degrees c. Those with lower rates of poverty d. Those with lower rates of primary providers Rates of under-immunization were increased in populations with an increased percentage of graduate degrees in a study of geographic clusters of under-immunized communities in northern California. Populations having a higher percentage of Asians have increased immunization rates. Higher levels of poverty are associated with under-immunization. The study did not look at the effect of the number of primary providers. 23. The primary care pediatric nurse practitioner is reviewing medical records for a newborn that is new to the clinic. The toddler’s mother was found to be HIV positive during her pregnancy with this child and received antiretroviral therapy during pregnancy. The child was born by cesarean section, begun on anti-retroviral prophylaxis, and did not breastfeed. What is the correct management for this child? a. Consult with a pediatric HIV specialist. b. Discontinue cART after 4 weeks of age. c. Obtain a CD4+ cell count and HIV RNA levels. d. Reinforce the need to give cART for life. PNPs may manage infants exposed in utero to HIV but should do so in consultation with a pediatric HIV specialist. cART should be given for 6 weeks. Lab work is ordered according to protocol at the direction of the specialist. Many children who are treated according to the protocol do not become HIV positive. 24. A child is brought to the clinic with a fever, headache, malaise, and a red, annular macule surrounded by an area of clearing and a larger, erythematous annular ring. The child complains of itching at the site. What will the primary care pediatric nurse practitioner do to determine the diagnosis? a. Ask about recent tick bites b. Obtain a skin culture c. Order blood cultures d. Perform serologic testing The presence of an erythema migrans rash with a positive history is diagnostic for Lyme disease, and no further testing is necessary. Because Borrelia burgdorferi is transmitted to humans through ticks, asking about recent tick bites is paramount to making this diagnosis. Skin and blood cultures are not indicated. Serology testing for IgG and IgM antibodies may be performed if the child is symptomatic without the characteristic EM rash. 25. A 9-month-old infant has had a fever of 103°F for 2 days and now has a diffuse, maculopapular rash that blanches on pressure. The infant’s immunizations are up-to-date. What will the primary care pediatric nurse practitioner do? a. Administer immunoglobulin G to prevent fulminant illness. b. Perform serologic testing for human herpes virus -6 and human herpes virus -7. c. Reassure the parent that this is a mild, self-limiting disease. d. Recommend avoiding contact with pregnant women. The infant has symptoms consistent with roseola infantum, which is a benign, self-limiting disease. It is not necessary to administer IgG or perform serologic testing or to avoid contact with pregnant women. 26. The parent of an infant asks why some vaccines, such as MMR, are not given along with the other series of immunizations at 2, 4, and 6 months of age. What will the primary care pediatric nurse practitioner tell this parent? a. Febrile seizures are more likely in younger infants with some vaccines. b. Maternal antibodies neutralize some vaccines and are delayed until 12 months. c. The risk of adverse effects is lower for some vaccines after the first year. d. Too many vaccines at once can overwhelm the infant’s immune system. Maternal antibodies may neutralize certain vaccines, so some are delayed until the child is 1 year old. Febrile seizures and adverse reactions are not more likely in younger infants. There is no evidence that a large number of vaccines can overwhelm the infant’s immune system. 27. A school-age child has fever of 104°F, sore throat, vomiting and malaise. The primary care pediatric nurse practitioner observes that the tonsils, oropharynx, and palate are erythematous and covered with exudate; the tongue is coated and red; and there is a red, sandpaper-like rash on the child’s neck, trunk, and extremities. A rapid strep test is positive. What will the nurse practitioner do to manage this child’s illness? a. Administer intramuscular ceftriaxone. b. Hospitalize for further diagnostic tests. c. Prescribe oral amoxicillin. d. Refer to a pediatric infectious disease specialist. Scarletina is caused by erythrogenic toxin from Group A streptococcus. Treatment is the same as for Group A streptococcus unless complications occur. IM antibiotics are not indicated. The child does not need hospitalization or referral to a specialist. 28. A 5-year-old child who has a history of pertussis infection as an infant is in the clinic for immunizations prior to kindergarten. Which vaccine will be given? a. DTaP b. DTP c. Td d. Tdap The duration of immunity after infection with pertussis in unknown and is thought to be short, so immunization for pertussis must still be provided. The DTP, with whole -cell pertussis vaccine is given in other countries but not in the U.S. Td does not contain pertussis. Tdap is given after age 7 years. 29. A toddler is receiving long-term antibiotics to treat osteomyelitis. Which laboratory test will the primary care pediatric nurse practitioner order to monitor response to therapy in this child? a. Blood cultures b. Erythrocyte sedimentation rate (ESR) c. Serum procalcitonin (Pro-CT) d. White blood count (WBC) ESR is a late measure of inflammation and is useful in helping monitor response to therapy, especially when long-term antibiotics are used. Blood cultures will most likely be negative during antibiotic treatment. Pro - CT is used to differentiate viral from bacterial infections. The WBC will most likely decrease over time with a treated infection and is not useful for monitoring response to therapy. 30. A 3-year-old child whose immunizations are up-to-date has been exposed to measles because of a localized outbreak among unvaccinated children. The parent reports that contact with infected children occurred within the last 2 days at a birthday party. What is the best course of action? a. Administer the MMR vaccine to help prevent disease. b. Give antiviral medications at the first sign of symptoms. c. Give the child a dose of immune globulin to mitigate the response. d. Reassure the parent that most exposed children will not get measles. The measles vaccine can be given to those exposed if given within 72 hours of exposure. IG may be given in those without prior measles vaccine. Antiviral medications are not effective. Nine of 10 children who are unimmunized or under-immunized will contract the disease if exposed. 31. An 18-month-old child who developed upper respiratory symptoms 1 day prior is brought to the clinic with a high fever, chills, muscle pains, and a dry, hacking cough. A rapid influenza test is negative and a viral culture is pending. What will the primary care pediatric nurse practitioner do? a. Consider therapy with rimantadine. b. Hospitalize for supportive treatment. c. Prescribe oseltamivir and follow closely d. Wait for cultures to determine treatment. A negative rapid viral culture should not be the determining factor when deciding on a clinical course of treatment when influenza is suspected. Children under age 2 years should be treated with antiviral medications. Rimantadine is not recommended unless susceptibility is reliable; cultures will not be confirmed for several days. It is not necessary to hospitalize unless the child has signs of respiratory distress or cardiac involvement. Antivirals should be initiated within 72 hours of onset of symptoms. 32. When reviewing a white blood cell (WBC) count, the primary care pediatric nurse practitioner suspects a viral infection when which WBC element is elevated? a. Bands b. Leukocytes c. Lymphocytes d. Neutrophils Lymphocytes are usually elevated during viral infections. Bands and neutrophils are generally elevated with bacterial infections. Leukocytes comprise all WBCs and are usually, although not always, elevated during bacterial infections. 33. A 5-year-old child who received VariZIG after exposure to varicella while immunocompromised during chemotherapy is in the clinic 5 months after stopping chemotherapy for kindergarten vaccines. What will the primary care pediatric nurse practitioner order for this child? a. MMR and Tdap b. MMR, Varivax, Tdap c. Tdap only d. Varivax and Tdap This child is eligible for all three vaccines. Varivax should be given 5 months after VariZIG, unless varicella disease occurred despite VariZIG administration. 34. A 7-year-old child whose immunizations are up-to-date has a fever, headache, stiff neck, and photophobia. What course of treatment is indicated? a. Empiric treatment with oral antibiotics or intramuscular ceftriaxone b. Hospitalization for diagnosis and treatment with antibiotics c. Immediate vaccination with meningococcal vaccine d. Outpatient lab work, including a CBC and blood and CSF cultures Any child suspected of having meningococcal meningitis should be hospitalized immediately with IV antibiotics started pending cultures. Empiric treatment is not indicated. Vaccination is not helpful once the disease has started. Outpatient lab [Show More]

Last updated: 1 year ago

Preview 1 out of 60 pages

Add to cart

Instant download

We Accept:

We Accept
document-preview

Buy this document to get the full access instantly

Instant Download Access after purchase

Add to cart

Instant download

We Accept:

We Accept

Reviews( 0 )

$15.00

Add to cart

We Accept:

We Accept

Instant download

Can't find what you want? Try our AI powered Search

OR

REQUEST DOCUMENT
50
0

Document information


Connected school, study & course


About the document


Uploaded On

Mar 26, 2021

Number of pages

60

Written in

Seller


seller-icon
gradesblaze

Member since 3 years

21 Documents Sold


Additional information

This document has been written for:

Uploaded

Mar 26, 2021

Downloads

 0

Views

 50

Document Keyword Tags

Recommended For You

Get more on EXAM »

$15.00
What is Browsegrades

In Browsegrades, a student can earn by offering help to other student. Students can help other students with materials by upploading their notes and earn money.

We are here to help

We're available through e-mail, Twitter, Facebook, and live chat.
 FAQ
 Questions? Leave a message!

Follow us on
 Twitter

Copyright © Browsegrades · High quality services·