Burns: Pediatric Primary Care, 6th Edition Chapter 27: Hematologic Disorders       Multiple Choice     1. 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   ANS: B 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.     2. 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.   ANS: A 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.     3. 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.   ANS: A 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.     4. 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.   ANS: A 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.     5. 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.   ANS: A 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.     6. 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.   ANS: A 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.     7. 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.   ANS: D 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.     8. 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.   ANS: A 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.     9. 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.   ANS: A 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.     10. 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   ANS: B 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.     11. 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.   ANS: B 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.     12. 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   ANS: A 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.     13. 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.   ANS: D 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 33: Gastrointestinal Disorders   Test Bank   Multiple Choice     1. A child is in the clinic after swallowing a metal bead. A radiograph of the GI tract shows a 6 mm cylindrical object in the child’s stomach. The child is able to swallow without difficulty and is not experiencing pain. What is the correct course of treatment?  a. Administer ipecac to induce vomiting. b. Have the parents watch for the object in the child’s stool. c. Insert a nasogastric tube to flush out the object. d. Refer the child for endoscopic removal of the object.   ANS: B A small foreign body that is not corrosive or sharp and that has reached the stomach is most likely to continue to pass through the GI tract and no intervention is necessary. Inducing vomiting increases the risk of aspiration of the FB. NG tube removal and endoscopy are not indicated unless the object has the potential to damage the GI tract; most objects that are not sharp or corrosive that have reached the abdomen will pass through without causing damage.     2. A toddler who was born prematurely refuses most solid foods and has poor weight gain. A barium swallow study reveals a normal esophagus. What will the primary care pediatric nurse practitioner consider next to manage this child’s nutritional needs? a. Consultation with a dietician b. Fiberoptic endoscopy evaluation c. Magnetic resonance imaging d. Videofluoroscopy swallowing study   ANS: D A videofluoroscopy swallowing study will evaluate other structural defects that may interfere with swallowing and is relatively non-invasive. A dietician consult may be a part of the overall plan, but the toddler first needs a thorough evaluation of potential problems. Fiberoptic endoscopy is invasive. MRI may be performed if videofluoroscopy is inconclusive, but this is an expensive test.     3. A school-age child has a 3-month history of dull, aching epigastric pain that worsens with eating and awakens the child from sleep. A complete blood count shows a hemoglobin of 8 mg/dL. What is the next step in management? a. Administration of H2RA or PPI medications b. Empiric therapy for H. pylori (HP) c. Ordering an upper GI series d. Referral for esophagogastroduodenoscopy (EGD)   ANS: D EGD is the procedure of choice in children for detecting PUD because it allows direct visualization of mucosa, localization of the source of bleeding, and collection of tissue specimens. Empiric therapy for HP is not recommended due to increased antibiotic resistance. An upper GI series may have false negative findings. Once peptic ulcer disease is diagnosed, H2RA or PPI medications are first-line drugs.     4. A 2-year-old child has an acute diarrheal illness. The child is afebrile and, with oral rehydration measures, has remained well hydrated. The parent asks what can be done to help shorten the course of this illness. What will the primary care pediatric nurse practitioner recommend? a. Clear liquids only b. Lactobacillus c. Loperamide d. Peppermint oil   ANS: B Lactobacillus, given early in a viral diarrheal illness, can decrease the duration of diarrhea by about 25 hours and is safe to use in children. Parents should begin refeeding early to stimulate enterocyte growth and help facilitate mucosal repair. Loperamide may be given to children over the age of 3 years. Peppermint oil may help reduce cramping, but its efficacy is not certain.     5. A school-age child has recurrent diarrhea with foul-smelling stools, excessive flatus, abdominal distension, and failure-to-thrive. A 2-week lactose-free trial failed to reduce symptoms. What is the next step in diagnosing this condition? a. Lactose hydrogen breath test b. Serologic testing for celiac disease c. Stool for ova and parasites d. Sweat chloride test for cystic fibrosis   ANS: B This child has symptoms consistent with celiac disease, especially FTT and foul-smelling stools. Since the lactose-free trial did not reduce symptoms, the likelihood of lactose intolerance is less and thus testing is not likely to be helpful. The symptoms are recurrent, so giardiasis is less likely. CF is still possible, but most children with CF are diagnosed as infants and have accompanying respiratory symptoms of some type.     6. A 12-month-old infant exhibits poor weight gain after previously normal growth patterns. There is no history of vomiting, diarrhea, or irregular bowel movements, and the physical exam is normal. What is the next step in evaluating these findings? a. Complete blood count and electrolytes b. Feeding and stooling history and 3-day diet history c. Stool cultures for ova and parasites d. Swallow study with videofluoroscopy   ANS: B Vomiting, diarrhea, and bowel irregularities are more predictive of organic causes of FTT, which are not present in this infant. A careful history and physical examination and limited laboratory evaluation are the first steps unless there is reason to think that an organic cause is present. The fact that the infant was previously gaining weight appropriately makes a swallowing disorder less likely.     7. The parent of an infant asks about using a probiotic medication. What will the primary care pediatric nurse practitioner tell this parent? a. Probiotic medications have demonstrated efficacy in treating colic. b. Probiotics are not safe to use to treat infants who have colic. c. There are no studies showing usefulness of probiotics to manage colic. d. There is no conclusive evidence about using probiotics to treat colic.   ANS: D While small studies have shown promise in treating colic in infants, the research is contradictory and there is no conclusive evidence about effectiveness. There is no evidence that probiotics are not safe.     8. A child is diagnosed with Crohn disease. What are likely complications for this child? a. Cancer of the colon and possible colectomy b. Intestinal obstruction with scarring and strictures c. Intestinal perforation and hemorrhage d. Liver disease and sepsis   ANS: B Intestinal obstruction with scarring and strictures are the major complications of CD. The other answers describe complications of ulcerative colitis.     9. A toddler is seen in the clinic after a 2-day history of intermittent vomiting and diarrhea. An assessment reveals an irritable child with dry mucous membranes, 3-second capillary refill, 2- second recoil of skin, mild tachycardia and tachypnea, and cool hands and feet. The child has had two wet diapers in the past 24 hours. What will the primary care pediatric nurse practitioner recommend? a. Anti-diarrheal medication and clear fluids for 24 hours b. Bolus of IV normal saline in the clinic until improvement c. Hospital admission for IV rehydration and oral fluids d. Oral rehydration solution with follow-up in 24 hours   ANS: D This child has mild to moderate dehydration, according to vital signs and symptoms, and may be managed with oral rehydration solution with good follow-up. Anti-diarrheal medications are generally not useful, but antiemetics may be used. It is not necessary to administer IV fluids or to hospitalize unless more severe dehydration occurs.     10. A 2-month-old infant cries up to 4 hours each day and, according to the parents, is inconsolable during crying episodes with fists and legs noted to be tense and stiff. The infant is breastfeeding frequently but is often fussy during feedings. The physical exam is normal and the infant is gaining weight normally. What will the primary care pediatric nurse practitioner recommend? a. A complete work-up, including laboratory and radiologic tests b. Eliminating certain foods from the mother’s diet c. Empiric treatment with a proton pump inhibitor medication d. Stopping breastfeeding and beginning a hydrolyzed formula   ANS: B A first step in a breastfeeding infant with symptoms of colic should be to try eliminating certain foods such as cow’s milk products, nuts, eggs, and fish from the mother’s diet to see if improvement occurs. It is not necessary to stop breastfeeding; hydrolyzed formulas may be tried in formula-fed infants. An infant with a normal exam and normal weight gain does not need further diagnostic studies. PPIs are not indicated as first-line therapy.     11. A school-age child has had abdominal pain for 3 months that occurs once or twice weekly and is associated with a headache and occasional difficulty sleeping, often causing the child to stay home from school. The child does not have vomiting or diarrhea and is gaining weight normally. The physical exam is normal. According to Bishop, what is included in the initial diagnostic work-up for this child? a. CBC, ESR, amylase, lipase, UA, and abdominal ultrasound b. CBC, ESR, CRP, and fecal calprotectin c. CBC, ESR, CRP, UA, stool for ova, parasites, and culture d. Stool for H. pylori antigen and serum IgA, IgG, tTg   ANS: A Bishop suggests these labs as an initial approach in children suspected of having functional abdominal pain, along with a 3-day trial of a lactose-free diet. Fecal calprotectin is added if the child has changes in stool habits suggestive of inflammatory changes in the intestinal tract. Answer C is correct according to Rasquin’s recommendations as is stool for H. pylori antigen.     12. An 18-month-old child has a 1-day history of intermittent, cramping abdominal pain with non-bilious vomiting. The child is observed to scream and draw up his legs during pain episodes and becomes lethargic in between. The primary care pediatric nurse practitioner notes a small amount of bloody, mucous stool in the diaper. What is the most likely diagnosis? a. Appendicitis b. Gastroenteritis c. Intussusception d. Testicular torsion   ANS: C Intussusception is characterized by intermittent pain associated with drawing up the legs, “currant jelly” stools, and lethargy in between episodes. Appendicitis is characterized by pain localizing to the RLQ and is not intermittent. Gastroenteritis is likely when vomiting precedes symptoms of pain or discomfort. Testicular torsion involves the testicles and thus has different physical findings and would not be accompanied with bloody stools.     13. A 9-year-old girl has a history of frequent vomiting and her mother has frequent migraine headaches. The child has recently begun having more frequent and prolonged episodes accompanied by headaches. An exam reveals abnormal eye movements and mild ataxia. What is the correct action?  a. Begin using an anti-migraine medication to prevent headaches. b. Prescribe ondansetron and lorazepam to help manage symptoms. c. Reassure the parent that this is expected with cyclic vomiting syndrome. d. Refer to a pediatric gastroenterologist for further workup.   ANS: D This child has an abnormal neurologic examination, which is a red flag warranting referral for further workup for children with cyclic vomiting syndrome. Anti-migraine medications are used in children over age 12 years and therefore should not be used for this patient. Ondansetron and lorazepam may be useful for unrelenting nausea and poor sleep, but this child needs to be referred to evaluate neurologic symptoms. These signs are not expected.     14. A 10-year-old child has had abdominal pain for 2 days, which began in the periumbilical area and then localized to the right lower quadrant. The child vomited once today and then experienced relief from pain followed by an increased fever. What is the likely diagnosis? a. Appendicitis with perforation b. Gastroenteritis c. Pelvic inflammatory disease (PID) d. Urinary tract infection (UTI)   ANS: A The child has the progression of symptoms typical of appendicitis with perforation – pain before vomiting that localizes to the RLQ and then relief of pain with onset of fever upon perforation. With gastroenteritis, vomiting precedes pain. PID symptomology includes increasing pain over time. The symptoms of an UTI include fever, chills, and urinary symptoms.     15. The parent of a 3-month-old reports that the infant arches and gags while feeding and spits up undigested formula frequently. The infant’s weight gain has dropped to the 5th percentile from the 12th percentile. What is the best course of treatment for this infant? a. Begin a trial of extensively hydrolyzed protein formula for 2 to 4 weeks. b. Institute an empiric trial of acid suppression with a proton pump inhibitor (PPI). c. Perform esophageal pH monitoring to determine the degree of reflux. d. Reassure the parent that these symptoms will likely resolve by 12 to 24 months.   ANS: A Formula-fed infants may be given a trial of a hydrolyzed protein formula to see if improvement occurs. An empiric trial of a PPI may be used in children and adolescents but is not recommended in infants. Esophageal pH monitoring may be performed in consultation with a specialist but not as first-line evaluation. The infant has warning signs of GERD that require further investigation and not just reassurance.     16. An adolescent is diagnosed with functional abdominal pain (FAP). The child’s symptoms worsen during stressful events, especially with school anxiety. What will be an important part of treatment for this child? a. Informing the parents that the pain is most likely not real b. Instituting a lactose-free diet along with lactobacillus supplements c. Teaching about the brain-gut interaction causing symptoms d. Using histamine2-blockers to help alleviate symptoms   ANS: C This child has symptoms associated with stress, and treatment should be aimed at biobehavioral methods, beginning with teaching about the brain-gut interaction. Even though the pain is functional, it is real. Lactose-free diets and lactobacillus supplements may be used with documented lactose intolerance, although there is a lack of high-quality evidence of their effectiveness. H2-blockers should not be used unless dyspepsia is present.

Burns: Pediatric Primary Care, 6th Edition Chapter 37: Dermatologic Disorders   Test Bank   Multiple Choice     1. A 3-year-old child has head lice. What will the initial treatment recommendation be to treat this child? a. Lindane b. Permethrin c. Pyrethrin d. Spinosad   ANS: B Permethrin is the treatment of choice for head lice because of its safety and efficacy. Pyrethrin has more treatment failures and is not the first-line treatment. Lindane has neurotoxic side effects and is only recommended when treatment failure occurs. Spinosad is used in children 4 years and older.     2. An adolescent has acne with lesions on the cheeks and under the chin. Which distribution is this? a. Athletic b. Frictional c. Hormonal d. Pomadal   ANS: C Hormonal acne has a beard distribution. Athletic acne occurs on the forehead, chin, and shoulders, caused by helmets and pads. Frictional occurs where bras, tight clothes, and headbands rub. A pomadal distribution occurs along the temple and forehead, as a result of pomades or oil-based cosmetics.     3. An infant is brought to clinic with bright erythema in the neck and flexural folds after recent treatment with antibiotics for otitis media. What is the treatment for this condition? a. 1% hydrocortisone cream to affected areas for 1 to 2 days b. Oral fluconazole 6 mg/kg on day 1, then 3 mg/kg/dose for 14 days c. Topical keratolytics and topical antibiotics for 7 to 10 days d. Topical nystatin cream applied several times daily   ANS: D Candida skin infections can occur in intertriginous areas in the neck, axilla, and groin, and appear as a bright erythematous rash. Topical nystatin is first-line therapy. Fifteen percent hydrocortisone is used if inflammation is severe but not instead of topical antifungal therapy. Oral fluconazole is used if resistant to treatment. Keratolytics and antibiotics are used to treat superficial folliculitis.     4. A child who has been taking antibiotics is brought to the clinic with a rash. The parent reports that the child had a fever associated with what looked like sunburn and now has “blisters” all over. A physical examination shows coalescent target lesions and widespread bullae and areas of peeled skin revealing moist, red surfaces. What will the primary care pediatric nurse practitioner do? a. Consult with a pediatric intensivist for admission to a pediatric intensive care unit. b. Order oral acyclovir 20 mg/kg/day in two doses for 6 to 12 months. c. Prescribe systemic antihistamines and antimicrobial medications as prophylaxis. d. Recommend analgesics, cool compresses, and oral antihistamines for comfort.   ANS: A This child has symptoms consistent with toxic epidermal necrolysis, which is potentially life-threatening. Children with symptoms should be admitted to the PICU for management. The other options are treatments for erythema multiforme, a more benign, viral-induced rash. Oral acyclovir is given when herpes simplex infection is possible.     5. An adolescent has acne characterized by papules and pustules mostly on the forehead and chin. What will the primary care pediatric nurse practitioner prescribe? a. Azelaic acid applied daily at nighttime b. Benzoyl peroxide applied twice daily c. Topical erythromycin with benzoyl peroxide d. Tretinoin applied nightly after washing the face   ANS: C Topical antibiotics combined with BPO are more effective than either drug alone and are especially effective in mild to moderate inflammatory acne or as adjunctive therapy with oral antibiotics. Azelaic acid is useful in persons with sensitive or dark skin and used for non-inflammatory acne. Topical antibiotics are best used in conjunction with BPO. Tretinoin is a keratolytic, useful for non-inflammatory acne.     6. During a well child examination of an infant, the primary care pediatric nurse practitioner notes 10 café au lait spots on the infant’s trunk. What is the potential concern associated with this finding? a. Endocrine disorders b. Malignancy c. Neurofibromatosis d. Sturge-Weber syndrome   ANS: C Café au lait spots are significant for neurofibromatosis and should be referred if more than 5 lesions are present. Atypical nevi are concerning for malignancy. Port-wine stains are concerning for Sturge-Weber syndrome. Acanthosis is a sign of diabetes.     7. A child is diagnosed with tinea versicolor. What is the correct management of this disorder? a. Application of selenium sulfide 2.5% lotion twice weekly for 2 to 4 weeks b. Oral antifungal treatment with fluconazole once weekly for 2 to 3 weeks c. Sun exposure for up to an hour every day for 2 to 4 weeks d. Using ketoconazole 2% shampoo on lesions twice daily for 2 to 4 weeks   ANS: A Selenium sulfide lotion or 1% shampoo is first-line treatment for children and younger adolescents. Oral antifungal medications are used in resistant cases in older adolescents. Sun exposure only intensifies lesions. Ketoconazole shampoo is used on older adolescents.     8. An African-American child has recurrent tinea capitis and has just developed a new area of alopecia after successful treatment several months prior. When prescribing treatment with griseofulvin and selenium shampoo, what else will the primary care pediatric nurse practitioner do? a. Monitor CBC, LFT, and renal function during therapy. b. Order oral prednisone daily for 5 to 14 days. c. Perform fungal cultures on family members and pets. d. Prescribe oral itraconazole or terbinafine.   ANS: C Because asymptomatic carriers may be present in the household, family members and pets should be cultured. It is not necessary to monitor lab work with griseofulvin unless there is a change in clinical status, due to the favorable safety profile of griseofulvin. Prednisone is used when severe inflammation is present. Oral itraconazole or terbinafine is used if resistance to griseofulvin occurs; this child has responded to griseofulvin.     9. A 4-year-old child has clusters of small, clear, tense vesicles with an erythematous base on one side of the mouth along the vermillion border, which are causing discomfort and difficulty eating. What will the primary care pediatric nurse practitioner recommend as treatment? a. Mupirocin ointment applied to lesions 3 times daily b. Oral acyclovir 20 to 40 mg/kg/dose for 7 to 10 days c. Topical acyclovir applied to lesions 4 times daily d. Topical diphenhydramine and magnesium hydroxide   ANS: D This child has lesions consistent with HSV-1. Topical anesthetics may be used for comfort and may be applied with cotton-tipped swabs. Mupirocin ointment is used for secondary bacterial infection. Oral acyclovir is used in more severe cases and most often with HSV-2. Topical acyclovir is useful for initial genital herpes infections.     10. A school-age child has several annular lesions on the abdomen characterized by central clearing with scaly, red borders. What is the first step in managing this condition? a. Fluoresce the lesions with a Wood’s lamp. b. Obtain fungal cultures of the lesions. c. Perform KOH-treated scrapings of the lesion borders. d. Treat empirically with antifungal cream.   ANS: D Unless the diagnosis is questionable, or if treatment failure occurs, tinea corporis is treated empirically with topical antifungal creams; therefore, it is not necessary to fluoresce the lesions, culture the lesions, or complete KOH testing of scrapings as an initial management step.     11. A child is brought to clinic with several bright red lesions on the buttocks. The primary care pediatric nurse practitioner examines the lesions and notes sharp margins and an “orange peel” look and feel. The child is afebrile and does not appear toxic. What is the course of treatment for these lesions? a. Hospitalize the child for intravenous antibiotics and possible I&D of the lesions. b. Initiate empiric antibiotic therapy and follow up in 24 hours to assess response. c. Obtain blood cultures prior to beginning antibiotic treatment. d. Perform gram stain and culture of the lesions before initiating antibiotics.   ANS: B The child has clinical signs of erysipelas, which is a superficial variant of cellulitis. Because the child is afebrile and doesn’t appear toxic, outpatient antibiotics with 24-hour follow-up can be initiated. If the child does not respond or becomes toxic, hospitalization and IV antibiotics are indicated. Blood cultures rarely are positive. Gram stain and cultures are performed if unusual organisms are suspected or if pus is present.     12. A child who has psoriasis, who has been using a moderate-potency topical steroid on thick plaques on the extremities and a high-potency topical steroid on more severe plaques on the elbows and knees, continues to have worsening of plaques. In consultation with a dermatologist, which treatment will be added?  a. Anthralin ointment in high strength applied for 10 to 30 minutes daily b. Calcipotriol cream applied liberally each day to the entire body c. Oral steroids and methotrexate therapy until plaques resolve d. Wideband ultraviolet therapy for 15 minutes twice daily   ANS: A Anthralin ointment is useful for plaques that are resistant to steroids. Calcipotriol cream is effective for mild to moderate plaques, but when applied in excessive quantities over large areas can cause hypercalcemia. Oral steroids are not indicated and may worsen symptoms by causing pustular flare. Methotrexate is used for severe disease, and these symptoms indicate that this is moderate disease. If UV light is used, narrowband UVB light therapy is preferred in children for safety and efficacy.     13. The primary care pediatric nurse practitioner notes velvety, brown thickening of skin in the axillae, groin, and neck folds of an adolescent Hispanic female who is overweight. What is the initial step in managing this condition? a. Consultation with a pediatric dermatologist b. Performing metabolic laboratory tests c. Prescribing topical retinoic acid cream d. Referral to a pediatric endocrinologist   ANS: B The initial step is to determine whether metabolic syndrome is the underlying cause for these lesions, which, according to the other physical findings, is most likely. If hyperinsulinemia is present, referral to a pediatric endocrinologist is the next step. A dermatology referral is not indicated. Unless the lesions are thick or cause discomfort, prescribing retinoic acid is not necessary.     14. A pre-school age child has honey-crusted lesions on erythematous, eroded skin around the nose and mouth, with satellite lesions on the arms and legs. The child’s parent has several similar lesions and reports that other children in the day care have a similar rash. How will this be treated? a. Amoxicillin 40 to 5 mg/kg/day for 7 to 10 days b. Amoxicillin-clavulanate 90 mg/kg/day for 10 days c. Bacitracin cream applied to lesions for 10 to 14 days d. Mupirocin ointment applied to lesions until clear   ANS: B When children have multiple impetigo lesions or non-bullous impetigo with infection in multiple family members or child care groups, oral antibiotics are indicated. Amoxicillin-clavulanate is a first-line drug for this indication. Amoxicillin is not used for skin infections. Bacitracin is bacteriostatic and may be used when only a few lesions are present and if bacterial resistance is not an issue. Mupirocin is used for mild impetigo when the case is isolated.     15. The primary care pediatric nurse practitioner is teaching a parent of a child with dry skin about hydrating the skin with bathing. What will the nurse practitioner include in teaching? a. Apply lubricating agents at least 1 hour after the bath. b. Have the child soak in a lukewarm water bath. c. Keep the child in the bath until the skin begins to “prune.” d. Soaping should be done at the beginning of the bath.   ANS: B When using bathing to hydrate dry skin, lukewarm water should be used. Lubricating agents should be applied immediately after patting the skin dry. The bath should last long enough to allow the skin to become moisturized without becoming supersaturated or “pruned.” Soaping and shampooing should be performed at the end of the bath followed by thorough rinsing.     16. A 9-month-old infant has vesiculopustular lesions on the palms and soles, on the face and neck, and in skin folds of the extremities. The primary care pediatric nurse practitioner notes linear and S-shaped burrow lesions on the parent’s hands and wrists. What is the treatment for this rash for this infant? a. Ivermectin 200 mcg/kg for 7 to 14 days, along with symptomatic treatment for itching b. Permethrin 5% cream applied to face, neck, and body and rinsed off in 8 to 14 hours c. Treatment of all family members except the infant with permethrin 5% cream and ivermectin d. Treatment with permethrin 5% cream for 7 days in conjunction with ivermectin 200 mcg/kg   ANS: B Permethrin 5% cream is the drug of choice for treating scabies and is intended for use in infants as young as 2 months of age. Infants will get lesions on the face and neck, and permethrin may be applied to the face, avoiding the eyes. Ivermectin is not recommended for children under 5 years old. Treatment must include the infant as well as all family members whether symptomatic or not.     17. An adolescent female has grouped vesicles on her oral mucosa. To determine whether these are caused by HSV-1 or HSV-2, the primary care pediatric nurse practitioner will order which test? a. Direct fluorescent antibody test b. Enzyme-linked immunosorbent assay c. Tzanck smear d. Viral culture   ANS: D Oral lesions are possible with both forms of herpesvirus. Viral culture is the gold standard for distinguishing HSV-1 from HSV-2. DFA and ELISA are usually used only with severe forms of infection. Tzanck smear dose not distinguish HSV-1 from HSV-2.     18. A school-age child has a rash without fever or preceding symptoms. Physical examination reveals a 3-cm ovoid, erythematous lesion on the trunk with a finely scaled elevated border, along with generalized macular, ovoid lesions appearing in a “Christmas tree” pattern on the child’s back. What is the initial action? a. Obtain a KOH preparation of a skin scraping to verify the diagnosis. b. Prescribe topical steroid creams to shorten the course of the disease. c. Reassure the child’s parents that the rash is benign and self-limited. d. Recommend topical antihistamines and emollients to control the spread.   ANS: C This rash is typical of pityriasis rosea, a benign, self-limited papulosquamous disease that is not contagious. Patients may be reassured that this is the case. Because the herald lesion is characteristic, it is not necessary to obtain a KOH scraping to look for tinea corporis. Topical steroids do not alter the course of the disease. Topical antihistamines and emollients may be used if itching occurs, but this is not the initial management action.     19. An adolescent who recently spent time in a hot tub while on vacation has discrete, erythematous 1- to 2-mm papules that are centered around hair follicles on the thighs, upper arms, and buttocks. How will the primary care pediatric nurse practitioner manage this condition? a. Culture the lesions and treat with appropriate IM antibiotics. b. Hospitalize for incision and drainage and intravenous antibiotics. c. Order an antistaphylococcal beta-lactamase-resistant antibiotic. d. Prescribe topical keratolytics and topical antibiotics.   ANS: D This adolescent has hot-tub folliculitis that is superficial at this point and may be treated with topical keratolytics and topical antibiotics. Culture is indicated if the lesions are resistant to treatment. IV and oral antibiotics and I&D are indicated for more severe episodes.     20. When prescribing topical glucocorticoids to treat inflammatory skin conditions, the primary care pediatric nurse practitioner will a. initiate therapy with a high-potency glucocorticoid. b. order lotions when higher potency is necessary. c. prescribe brand-name preparations for consistent effects. d. use fluorinated steroids to minimize adverse effects.   ANS: C Brand-name preparations often have a more consistent base and potency. PNPs should be familiar with a few high-, medium-, and low-potency products and use those consistently. Therapy should be initiated with the lowest possible potency. Lotions have a lower potency than ointments and creams. Fluorinated steroids have the highest potency and a higher risk of side effects     21. A child has several circular, scaly lesions on the arms and abdomen, some of which have central clearing. The primary care pediatric nurse practitioner notes a smaller, scaly lesion on the child’s scalp. How will the nurse practitioner treat this child? a. Obtain scrapings of the lesions for fungal cultures. b. Order prescription-strength antifungal creams. c. Prescribe oral griseofulvin for 2 to 4 weeks. d. Recommend OTC antifungal creams and shampoos.   ANS: C Whenever tinea lesions occur on the scalp or nails, oral griseofulvin must be given for 2 to 4 weeks. Unless the infection is resistant to treatment, fungal cultures are not necessary. Topical medications alone are not effective for tinea capitus.     22. A child will need an occlusive dressing to treat lichen simplex chronicus. What will the primary care pediatric nurse practitioner tell the parents about applying this treatment? a. Apply ointment before the dressing. b. Plastic wrap should not be used. c. The dressing should be applied to dry skin. d. Change the dressing twice daily.   ANS: A Occlusive dressings are placed over creams and ointments to enhance hydration and absorption of topical medications. Plastic wrap is often used. The medications and dressings should be applied to damp skin. The dressing should not be left on more than 8 hours.     23. A previously healthy school-age child develops herpes zoster on the lower back. What will the primary care pediatric nurse practitioner do to manage this condition? a. Order Burow solution and warm soothing baths as comfort measures. b. Prescribe oral acyclovir 30 mg/kg/day in 4 doses/day for 5 days. c. Recommend topical antihistamines to control itching. d. Stress the need to remain home from school until the lesions are gone.   ANS: A Children with herpes zoster should be treated with comfort measures (symptomatic treatment). Oral acyclovir is not recommended for all children but may be useful in children who are immunosuppressed or have more severe forms. Topical antihistamines are used with caution in children because of the risk of toxicity. If the lesions can be covered, children do not need to be kept home from school.     24. A child has small, firm, flesh-colored papules in both axillae which are mildly pruritic. What is an acceptable initial approach to managing this condition? a. Application of trichloroacetic acid 25% to 50% using a dropper b. Applying liquid nitrogen for 2 to 3 seconds to each lesion c. Reassuring the parents that these are benign and may disappear spontaneously d. Referral to a dermatologist for manual removal of lesions with curettage   ANS: C Molluscum contagiosum is a benign viral skin infection; most lesions disappear within 6 months to 2 years. An initial “wait and see” approach is acceptable. If itching is severe, the risk is autoinoculation and spread of lesions, along with increased discomfort and then other treatment measures may be attempted, depending on the severity. Topical medications, such as trichloroacetic acid or liquid nitrogen may be used if the lesions become uncomfortable or persist and should be used with caution. More severe outbreaks may require removal with curettage.     25. A child is brought to the clinic with a generalized, annular rash characterized by raised wheals with pale centers. On physical examination, the child’s lungs are clear and there is no peripheral edema. A history reveals ingestion of strawberries earlier in the day. What is the initial treatment? a. Aqueous epinephrine 1:1000 subcutaneously b. Cetirizine once in clinic and then once daily for 2 weeks c. Diphenhydramine 0.5 to 1 mg/kg/dose every 4 to 6 hours d. Prednisone 1 to 2 mg/kg/day for 1 week with rapid taper   ANS: C Diphenhydramine is given initially as long as anaphylaxis and angioedema are not present. Aqueous epinephrine is used for anaphylaxis and angioedema. Cetirizine is less effective than diphenhydramine. Prednisone is used for refractory episodes.     26. A child has an area of inflammation on the neck that began after wearing a hand-knot woolen sweater. On examination, the skin appears chafed with mild erythematous patches. The lesions are not pruritic. What is an appropriate initial treatment? a. Application of a lanolin-based emollient b. Burow solution soaks and cool compresses c. Oral antihistamines given 4 times daily d. Topical corticosteroids applied 2 to 3 times daily   ANS: D Topical corticosteroids are useful for contact dermatitis. Lanolin-based emollients are contraindicated when inflammation is present. Burow solution soaks are useful for vesicular rashes. Oral antihistamines are not indicated unless itching and scratching occur.     27. An adolescent who had cradle cap as an infant is in the clinic with thick crusts of yellow, greasy scales on the forehead and behind the ears. What will the primary care pediatric nurse practitioner recommend? a. Daily application of ketoconazole 2% topical cream b. High-potency topical corticosteroids applied daily c. Mineral oil and shampoo on the affected areas d. Selenium sulfide shampoo twice weekly to the face   ANS: A For facial dermatitis, daily ketoconazole 2% topical cream may be used. If steroids are prescribed, only low-dose steroids should be used on the face. Mineral oil and shampoo are recommended for cradle cap in infants. Selenium sulfide shampoo is used for scalp dermatitis.     28. A school-age child is brought to clinic after a pediculosis capitis infestation is reported at the child’s school. If this child is positive, what will the primary care pediatric nurse practitioner expect to find on physical examination, along with live lice near the scalp? a. Excoriated macules along the child’s collar and underwear lines b. Inflammation and pustules on the face and neck c. Itching of the scalp, with skin excoriation on the back of the head d. Linear or S-shaped lesions in webs of fingers and sides of hands   ANS: C Head lice commonly cause itching of the scalp, especially on the back of the head and neck, along with skin excoriation, and may be the only initial sign. Excoriated lesions along underwear lines are typical of body lice. Inflammation and pustules occur with acne. Linear or S-shaped lesions occur with scabies infestations.