Burns Pediatric Final Exam Study Guide latest version with accurate questions and answers (PASS GUARANTEED)

1. The primary care pediatric nurse practitioner understands that a major child health outcome associated

with worldwide climate change is :

a. cost of living.

b. education.

c. nutrition.

d. pollution.

ANS: C

There is growing evidence that climate change is having a dramatic effect on food crops that leads to food

distribution issues and food insecurity among families.

2. The primary care pediatric nurse practitioner understands that, to achieve the greatest world-wide

reduction in child mortality from pneumonia and diarrhea, which intervention is most effective?

a. Antibiotics

b. Optimal nutrition

c. Vaccinations

d. Water purification

ANS: C

Rotavirus is the most common cause of diarrhea globally and Strep pneumonia is the leading cause of

pneumonia, and together these are the leading infectious causes of childhood morbidity and mortality

globally. Both are vaccine-preventable diseases. Antibiotics to treat pneumonia, optimal nutrition, and

clean water all help to reduce morbidity and mortality, but vaccination prevents the diseases from

occurring.

3. When providing well child care for an infant in the first year of life, the primary care pediatric nurse

practitioner is adhering to the most recent American Academy of Pediatrics Recommendations for

Preventive Pediatric Health Care guidelines by :

a. focusing less on development and more on illness prevention and nutrition.

b. following guidelines established by the Bright Futures publication.

c. scheduling well-baby visits to coincide with key developmental milestones.

d. seeing the infant at ages 2, 4, 6, and 12 months when immunizations are due.

ANS: C

In the most recent AAP Recommendations for Preventive Pediatric Health Care, there is a greater

emphasis on behavioral and developmental issues and a recommendation that well child care be based on

child and family development rather than the periodicity of immunization schedules. This will require a

revision of the current recommendations in Bright Futures.

4. Which is true about the health status of children in the United States?

a. Globalism has relatively little impact on child health measures in the U.S.

b. Obesity rates among 2- to 5-year-olds have shown a recent significant decrease.

c. The rate of household poverty is lower than in other economically developed nations.

d. Young children who attend preschool or day care have higher food insecurity.

ANS: B

Obesity rates are a major concern for child health in the U.S. but recently have stabilized in the rate of

increase and have declined among 2- to 5-year-olds between 2004 and 2013. Globalism has an increasing

effect on child health in the U.S. The rate of household poverty in the U.S. is higher than in other

economically developed nations. Young children who attend preschool or day care have lower food

insecurity.

5. Which region globally has the highest infant mortality rate?

a. Indonesia

b. Southern Asia

c. Sub-Saharan Africa

d. Syria

ANS: C

Although Sub-Saharan Africa and Southern Asia together account for 81% of the infant mortality rate

globally, Sub-Saharan Africa has the highest infant mortality rate in the world.

1. The parent of a toddler is concerned that the child may have autism. The primary care pediatric nurse

practitioner completes a Modified Checklist for Autism in Toddlers (M-CHAT) tool, which indicates

several areas of concern. What will the nurse practitioner do?

a. Administer a Childhood Autism Rating Scale (CARS) in the clinic.

b. Consult a specialist to determine appropriate early intervention strategies.

c. Refer the child to a behavioral specialist for further evaluation.

d. Tell the parent that this result indicates that the child has autism.

ANS: C

The M-CHAT is a screening tool and is useful for detecting behaviors that may indicate autism. This

instrument has been found to have acceptable sensitivity, specificity, and significant positive predictive

value. If these behaviors are detected, the PNP should refer the child to a specialist for further assessment,

using more diagnostic tools. The CARS may be used but requires specialty training and proper

credentials. Until the diagnosis is determined, strategies for intervention are not discussed. The M-CHAT

is a screening tool and is not diagnostic.

2. The mother of a newborn tells the primary care pediatric nurse practitioner that she is worried that her

child will develop allergies and asthma. Which tool will the nurse practitioner use to evaluate this

risk?

a. Three-generation pedigree

b. Review of systems

c. Genogram

d. Ecomap

ANS: A

The three-generation pedigree is used to map out risks for genetic diseases in families, as well as

conditions with modifiable risk factors. The review of systems is used to evaluate the history of the

child's body systems. The genogram is an approach to developing a family database to provide a graphic

representation of family structure, roles, and problems of recurring significance in a family. The ecomap

is used to identify relationships in the family and community that are supportive or harmful.

3. The primary care pediatric nurse practitioner is performing a well child check-up on a 20-month-old

child. The child was 4 weeks premature and, according to a parent-completed developmental

questionnaire, has achieved milestones for a 15-month-old infant. Which action is correct?

a. Perform an in-depth developmental assessment screen at this visit to evaluate this child.

b. Reassure the parent that the child will catch up to normal development by age 2 years.

c. Re-evaluate this child's development and milestone achievements at the 2-year visit.

d. Refer the child to a specialty clinic for evaluation and treatment of developmental delay.

ANS: A

This child should be at a 19-month adjusted age for prematurity so, according to the parent screen, is 4

months behind. The PNP should perform a more in-depth screen to evaluate this delay. Waiting to see if

the child will "catch up" or assuring the parent that this will happen will cause the delays to become more

severe. A referral to a specialty clinic should not be made solely on the basis of the parent-completed

questionnaire but only after further evaluation of possible delays.

4. When formulating developmental diagnoses for pediatric patients, the primary care pediatric nurse

practitioner may use which resource?

a. DC: 0-3R

b. ICD-10-CM

c. ICSD-3

d. NANDA International

ANS: A

The DC: 0-3R refers to the Diagnostic Classification of Mental Health and Developmental Disorders of

Infancy and Early Childhood and is useful for developmental problem diagnosis. The ICD-10-CM is the

International Classification of Diseases-Tenth Revision, Clinical Modification and is useful for

identifying physiologic diseases. The ICSD-3 is the International Classification of Sleep Disorders - 3rd

edition. NANDA International is used to label problems in the functional health domain.

5. The primary care pediatric nurse practitioner is evaluating health literacy in the mother of a new

preschool-age child. How will the nurse practitioner assess this?

a. Ask the child how many books he has at home.

b. Ask the mother about her highest grade in school.

c. Ask the mother to determine the correct dose of a drug from a label.

d. Ask the mother to read a health information handout aloud.

ANS: A

The "newest vital sign," or health literacy, can be determined quickly by asking the parent how many

children's books are in the home. Greater than 10 books in the home is an independent positive predictor

of adequate parent health literacy. The other questions may determine a specific level of literacy in

general but are not as efficient.

6. The primary care pediatric nurse practitioner learns that the mother of a 3-year-old child has been

treated for depression for over 5 years. Which aspect of this child's development will be of the most

concern to the nurse practitioner?

a. Fine motor

b. Gross motor

c. Social/emotional

d. Speech and language

ANS: D

Maternal depression in the first year of life has been associated with poorer language development at 3

years of age.

7. The primary care pediatric nurse practitioner sees a 3-year-old child who chronically withholds stools,

in spite of the parents' attempts to stop the behavior, requiring frequent treatments with laxative

medications. Which diagnosis will the nurse practitioner use to facilitate third-party reimbursement?

a. Altered elimination pattern

b. Elimination disorder

c. Encopresis

d. Parenting alteration

ANS: C

Encopresis is a medical diagnosis, classified in the ICD-10-CM, and is recognized for reimbursement

purposes. "Altered elimination pattern" and "Parenting alteration" are NANDA International diagnoses

and are not recognized for reimbursement. "Elimination disorder" is a developmental diagnosis.

8. A child is in the clinic for evaluation of an asthma action plan. The primary care pediatric nurse

practitioner notes that the child's last visit was for a pre-kindergarten physical and observes that the

child is extremely anxious. What will the nurse practitioner do initially?

a. Ask the child's parent why the child is so anxious.

b. Perform a physical assessment to rule out shortness of breath.

c. Reassure the child that there is nothing to be afraid of.

d. Review the purpose of this visit and any anticipated procedures.

ANS: D

The PNP should remember that young children are learning "scripts" for health care visits and may be

stressed when recalling previous visits, especially if those involved immunizations. The PNP should

explain the purpose and any anticipated procedures for this visit to help put the child at ease.

9. When meeting with a new family, the primary care pediatric nurse practitioner develops a database

that identifies family members and others living in the household, relationships with others outside the

household, and significant behavioral and emotional problems. Which tool will the nurse practitioner

use to record this information?

a. CRAFFT

b. Ecomap

c. Genogram

d. Pedigree

ANS: C

The genogram is an approach to developing a family database to provide a graphic representation of

family structure, roles, and problems of recurring significance in a family. The CRAFFT tool is used to

assess substance abuse in adolescents. The ecomap is used to identify relationships in the family and

community that are supportive or harmful. The pedigree is used to identify potential genetic disorders.

10. The primary care pediatric nurse practitioner evaluates a school-age child whose body mass index

(BMI) is greater than the 97th percentile. The nurse practitioner is concerned about possible metabolic

syndrome and orders laboratory tests to evaluate this. Which diagnosis will the nurse practitioner

document for this visit?

a. Metabolic syndrome

b. Nutritional alteration: more than required

c. Obesity

d. Rule out type 2 diabetes mellitus

ANS: C

A problem should never be included on the problem list that is not supported by subjective and objective

data found and recorded in the database. This child has a BMI that suggests obesity, so this may be used

as a diagnosis. Metabolic syndrome is a diagnosis that is determined by laboratory data, which has not

been evaluated yet. Nutritional alteration is a NANDA diagnosis and not acceptable for reimbursement.

"Rule out" should not be used as a diagnosis, but may be considered part of a plan.

11. The primary care pediatric nurse practitioner performs a developmental assessment on a 3-year-old

child and notes normal cognitive, fine-motor, and gross-motor abilities. The child responds

appropriately to verbal commands during the assessment but refuses to speak when asked questions.

The parent tells the nurse practitioner that the child talks at home and that most other adults can

understand what the child says. The nurse practitioner will :

a. ask the parent to consider a possible speech delay and report any concerns.

b. continue to evaluate the child's speech at subsequent visits.

c. refer the child for a speech and hearing evaluation.

d. tell the parent to spend more time in interactive conversations with the child.

ANS: B

Development should be monitored over time and within the context of the child's overall well-being,

rather than at an isolated testing session. The child has normal development in observed measures and

appears to hear and understand well. By parental report, the child is able to speak. The PNP should

continue to evaluate speech over time, since this refusal to speak may be associated with shyness or

intimidation in the clinic. It is not necessary to tell the parent that the child has a possible speech delay.

Unless an actual speech delay is observed, a referral is not indicated, nor is it necessary to implement a

home therapy.

12. The primary care pediatric nurse practitioner is performing a well child assessment on an adolescent

and is concerned about possible alcohol and tobacco use. Which assessment tool will the nurse

practitioner use?

a. CRAFFT

b. HEEADSSS

c. PHQ-2

d. RAAPS

ANS: A

The CRAFFT tool is a six-question tool used to screen for adolescent substance abuse. The HEEADSSS

is used as a psychosocial screening tool. The PHQ-2 is a rapid screen for depression. The RAAPS is used

to assess risk behaviors that contribute to most morbidity, mortality, and social problems in teens.

13. The primary care pediatric nurse practitioner is assessing a toddler whose weight and body mass index

(BMI) are below the 3rd percentile for age. The nurse practitioner learns that the child does not have

regular mealtimes and is allowed to carry a bottle of juice around at all times. The nurse practitioner

plans to work with this family to develop improved meal patterns. Which diagnosis will the nurse

practitioner use for this problem?

a. Failure to thrive

b. Home care resources inadequate

c. Nutrition alteration - less than required

d. Parenting alteration

ANS: D

Because the PNP is planning to intervene by helping the parents to provide appropriate food habits, the

correct diagnosis should be "Parenting alteration." "Failure to thrive" is a medical diagnosis and requires

a medical and social evaluation to rule out organic causes or detect neglect. "Home care resources

inadequate" would be used if the PNP suspects that the family lacks adequate funds to purchase food.

"Nutrition alteration" is a NANDA diagnosis and would be used if the PNP planned to consult with a

dietician or give nutritional information.

14. The primary care pediatric nurse practitioner is obtaining a medical history about a child. To integrate

both nursing and medical aspects of primary care, which will be included in the medical history?

a. Complementary medications, alternative health practices, and chief complaint

b. Developmental delays, nutritional status, and linear growth patterns

c. Medication currently taking, allergy information, and family medical history

d. Speech and language development, beliefs about health, and previous illnesses

ANS: D

An assessment model that integrates the nursing and medical aspects of primary care uses three domains:

developmental problems (speech and language development), functional health problems (beliefs about

health), and diseases (chief complaint). The other examples all use domains associated with the traditional

medical model and do not contain nursing aspects associated with functional health problems.

1. The primary care pediatric nurse practitioner learns that an African-American family lives in a

neighborhood with a high crime rate and suggests that they try moving to another neighborhood for

the safety of their children. This is an example of

a. cultural sensitivity.

b. group bias.

c. individual privilege.

d. racial awareness.

ANS: C

Privilege can be individual- or group-based and refers to the often unconscious lack of understanding of

what other groups must deal with. The PNP is not aware that the family may lack the resources to move,

may be fearful of moving to a "white" neighborhood, or may even feel safe around people that they know.

Cultural sensitivity is an awareness of and respect for other cultures. Group bias is a prejudice, based on

cultural, racial, or ethnic differences, toward a group of people. Racial awareness would describe an

awareness of cultural differences based on race.

2. The primary care pediatric nurse practitioner is examining a child whose parents recently emigrated

from a war-torn country in the Middle East. Which is a priority assessment when performing the

patient history?

a. Asking about physical, psychological, and emotional trauma

b. Determining the parents' English language competency and literacy level

c. Learning about cultural preferences and complementary medicine practices

d. Reviewing the child's previous health and illness records

ANS: A

Recent history that includes trauma, loss, and refugee camp experience may exacerbate difficulties

adjusting to life in the U.S. and can lead to acute and chronic physical and mental health concerns. All of

the other parts of the history will be necessary, but this should be a priority, since the family has escaped a

war-torn country.

3. The primary care pediatric nurse practitioner in a community health center meets a family who has

recently immigrated to the United States who speak only Karon. They arrive in the clinic with a

church sponsor, who translates for them. The pediatric nurse practitioner notices that the sponsor

answers for the family without giving them time to speak. The pediatric nurse practitioner will :

a. ask the sponsor to allow the family to respond.

b. develop the plan of care and ask the sponsor to make sure it is followed.

c. request that the sponsor translate written instructions for the family.

d. use the telephone interpreter service to communicate with the family.

ANS: D

Federally funded managed care networks and community health centers are required to have interpreters

accessible for clients with limited English proficiency. A commercial telephone interpreter service has

been shown to be as effective as an "in-person" interpreter. Relying on family members or community

members may not be reliable and may jeopardize patient confidentiality. This interpreter is answering for

the clients without hearing what they have to say, which can compromise care.

4. The primary care pediatric nurse practitioner provides well child care for a community of immigrant

children from Central America. The pediatric nurse practitioner is surprised to learn that some of the

families are Jewish and not Catholic. This response is an example of cultural :

a. collectivism.

b. constructivism.

c. essentialism.

d. individualism.

ANS: C

An essentialist view of culture, which dominates the health care literature, portrays an ethnic minority

group as having a static set of traits and oversimplifies cultural information, applying traits to all members

of the group. Assuming that all people from Central America are Catholic is an example of this

oversimplification. Collectivism refers to a member of an ethnic group who perceives himself or herself

to be intrinsically part of that group. A constructive view recognizes culture as complex and dynamic and

sees people as individuals who may belong to multiple cultures simultaneously. Individualism recognizes

the individual, and not the group, as the basic unit of survival.

5. The primary care pediatric nurse practitioner cares for children from a Native American family and

learns that they used many herbs to treat and prevent illness. Which approach will the pediatric nurse

practitioner use to promote optimum health in the children?

a. Ask about the types of practices used and when they are applied.

b. Provide a list of harmful herbs and ask the family to avoid those.

c. Suggest that the family avoid using these remedies in their children.

d. Tell the parents to use the herbs in conjunction with modern medications.

ANS: A

The challenge, when working with families from different cultural backgrounds, who use alternative or

complementary medicines, is to find ways to achieve a mutual understanding of the differences and to

negotiate an acceptable plan of care. The first step is to begin a discussion about these practices.

Providing a list of harmful herbs, suggesting that the family avoid certain herbs, and suggesting that the

herbs are only an adjunct to "modern medicine" will sound disparaging and will convey a sense of

mistrust.

6. A primary care pediatric nurse practitioner working in a community health center wishes to develop a

program to assist impoverished children and families to have access to healthy foods. Which strategy

will the pediatric nurse practitioner employ to ensure the success of such a program?

a. Asking community members to assist in researching and implementing a program

b. Designing a community garden approach that involves children and their parents

c. Gaining support from the corporate community to provide needed resources

d. Providing evidence-based information about the importance of a healthy diet

ANS: A

Community collaboration can be fostered through community-based participatory research (CBPR),

which is transformative research that bridges the gap between science and practice by actively engaging

communities with formally trained researchers. In this type of research, community members formally

participate in all aspects of the process, making the findings more relevant to the community it affects the

most. Designing a community garden approach without first knowing whether the community needs or

wants it does not ensure success. Gaining support from the corporate community without input from the

affected community does not guarantee success. Giving evidence-based information does not involve the

community members in research and does not increase success.

7. The primary care pediatric nurse practitioner works with families from a variety of cultures and

socioeconomic classes. Which is an example of cultural humility in practice?

a. Giving health care advice that takes cultural differences into account

b. Identification of other cultures that may be superior to one's own culture

c. Receptivity to learning about the perspectives of other cultures

d. Respecting other cultures while maintaining the views of one's own

ANS: C

Cultural humility is defined as the lifelong commitment to developing mutually beneficial,

nonpaternalistic partnerships and is based on a model of passive volition, receptivity, and being open to

learning from others. Practitioners who have cultural humility are always seeking to learn about other

cultures. Cultural humility involves asking questions, rather than giving answers. Cultural humility does

not mean identifying one's own culture as inferior. Practitioners who are culturally competent are open to

the influence of other cultures.

8. A Somalian immigrant mother is concerned that her 8-year-old child is underweight. The primary care

pediatric nurse practitioner notes that the child's weight is at the 25th percentile. After realizing that

the mother is comparing her child to a group of American-born children who are overweight, the

pediatric nurse practitioner is able to convince the mother that this is a normal weight. Which domain

of cultural competence does this represent?

a. Global

b. Interpersonal

c. Intrapersonal

d. Organizational

ANS: B

The interpersonal domain of cultural competence refers to how cultural competence is manifested

between and among individuals and includes all relationships within the health care setting. The PNP

becomes aware of cultural norms in body weight and uses this knowledge to discuss healthy weights with

the parent. The global domain recognizes a movement toward integration and interconnection of the

world population in economic, political, technological, and sociocultural terms. The intrapersonal domain

refers to an understanding of the self to understand one's own cultural background. The organizational

domain is knowledge of institutional culture and how it affects health care.

9. The primary care pediatric nurse practitioner prescribes a twice daily inhaled corticosteroid for a 12-

year-old child. At a well child visit, the child reports not using the medication on a regular basis.

Which response by the pediatric nurse practitioner demonstrates an understanding of client-centered

care?

a. Asking the child to describe usual daily routines and schedules

b. Referring the family to a social worker to help with medication compliance

c. Reviewing the asthma action plan with the parent and the child

d. Teaching the child how the medication will help to control asthma symptoms

ANS: A

In a client-centered relationship, there is reciprocal communication and understanding. The PNP should

be able to understand the client's perspective and unique situation. The first step is to evaluate possible

reasons for nonadherence and not to make referrals or re-educate until potential barriers have been

identified and negotiation with the client has occurred.

10. The parents of a special needs child tell the primary care pediatric nurse practitioner that they are

planning a 3-month visit to their home country in Africa. The pediatric nurse practitioner assists the

family to obtain a sufficient supply of medications and formula and to make sure that the child's

equipment can be transported and used during the trip and at the destination. This is an example of

a. global application.

b. global awareness.

c. system application.

d. system awareness.

ANS: A

Global application involves having a willingness and ability to adjust to the needs of clients, families, and

communities both nationally and globally. Global awareness involves knowledge of diseases, political,

and economic factors worldwide that affect health. System application involves assisting clients to

overcome institutional barriers to effective interventions. System awareness is knowledge of these

barriers.

1. During a well child exam, the primary care pediatric nurse practitioner learns that the parents of a

young child fight frequently about finances. The parents state that they do not fight in front of the

child and feel that the situation is temporary and related to the father's job layoff. What will the nurse

practitioner do?

a. Reassure them that the child is too young to understand.

b. Recommend that they continue to not argue in front of the child.

c. Suggest counseling to learn ways to handle stress.

d. Tell them that the conflict will resolve when the situation changes.

ANS: C

Marital problems can result in child behavior difficulties and anxieties, and conflict can be picked up by

the child. The parents should try to learn to modify unhealthy behaviors, such as increased conflict during

stressful situations. Even when children do not understand, they pick up on cues from the parents about

anxiety and stress and can internalize these feelings. Avoiding arguments in front of the child does not

alleviate the underlying conflict and stress. The behavior of fighting during this stressful situation may

indicate a pattern of response to stress and will only recur with each subsequent stressful period.

2. The primary care pediatric nurse practitioner conducts a well baby exam on an infant and notes mild

gross motor delays but no delays in other areas. Which initial course of action will the nurse

practitioner recommend?

a. Consult a developmental specialist for a more complete evaluation.

b. Prepare the parents for a potentially serious developmental disorder.

c. Refer the infant to an early intervention program for physical therapy.

d. Teach the parents to provide exercises to encourage motor development.

ANS: D

The child who has mild delays in only one area may be managed initially by having the parent provide

appropriate exercises. If this is not effective, or if delays become more severe, referrals for evaluation or

early intervention services are warranted. A mild delay does not necessarily signal a serious disorder, so

this action is not indicated.

3. The primary care pediatric nurse practitioner sees a developmentally delayed toddler for an initial

visit. The family has just moved to the area and asks the nurse practitioner about community services

and resources for their child. What should the nurse practitioner do initially?

a. Ask the parents if they have an individualized family service plan (IFSP).

b. Consult with a physician to ensure the child gets appropriate care.

c. Inform the family that services are provided when the child begins school.

d. Refer the family to a social worker for assistance with referrals and services.

ANS: A

Families with children who have developmental delays are eligible for early intervention services and

should have IFSPs in place. This family may have one from their previous community, and it can be used

as a starting point to determine needs. It is not necessary to consult with a physician to coordinate

community resources. Early intervention is provided from birth, according to federal law. Until the

specific referrals are known, the social worker is not consulted.

4. The primary care pediatric nurse practitioner is examining a newborn infant recently discharged from

the neonatal intensive care unit after a premature birth. The parent is upset and expresses worry about

whether the infant will be normal. What will the nurse practitioner do in this situation?

a. Explain to the parent that developmental delays often do not manifest at first.

b. Perform a developmental assessment and tell the parent which delays are evident.

c. Point out the tasks that the infant can perform while conducting the assessment.

d. Refer the infant to a developmental specialist for a complete evaluation.

ANS: C

When discussing developmental delays with parents, it is important to be positive and to initially focus on

strengths. Explaining that developmental delays develop over time is true but does not reassure the parent

or help the parent cope with feelings. Referrals are not indicated unless delays are present and may take

time.

5. Which recommendation will a primary care pediatric nurse practitioner make when parents ask about

ways to discipline their 3-year-old child who draws on the walls with crayons?

a. Give the child washable markers so the drawings can be removed easily.

b. Provide a roll of paper for drawing and teach the child to use this.

c. Put the child in "timeout" each time the child draws on the walls.

d. Take the crayons away from the child to prevent the behavior.

ANS: B

Discipline involves training or education that molds appropriate behavior and is used to teach the child

what is permitted and encouraged. Providing an appropriate outlet for drawing helps to teach the child

where to use the crayons. Using washable markers allows the parents to clean the walls but does not teach

the child appropriate behaviors. Timeout and taking away the crayons are forms of punishment, or a loss

of privileges, that are administered as a form of retribution.

6. The primary care pediatric nurse practitioner enters an exam room and finds a 2-month-old infant in a

car seat on the exam table. The infant's mother is playing a game on her smart phone. The nurse

practitioner interprets this behavior as :

a. a sign that the mother has postpartum depression.

b. extremely concerning for potential parental neglect.

c. of moderate concern for parenting problems.

d. within the normal range of behavior in early parenthood.

ANS: C

A parent who seems disinterested in a child raises moderate concerns for parenting problems. It does not

necessarily signal postpartum depression. It is not a mark for extreme concern. It is not within the

expected range of behaviors.

7. During a well child assessment of an 18-month-old child, the primary care pediatric nurse practitioner

observes the child becoming irritable and uncooperative. The parent tells the child to stop fussing.

What will the nurse practitioner do?

a. Allow the parent to put the child in a "timeout."

b. Ask the parent about usual discipline practices.

c. Offer the child a book or a toy to look at.

d. Stop the exam since the child has reached a "meltdown."

ANS: C

The child has exhibited early signs of misbehavior. At this stage, distraction and active engagement may

be used to stop more problems from occurring. It is not necessary to use a timeout because the child

hasn't reached the point where cooperation is impossible. The PNP should model appropriate

interventions by offering the child a distraction and may ask the parent about discipline practices later in

the visit. The child is not at a "meltdown" state.

8. The primary care pediatric nurse practitioner performs a physical examination on a 9-month-old infant

and notes two central incisors on the lower gums. The parent states that the infant nurses, takes solid

foods three times daily, and occasionally takes water from a cup. What will the pediatric nurse

practitioner counsel the parent to promote optimum dental health?

a. To begin brushing the infant's teeth with toothpaste

b. To consider weaning the infant from breastfeeding

c. To discontinue giving fluoride supplements

d. To make an appointment for an initial dental examination

ANS: D

The American Academy of Pediatric Dentistry recommends a first dental examination at the time of

eruption of the first tooth and no later than 12 months old. Parents should be counseled to clean the

infant's teeth but with water only. Weaning from breastfeeding is not indicated, although mothers should

not let the infant nurse while sleeping to prevent milk from bathing the teeth. Fluoride supplements

should not be discontinued.

9. The primary care pediatric nurse practitioner has a cohort of patients who have special health care

needs. Which is an important role of the nurse practitioner when caring for these children?

a. Care coordination and collaboration

b. Developing protocols for parents to follow

c. Monitoring individual education plans (IEPs)

d. Providing lists of resources for families

ANS: A

Care coordination is one of the key elements for children with special health care needs. PNPs are

especially suited for this role and have the unique skills to function as care coordinators. Care for these

children should involve shared decision making and individualized care and not "cookbook" approaches.

The PNP may advocate for children's health care needs for the IEP but does not monitor these. The PNP

should not just give parents lists of phone numbers but should assist them to make appointments.

10. A single mother of an infant worries that living in a household with only one parent will cause her

child to be maladjusted. To help address the mother's concerns, the primary care pediatric nurse

practitioner will suggest :

a. developing consistent daily routines for the child.

b. exposing her child to extended family members when possible.

c. not working outside the home during the first few years.

d. taking her child to regular play date activities with other children.

ANS: A

Providers can teach parents that providing predictable, consistent, and loving care helps an infant to learn

trust and help influence positive brain development. Involving extended family members and going to

play dates are good ways to socialize children but are not essential to learning trust. It may not be possible

for her to be a stay-at-home mother.

1. The primary care pediatric nurse practitioner performs a well baby examination on a 7-day-old infant

who is nursing well, according to the mother. The nurse practitioner notes that the infant weighed

3250 grams at birth and 2990 grams when discharged on the second day of life. The infant weighs

3080 grams at this visit. Which action is correct?

a. Follow up at the 2-month checkup.

b. Refer to a lactation consultant.

c. Schedule a weight check in 1 week.

d. Suggest supplementing with formula.

ANS: C

This infant lost about 8% of its birth weight, which is normal and, since discharge home, has gained at

least 15 grams per day, which is also normal. The PNP should schedule a weight check in a week to make

sure the infant regains its birth weight, since most should regain this in 10 to 14 days and since this loss of

birth weight is at the high end of normal. It is not necessary to refer to a lactation consultant or

supplement with formula, since the infant is gaining weight adequately.

2. The parent of a newborn infant asks the primary care pediatric nurse practitioner when to intervene to

help the infant's future intellectual growth. What will the nurse practitioner tell the parent?

a. Cognitive learning begins during the toddler years.

b. Intellectual growth begin when speech develops.

c. Language and literacy skills begin at birth.

d. Preschool is an optimal time to begin general learning.

ANS: C

General learning and acquisition of skills for later reading and writing begin at birth, not in kindergarten

or first grade, and these skills grow with everyday loving interactions between infants and caregivers.

Cognitive learning changes during toddler years but begins at birth. Intellectual growth is not tied to

speech alone.

3. During an assessment of a 4-week-old infant, the primary care pediatric nurse practitioner learns that a

breastfed infant nurses every 2 hours during the day but is able to sleep for a 4-hour period during the

night. The infant has gained 20 grams per day in the interval since last seen in the clinic. What will the

nurse practitioner recommend?

a. Continuing to nurse the infant using the current pattern

b. Nursing the infant for longer periods every 4 hours

c. Supplementing with formula at the last nighttime feeding

d. Waking the infant every 2 hours to nurse during the night

ANS: A

Infants who are encouraged to breastfeed every 2 to 3 hours may have one longer stretch of 4 hours at

night. This infant is gaining between 0.5 and 1 gram per day, which is appropriate. It is not necessary to

alter the pattern of nursing or to supplement with formula.

4. The mother of a 6-week-old breastfeeding infant tells the primary care pediatric nurse practitioner that

her baby, who previously had bowel movements with each feeding, now has a bowel movement once

every third day. What will the nurse practitioner tell her?

a. Her baby is probably constipated.

b. It may be related to her dietary intake.

c. She should consume more water.

d. This may be normal for breastfed babies.

ANS: D

Infants begin to have fewer bowel movements and may have bowel movements ranging from once or

twice daily to once every other day when breastfed. Unless there are other signs, the baby is probably not

constipated. The mother does not need to change her intake of foods or water, unless constipation is

present.

5. The mother of a 3-month-old child tells the primary care pediatric nurse practitioner that it is "so

much fun" now that her infant coos and smiles and wants to play. What is important for the nurse

practitioner to teach this mother?

a. Appropriate ways to stimulate and entertain the infant

b. How to read the infant's cues for overstimulation

c. The importance of scheduling "play dates" with other infants

d. To provide musical toys to engage the infant

ANS: B

By 3 months, infants demonstrate a social smile and will become more active, alert, and responsive.

Parents may mistakenly assume that the infant can handle more activity and stimulation when this occurs,

and the PNP should teach caregivers how to recognize infant cues for the need to rest or to have

decreased stimulation.

6. The mother of a 6-month-old infant is distressed because the infant can say "dada" but not "mama"

and asks the primary care pediatric nurse practitioner why this is when she is the one who spends

more time with the infant. How will the nurse practitioner respond?

a. "At this age, your baby does not understand the meaning of sounds."

b. "Babies at this age cannot make the 'ma' sound."

c. "Most sounds made by babies at this age are accidental."

d. "This may mean that your baby doesn't hear well."

ANS: A

At 6 months, infants delight in vocalizing sounds that they learn by imitation but do not ascribe meaning

to the sounds they make. Infants can say "mama" but without meaning. Babies make sounds on purpose

by imitating what they hear. A preference for one sound early in speech does not indicate a hearing

deficit.

7. The primary care pediatric nurse practitioner is performing a well baby examination on a 2-month-old

infant who has gained 25 grams per day in the last interval. The mother is nursing and tells the nurse

practitioner that her infant seems fussy and wants to nurse more often. What will the nurse

practitioner tell her?

a. She may not be making as much breastmilk as before.

b. She should keep a log of the frequency and duration of each feeding.

c. The infant may be going through an expected growth spurt.

d. The infant should stay on the previously established nursing schedule.

ANS: C

Infants may have a growth spurt at 6 to 8 weeks, and mothers who are breastfeeding may be concerned

that they are not making enough milk when they notice that the infant is fussy and wanting to nurse more

often. The PNP should reassure the mother that this is expected. It is not necessary, since the infant is

gaining weight appropriately, for the mother to keep a log. The mother should follow the infant's cues for

feeding since the extra suckling will increase the milk supply to meet the growing infant's needs.

8. The primary care pediatric nurse practitioner is performing a well child examination on a 9-month-old

infant whose hearing is normal but who responds to verbal cues with only single syllable

vocalizations. What will the nurse practitioner recommend to the parents to improve speech and

language skills in this infant?

a. Provide educational videos that focus on language.

b. Read simple board books to the infant at bedtime.

c. Sing to the child and play lullabies in the baby's room.

d. Turn the television to Sesame Street during the day.

ANS: B

The best way to improve language skills is to read to children. As long as the reading includes positive

interactions with the baby and the reader, the baby is learning language. Educational videos, music, and

television are all passive media and do not involve this interaction.

9. The parent of a 5-month-old is worried because the infant becomes fussy but doesn't always seem

interested in nursing. What will the nurse practitioner tell this parent?

a. The infant may be expressing a desire to play or to rest.

b. The parent should give ibuprofen for teething pain before nursing.

c. This is an indication that the infant is ready for solid foods.

d. This may indicate gastrointestinal discomfort such as constipation.

ANS: A

At this age, infants may cry when they are tired or need social interaction and not just when they are

hungry. The PNP should teach parents about this change in social development so they can be responsive

to their infant's needs. Solid foods are not added until age 6 months. Teething usually does not begin until

at least 6 months. GI discomfort usually occurs after eating.

10. The primary care pediatric nurse practitioner is examining a 12-month-old infant who was 6 weeks

premature and observes that the infant uses a raking motion to pick up small objects. The PEDS

questionnaire completed by the parent did not show significant developmental delays. What will the

nurse practitioner do first?

a. Perform an in-depth developmental assessment.

b. Reassure the parent that this is normal for a premature infant.

c. Refer the infant to a developmental specialist.

d. Suggest activities to improve fine motor skills.

ANS: A

When developmental screening indicates an infant is not progressing at the expected rate, additional

testing to determine the degree of delay is necessary. A referral may be needed if a delay is determined.

This is not normal for this degree of prematurity

infants should develop a pincer grasp by 9 to 10 months

of age.

1. 1. The parent of a 4-year-old points to a picture and says, "That's your sister." The

child responds by saying, "No! It's my baby!" This is an example of which type of thinking in

preschool-age children?

a. a. Animism

b. b. Artificialism

c. c. Egocentrism

d. d. Realism

ANS: D

Children at this age are developing their ability to establish causality. Nominal realism occurs

when children think that one type of thing can only be called by one name. All dogs are dogs

and not various breeds. Animism refers to the belief that objects possess person-like qualities.

Artificialism occurs when children think things are caused by a controlling force. Egocentrism is

when children see things only as they relate to themselves.

1. 2. The primary care pediatric nurse practitioner performs a developmental

assessment on a 32-month-old child. The child's parent reports that about 70% of the child's

speech is intelligible. The pediatric nurse practitioner observes that the child has difficulty

pronouncing "t," "d," "k," and "g" sounds. Which action is correct?

a. a. Evaluate the child's cognitive abilities.

b. b. Obtain a hearing evaluation.

c. c. Reassure the parent that this is normal.

d. d. Refer the child to a speech therapist.

ANS: C

Intelligibility of speech reaches about 66% between the ages of 24 and 36 months. Tongue-

contact sounds are more intelligible by age 5 years. This child exhibits normal speech for age. It

is not necessary to perform a cognitive assessment based on these findings. Referrals for

hearing and speech evaluations are not indicated, since these findings are within normal limits.

1. 3. The primary care pediatric nurse practitioner is offering anticipatory guidance to

the parents of a 12-month-old child. The parents are bilingual in Spanish and English and

have many Spanish-speaking relatives nearby. They are resisting exposing the child to

Spanish out of concern that the child will not learn English well. What will the pediatric nurse

practitioner tell the parents?

a. a. Children who learn two languages simultaneously often confuse them in

conversation.

b. b. Children with multi-language proficiency do not understand that others cannot

do this.

c. c. Learning two languages at an early age prevents children from developing a

dominant language.

d. d. Most bilingual children are able to shift from one language to another when

appropriate.

ANS: D

Most children who are bilingual are able to sort out the languages in conversation but may "code

switch" at times for clarity as they speak. They seem to understand that not everyone has this

ability. Most children who are bilingual develop a dominant language.

1. 4. The parents of a 3-year-old child are concerned that the child has begun refusing

usual foods and wants to eat mashed potatoes and chicken strips at every meal and snack.

The child's rate of weight has slowed, but the child remains at the same percentile for weight

on a growth chart. What will the primary care pediatric nurse practitioner tell the parents to

do?

a. a. Allow the child to choose foods for meals to improve caloric intake.

b. b. Place a variety of nutritious foods on the child's plate at each meal.

c. c. Prepare mashed potatoes and chicken strips for the child at mealtimes.

d. d. Suggest cutting out snacks to improve the child's appetite at mealtimes.

ANS: B

Young children should have three meals and two nutritious snacks each day. The parents'

responsibility is to provide nutritious foods and allow children to choose how much they will eat.

Children who are allowed to choose foods will likely make selections that are not healthy.

Parents should be discouraged from preparing separate meals for their children. Snacks are

necessary to maintain adequate intake and energy.

1. 5. The parent of a 24-month-old child asks the primary care pediatric nurse

practitioner when toilet training should begin. How will the pediatric nurse practitioner

respond?

a. a. "Begin by reading to your child about toileting."

b. b. "Most children are capable by age 2 years."

c. c. "Tell me about your child's daily habits."

d. d. "We should assess your child's motor skills."

ANS: C

To assess the parent's understanding of toilet readiness, the nurse practitioner will ask the

parents about the child's daily habits and routines to see if the child has predictable patterns

that can be the basis for toilet training. While providing storybooks about toileting can help

children learn, the first step is to assess toilet readiness. Even though many children are

capable at this age, evaluating personal readiness is key to beginning toilet training.

Assessment of motor skills may be a second step.

1. 6. The primary care pediatric nurse practitioner is counseling the parents of a toddler

about appropriate discipline. The parents report that the child is very active and curious, and

they are worried about the potential for injury. What will the pediatric nurse practitioner

recommend?

a. a. Allow the child to explore and experiment while providing appropriate limits.

b. b. Be present while the child plays to continually teach the child what is

appropriate.

c. c. Let the child experiment at will and to make mistakes in order to learn.

d. d. Say "no" whenever the child does something that is not acceptable.

ANS: A

The child who is securely attached uses the parents as a base from which to safely explore the

world. Toddlers learn by doing and need to experiment to gain mastery over the environment. It

is important that parents are present for safety, but parents should not be ever-present and

controlling. Parents should be close by and should intervene if the child is at risk for injury.

Continual criticism and the use of the word "no" can make the toddler feel powerless.

1. 7. The primary care pediatric nurse practitioner performs a physical examination on

a 9-month-old infant and notes two central incisors on the lower gums. The parent states

that the infant nurses, takes solid foods three times daily, and occasionally takes water from

a cup. What will the pediatric nurse practitioner counsel the parent to promote optimum

dental health?

a. a. To begin brushing the infant's teeth with toothpaste

b. b. To consider weaning the infant from breastfeeding

c. c. To discontinue giving fluoride supplements

d. d. To make an appointment for an initial dental examination

ANS: D

The American Academy of Pediatric Dentistry recommends a first dental examination at the

time of eruption of the first tooth and no later than 12 months old. Parents should be counseled

to clean the infant's teeth but with water only. Weaning from breastfeeding is not indicated,

although mothers should not let the infant nurse while sleeping to prevent milk from bathing the

teeth. Fluoride supplements should not be discontinued.

1. 8. During a well child assessment of an 18-month-old child, the primary care

pediatric nurse practitioner observes the child point to a picture of a dog and say, "Want

puppy!" The nurse practitioner recognizes this as an example of

a. a. holophrastic speech.

b. b. receptive speech.

c. c. semantic speech.

d. d. telegraphic speech.

ANS: D

Syntax, or the structure of words in sentences or phrases, is developed in stages between the

ages of 8 months and 3.5 years. Telegraphic speech begins at about 18 months of age when

children speak in phrases with many words omitted, so that the sentence sounds like a

telegram. Holophrastic speech is the use of a single word to express a complete idea.

Receptive speech refers to the ability to understand a word without necessarily being able to

use the word. Semantics is the understanding that words have specific meanings.

1. 9. The primary care pediatric nurse practitioner is evaluating a 2-year-old with a

documented speech delay. Screenings to assess motor skills and cognition are normal, and

the child passed a recent hearing test. What will the pediatric nurse practitioner do next?

a. a. Ask the child's parents whether they read to the child.

b. b. Give parents educational materials to encourage speech.

c. c. Refer the child to an early intervention program.

d. d. Suggest that they purchase age-appropriate music videos.

ANS: A

Language development requires oral-motor ability, auditory perception, and cognitive ability,

which this child has been shown to have, as well as the psychosocial-cultural environment to

motivate the child to engage in language use. The PCPNP's initial step should be to determine

whether the parents provide such an environment. Educational materials may be used after it is

determined that these are useful. Early intervention may be used if the speech delay persists.

Music videos do not necessarily engage the child in expression of speech.

1. 10. The mother of a 3-year-old child takes the child to a play group once a week.

She expresses concern that the child plays with toys but does not interact with the other

toddlers. What will the primary care pediatric nurse practitioner counsel the mother?

a. a. The child probably is very shy but will outgrow this tendency with repeated

exposure to other children.

b. b. The toddler may have a language delay that interferes with socialization with

other children.

c. c. Toddlers may be interested in other children but usually do not engage in

interactive play.

d. d. Toddlers need more structured play to encourage interaction and socialization

with others.

ANS: C

Parallel play is common among toddlers who, although they may be fascinated by other

children, generally do not engage with peers in an interactive manner. This does not mean that

the child is shy or has a language delay, although in preschool years, the development of

symbolic language increases interactive play. Children need both structured and free play, but

structured play will not increase interaction during this normally parallel period.

1. The primary care pediatric nurse practitioner is preparing to conduct a well child assessment of an 8-

year-old child. How will the nurse practitioner begin the exam?

a. Ask the child about school, friends, home activities, and sports

b. Discuss the purpose of the visit and explain the procedures that will be performed

c. Offer age-appropriate information about usual developmental tasks

d. Provide information about healthy nutrition and physical activities

ANS: A

To build rapport with the child and parent, the PNP will begin by asking direct questions to the child,

encouraging the child to share information about daily routines. The other answers list aspects of the well

child visit that can be introduced after the initial conversation.

2. The primary care pediatric nurse practitioner is examining a 6-year-old child who attends first grade.

The child reports "hating" school. The parent states that the child pretends to be sick frequently in

order to stay home from school. To further assess this situation, the nurse practitioner will first ask the

child :

a. about school performance and grades.

b. why school is so distressing.

c. to name one or two friends.

d. whether bullying is taking place.

ANS: C

The earliest school-age psychosocial milestone occurs when children learn to separate easily from family,

allowing them to go to school. Mastery of these skills enables them to develop and maintain peer

friendships. Social interaction skills are necessary in order to develop mastery over school activities.

Asking the child to describe why school is distressing may not elicit information, since the child may not

be able to articulate this. Bullying is not the only reason for disliking school, but, if it is, will emerge

during a discussion about friends and schoolmates.

3. A school-age child has begun refusing all cooked vegetables. What will the primary care pediatric

nurse practitioner recommend to the parent?

a. Allow the child to make food choices since this is usually a phase

b. Ensure that the child has three nutritious meals and two nutritious snacks each day

c. Prepare vegetables separately for the child to encourage adequate intake

d. Teach the child how important it is to eat healthy fruits and vegetables

ANS: B

Children have food jags that are generally self-limited. The parent's responsibility is to provide three

nutritious meals and two nutritious snacks each day so that all available choices are acceptable. Allowing

food choices may result in an overabundance of non-nutritious foods selected. It is not necessary to

prepare separate dishes for a child who is going through a temporary phase. Teaching the child about

nutrition is important but will not likely have much impact during this phase.

4. The parent of a 6-year-old child expresses concern that the child may have ADHD. Which screening

tool will the primary care pediatric nurse practitioner use to evaluate this possibility?

a. Behavioral and Emotional Screening System for Children (BESS-2)

b. Behavioral Assessment for Children - 2nd ed. (BASC-2)

c. Conner's 3 Parent and Teacher Rating Scale

d. Pediatric Symptom Checklist (PSC)

ANS: C

The Conner's Parent and Teacher Rating Scale is used to assess ADHD symptoms in children aged 6 to

18 years. The BESS-2 is used to evaluate social emotional and mental health in children. The BASC-2 is

used to further assess children who have positive findings on the BESS-2. The PSC is used to assess

cognitive, emotional, and behavioral problems in children.

5. The primary care pediatric nurse practitioner performs a physical examination on a 12-year-old child

and notes poor hygiene and inappropriate clothes for the weather. The child's mother appears clean

and well dressed. The child reports getting 6 to 7 hours of sleep each night because of texting with

friends late each evening. What action by the nurse practitioner will help promote healthy practices?

a. Discuss setting clear expectations about self-care with the mother

b. Give the child information about sleep and self-care

c. Reassure the mother that this "non-compliance" is temporary

d. Tell the mother that experimenting with self-care behaviors is normal

ANS: A

Parents of school-age children should be advised to set clear limits for their children for cleanliness,

healthy exercise, hours of sleep, and other health promotion behaviors to encourage the development of

responsibility for these things. Giving the child information can be done along with setting expectations,

but, at this age, the parent should still be supervising. While "non-compliance" is a part of this process,

and is a means of asserting independence, parents need to discuss this with children to resolve the issue.

6. The parents of a 12-year-old child are concerned that some of the child's older classmates may be a

bad influence on their child, who, they say, has been raised to believe in right and wrong. What will

the primary care pediatric nurse practitioner tell the parent?

a. Allowing the child to make poor choices and accept consequences is important for learning values

b. Children at this age have a high regard for authority and social norms, so this is not likely to

happen

c. Moral values instilled in the early school-age period will persist throughout childhood

d. The pressures from outside influences may supersede parental teachings and should be confronted

ANS: D

Although early school-age children learn values from their parents, these may be challenged as children

learn that others have different values. Parents must confront and negotiate these issues daily with their

children. While children may make poor choices and subsequently learn from the consequences, it is best

for parents to actively discuss these issues with their children. Children do have a high regard for

authority and social norms but may easily transfer this authority to other, less reliable people, such as

peers. Moral values may not persist if other sources of authority become prominent.

7. The parent of a 10-year-old boy tells the primary care pediatric nurse practitioner that the child

doesn't appear to have any interest in girls and spends most of his time with a couple of other boys.

The parent is worried about the child's sexual identity. The nurse practitioner will tell the parent

a. children at this age who prefer interactions with same-gender peers usually have a homosexual

orientation.

b. children experiment with sexuality at this age as a means of deciding later sexual orientation.

c. this attachment to other same-gender children is how the child learns to interact with others.

d. to encourage mixed-gender interactions in order to promote development of sexual values.

ANS: C

At age 10, children usually develop an intense same-gender relationship with a peer. This is how the child

learns to expand the self, shares feelings, and learns how others manage problems. It does not indicate

later sexual orientation and is not a characteristic of experimentation with sexuality. It is not necessary to

encourage mixed-gender interactions.

8. During a well child exam on a 5-year-old child, the primary care pediatric nurse practitioner assesses

the child for school readiness. Which finding may be a factor in limiting school readiness for this

child?

a. Adherence to daily family routines and regular activities

b. Having two older siblings who attend the same school

c. Parental concerns about bullying in the school

d. The child's ability to recognize four different colors

ANS: C

Parental expectation is the strongest predictor of school success in children. Parents who are worried

about what may happen in school can transmit this anxiety to the child. Children who have a secure

family life with daily routines will do better in school. Having older siblings who attend school increases

success. Children at this age are expected to know four colors, so this is an indication of school readiness.

9. The primary care pediatric nurse practitioner is evaluating recurrent stomach pain in a school-age

child. The child's exam is normal. The nurse practitioner learns that the child reports pain most

evenings after school and refuses to participate in sports but does not have nausea or vomiting. The

child's grandmother recently had gallbladder surgery. Which action is correct?

a. Encourage the child to keep a log of pain, stool patterns, and dietary intake

b. Order radiologic studies and laboratory tests to rule out systemic causes

c. Reassure the child and encourage resuming sports when symptoms subside

d. Refer the child to a counselor to discuss anxiety about health problems

ANS: A

The PNP suspects a somatic disorder after a normal exam and should encourage the child to keep a food

or pain diary to help manage symptoms. The PNP should not "medicalize" the problem with tests. The

child should be encouraged to resume sports and participate in normal activities. If the symptoms persist,

referral for counseling is warranted.

10. During a well child exam of a school-age child, the primary care pediatric nurse practitioner learns

that the child has been having angry episodes at school. The nurse practitioner observes the child to

appear withdrawn and sad. Which action is appropriate?

a. Ask the child and the parent about stressors at home

b. Make a referral to a child behavioral specialist

c. Provide information about anger management

d. Suggest consideration of a different classroom

ANS: A

School-age children are learning to manage emotions and need help to manage their feelings in acceptable

ways. A variety of stressors, including parental divorce, substance abuse, bullying in school, and early

responsibilities, can cause anxiety in the child, who may not manage these feelings well. Until the

underlying cause is better understood, management options cannot be determined, so referrals to

specialists, information about anger management, or moving to a different classroom may not be

indicated.

11. The primary care pediatric nurse practitioner is examining a school-age child who complains of

frequent stomach pain and headaches. The parent reports that the child misses several days of school

each month. The child has a normal exam. Before proceeding with further diagnostic tests, what will

the nurse practitioner initially ask the parent?

a. About the timing of the symptoms each day and during the week

b. How well the child performs in school and in extracurricular activities

c. If the parent feels a strong need to protect the child from problems

d. Whether there are any unusual stressors or circumstances at home

ANS: A

Children with school refusal or school phobia often have symptoms that gradually improve as the day

progresses and often disappear on weekends. The PNP should ask about the frequency and duration of the

symptoms to evaluate this pattern. The other options are important questions when management of school

phobia has begun as a way of understanding underlying causes for the reluctance to go to school.

12. The parent of a 5-year-old child who has just begun kindergarten expresses concern that the child will

have difficulty adjusting to the birth of a sibling. What will the primary care pediatric nurse

practitioner recommend?

a. Allowing the child opportunities to discuss feelings about the baby

b. Giving the child specific baby care tasks to promote sibling bonding

c. Having snack time with the child each day to discuss the school day

d. Providing reassurance that the sibling will not replace the child

ANS: C

Family routines provide support to children and help them self-regulate, especially during times of

change, and serve as a buffer during times of change and transition. This child has two major changes, so

setting aside regular time to spend with the child will help stabilize these changes. The other options may

be useful as well, but routines and special activities are most important.

1. The primary care pediatric nurse practitioner is examining a 15-year-old female who reports having

her first period at age 13. She states that she has had five periods in the last year, with the last one 2

months prior. She participates in basketball at school. Which action is correct?

a. Perform biometric screening to determine lean body mass.

b. Prescribe oral contraceptives pills to regulate her periods.

c. Reassure her that this is perfectly normal at her age.

d. Refer her to an endocrinologist for hormonal evaluation.

ANS: A

Although it can take 18 to 24 months for adolescents to establish regulatory cycles, periods can also be

affected by athletic activity that decreases body fat. The PNP should assess the percentage of lean body

mass, which should be 75% or less to maintain regular ovulatory cycles. OCPs are useful for regulating

periods if this persists and other causes are ruled out. It is not necessary to refer her to an endocrinologist

unless problems persist in spite of standard management.

2. The parent of a 14-year-old child tells the primary care pediatric nurse practitioner that the child skips

classes frequently in spite of various disciplinary measures, such as grounding and extra homework

and is earning Cs and Ds in most classes. What will the nurse practitioner recommend?

a. Counseling for emotional problems

b. Development of an Individual Education Plan

c. Evaluation for possible learning disorders

d. Referral for a behavioral disorder

ANS: C

Frequent school absenteeism, class skipping, and other types of school avoidance may indicate a problem

with cognitive ability and should be assessed. When cognitive disorders are ruled out, other issues, such

as behavioral and emotional problems may be considered. IEPs are used for children who have identified

special physiological or cognitive needs and may be useful if a cognitive disorder is identified.

3. The primary care pediatric nurse practitioner is performing a well child exam on a 12-year-old female

who has achieved early sexual maturation. The mother reports that she spends more time with her

older sister's friends instead of her own classmates. What will the nurse practitioner tell this parent?

a. Early-maturing girls need to identify with older adolescents to feel a sense of belonging.

b. Girls who join an older group of peers may become sexually active at an earlier age.

c. Spending time with older adolescents indicates a healthy adjustment to her maturing body.

d. The association with older adolescents will help her daughter to gain social maturity.

ANS: B

While it is true that early maturing females may join an older group of peers to feel that they fit in, the

ones who do put themselves at risk for risky behaviors, including sexual activity. Although many teens

feel awkward when they mature at different rates than their peers, joining a group of older peers

demonstrates a poor adjustment and does not promote social maturity.

4. The primary care pediatric nurse practitioner is performing a well child assessment on a 13-year-old

female whose mother asks when her daughter's periods may start. Which information will the nurse

practitioner use to help estimate the onset of periods?

a. The age of the mother's menarche

b. The patient's age at thelarche

c. When adrenarche occurred

d. Whether linear growth has stopped

ANS: B

Thelarche, or the development of breast budding, generally precedes menarche by 2.5 years, so this

should be determined when attempting to predict this milestone. The age of the mother at menarche is not

a reliable indicator. Adrenarche is related to adrenal and not gonadal development and is less valid than

other secondary sex characteristics in assessing sexual maturation. Rapid linear growth usually begins

after thelarche and peaks about a year later but is not used to predict menarche.

5. The mother of a 15-year-old adolescent female tells the primary care pediatric nurse practitioner that

her daughter has extreme mood swings prior to her periods, which the adolescent vehemently denies.

When asked if she notices anything different just before her periods, the adolescent points to her

mother and says, "She gets really hard to live with." This demonstrates which characteristic of

adolescent thinking?

a. Apparent hypocrisy

b. Imaginary audience

c. Overthinking

d. Personal fable

ANS: A

Apparent hypocrisy is the notion that rules apply differently to adolescents than to others. The adolescent

who chalks up the conflict with her mother related to her premenstrual mood swings does not see her own

role in the conflict. Imaginary audience is the perception that everyone is thinking about them. Personal

fable is the idea that they are special. Overthinking involves making things more complicated than they

need to be.

6. During a well child assessment of a 13-year-old male, the primary care pediatric nurse practitioner

notes small testicles and pubic and axillary hair. To further evaluate these findings, the nurse

practitioner will ask the patient about

a. alcohol and tobacco use.

b. changes in voice.

c. increase in height and weight.

d. participation in sports.

ANS: D

The initial sign of puberty in males is testicular enlargement. If this does not precede other changes, the

PNP should consider whether the boy is taking exogenous anabolic steroids, common among those who

wish to improve athletic ability. These findings are not concerning for alcohol or tobacco use. Voice

changes and rapid growth may occur with pubic hair development, but the primary concern is anabolic

steroid use.

7. The parent of an adolescent reports noting cutting marks on the teen's arms and asks the primary care

pediatric nurse practitioner what it means. What will the nurse practitioner tell this parent?

a. Cutting is a way of dealing with emotional distress.

b. It is a method of fitting in with other adolescents.

c. The behavior is common and will usually stop.

d. This type of behavior is a type of suicide attempt.

ANS: A

Self-injurious behavior (SIB) is used as a coping strategy to relieve distress, anger, and stress. It is not

commonly done among adolescents and is not a way of fitting in with a peer group. Because it indicates

underlying distress, adolescents must get help identifying these causes. Many have a history of physical,

sexual, or emotional abuse. Although individuals who engage in SIB are more likely to attempt suicide in

the future, the act itself is not a suicide attempt.

8. The parent of a 14-year-old child tells the primary care pediatric nurse practitioner that the adolescent

has expressed a desire to be a vegetarian, is refusing all meat served at home, and wants the family to

eat vegetarian meals. What will the nurse practitioner tell the parent?

a. Do not allow a vegetarian diet in order to maintain appropriate limits for the adolescent.

b. Provide vegetarian options for the adolescent that preserve adequate nutrition and protein intake.

c. Suggest that the adolescent prepare appropriate vegetarian dishes to complement family meals.

d. Tell the adolescent that a vegetarian diet may be considered in adulthood but not while living at

home.

ANS: C

Early adolescents begin to develop their own value system and may try value systems other than the one

that they have learned from their family, which is a normal part of establishing personal identity. The

parent may allow expression of other values, such as a vegetarian diet, as long as nutritional needs are met

and the adolescent takes responsibility for preparing the food.

9. The primary care pediatric nurse practitioner is performing an exam on an adolescent male who asks

about sexual identity because of concern that a friend is worried about being gay. Which response will

the nurse practitioner make in this situation?

a. Provide the teen with a questionnaire to gain information about his sexuality.

b. Remind the adolescent that mandatory reporting requires disclosure to parents.

c. Suggest that the adolescent discuss sexual concerns with his parents.

d. Tell the adolescent that, unless he is at risk, what he says will be confidential.

ANS: D

Adolescents should be encouraged to divulge information about their sexuality to providers by assuring

them that confidentiality will be maintained unless the health of the child or others is at risk. The

adolescent may be trying to ask questions about himself in a manner that doesn't implicate his own

sexuality, so the PNP should attempt to gain his confidence. Questionnaires may be useful when

collecting information, but this adolescent has already begun a discussion about the topic. An adolescent

who is concerned about being gay may not be ready to come out to his parents.

10. The primary care pediatric nurse practitioner is performing a well child exam on a 17-year-old female

whose mother is present during the history. The mother expresses concern that her daughter wishes to

have an eyebrow piercing and states that she is opposed to the idea. What will the nurse practitioner

do?

a. Provide information about piercings and encourage continued discussion.

b. Remind the adolescent that her mother is responsible for her health.

c. State that piercings are relatively harmless and are an expression of individuality.

d. Suggest that she wait until she is 18 years old and can make her own decisions.

ANS: A

Adolescents who pierce their noses or have strange haircuts may be irritating to parents, but these are

ways of expressing individuality and help them to achieve psychosocial milestones. The fact that the teen

and her mother are discussing this is a good sign that the adolescent isn't in complete rebellion. The PNP

should provide accurate health information and encourage continued dialogue. Although it is true that

piercings are relatively harmless, the PNP shouldn't "side" with the teen during an open discussion or tell

the teen that the mother is "in charge."

11. The mother of a 16-year-old male was recently divorced after several years of an abusive relationship

and tells the primary care pediatric nurse practitioner that the adolescent has begun skipping school

and hanging out with friends at the local shopping mall. When she confronts her child, he responds by

saying that he hates her. What will the nurse practitioner tell this mother?

a. Adolescence is marked by an inability to comprehend complex situations.

b. Adolescence is typically marked by tempestuous and transient episodes.

c. Adolescents normally have extreme, disruptive conflicts with parents.

d. Adolescents often need counseling to help them cope with life events.

ANS: D

Adolescent brains respond differently to toxic stress, so counseling is indicated to help them manage

serious events, such as family abuse and divorce. Early adolescents have concrete thinking, but the formal

operational thinking occurs later. "Storm and stress" are not the norm in adolescence nor are disruptive

periods of conflict.

12. The parent of a 16-year-old tells the primary care pediatric nurse practitioner that the teen was

recently caught smoking an electronic cigarette (e-cigarette). What will the nurse practitioner tell this

parent?

a. E-cigarette use may be a risk factor for later substance abuse.

b. Experimentation with e-cigarettes does not lead to future tobacco use.

c. Most teens who experiment with tobacco usually do not become addicted.

d. This form of nicotine ingestion is safer than regular cigarettes.

ANS: A

Although many adolescents consider e-cigarettes to be a safe form of tobacco use, increasing evidence

indicates that their use may be a significant risk factor for later marijuana and substance abuse. The risk

of dependence and addiction is the same for e-cigarettes and other cigarettes, since both use nicotine.

Only 41% of teens try tobacco

80% of older adolescents do not smoke.

1. The primary care pediatric nurse practitioner sees a 17-year-old client who quit smoking almost a year

prior but who reports having renewed cravings when around friends who smoke. Using knowledge of

the maintenance stage of change, the primary care pediatric nurse practitioner will

a. go over with the adolescent about the health risks associated with smoking.

b. recommend avoiding friends who smoke and making new friends.

c. remind the adolescent about the struggles associated with quitting smoking.

d. suggest that the teen consider taking up a sport or other physical activity.

ANS: D

During the maintenance stage, the PNP should help the client with plans to prevent relapse, including

establishing new behaviors as long-term changes. Adding a sport can help the client enjoy the benefits of

not smoking, while substituting one activity for another. The adolescent already knows about the health

risks and the difficulties of quitting. Suggesting giving up friends may be seen as another hardship and is

not part of the maintenance stage.

2. The pediatric nurse practitioner provides primary care for a special needs infant whose parent takes an

active role in the infant's care. The parent has a high school diploma and asks many questions about

her infant's treatments. Which approach will the nurse practitioner take to ensure health literacy for

this parent?

a. Ask the parent to read back all information given.

b. Encourage the parent to ask questions when confused.

c. Provide written materials presented at an 8th grade level.

d. Reinforce written information with verbal instructions.

ANS: A

The PNP should take a precautionary approach and assume that all clients will have health literacy

limitations. Assessment of health literacy can be done by asking clients to "read back" the information the

provider gives. While encouraging questions is important, parents may not want to admit that they are

confused and may not ask questions. Written materials should be given at a 5th grade level. Parents who

do not understand medical terms will not understand written or verbal information.

3. The primary care pediatric nurse practitioner is counseling an obese adolescent whose parents both

have type 2 diabetes mellitus. Which health behavior prediction model is useful when the nurse

practitioner discusses lifestyle changes with this client?

a. Behavioral change model

b. Health belief model

c. Health promotion model

d. Transtheoretical model

ANS: B

The health belief model explains behavior used to prevent disease rather than to promote health. Clients

need to believe that they are vulnerable to the disease, will have negative consequences if they are

affected, and that taking action will reduce the risk. The adolescent who believes that there is a risk of

diabetes may be willing to undertake lifestyle changes if taught that these can reduce the risk. The

behavioral change model is useful for changing behaviors to promote health. The health promotion model

has a focus on health promotion and not disease promotion. The transtheoretical model identifies the

stages of change.

4. The primary care pediatric nurse practitioner is assessing the health literacy of the parent of a toddler.

Which tool will the nurse practitioner use to estimate reading level?

a. Flesch-Kincaid Readability Test

b. Gunning Fog Index

c. Number of children's books in the home

d. SMOG

ANS: D

The best tool to estimate reading level is the SMOG. The Gunning Fog Index and the Flesch-Kincaid

Readability Test are used as well but are not considered the best indices. The number of children's books

in the home can be asked as a screen but is not a reliable estimate of true literacy.

5. The primary care pediatric nurse practitioner examines an infant whose weight is below the 3rd

percentile and whose mother does not comply with the feeding regimen. When attempting to enlist the

help of the infant's grandmother, the grandmother says, "My daughter was like this when she was a

baby and she turned out all right." Which approach will the nurse practitioner take to improve the

outcome for this infant?

a. Ask the grandmother about her daughter's health during childhood.

b. Explain that the condition is potentially serious if not treated.

c. Give the grandmother and mother information about normal growth.

d. Refer the family to a social worker to investigate possible neglect.

ANS: A

This family has an altered perception of health and health behaviors based on their own experience with

the condition. The grandmother considers this infant's weight similar to her own daughter's and assumes

that things will resolve. The PNP should evaluate the mother's health to see if any problems occurred.

Giving more information or trying to alarm the family will not be effective if their perception is that

everything is normal. It is not necessary to refer to a social worker unless the condition persists.

6. An adolescent who is overweight expresses a desire to lose weight in order to participate in sports but

tells the primary care pediatric nurse practitioner that he doesn't want to give up sweets and soft

drinks because he enjoys them too much. Which stage of change does this represent?

a. Action

b. Contemplation

c. Precontemplation

d. Preparation

ANS: B

The contemplation stage occurs when the individual is aware that a problem exists and struggles with the

costs and energy required for change. This client knows what to do but doesn't want to give up the

enjoyment of certain treats. The action phase occurs when behaviors to eliminate the problem occur. The

precontemplation stage occurs when the individual wishes to change but is resistant to change without

clear reason for being so. The preparation stage occurs when the individual makes small behavior

changes, such as giving up sweetened soda first, in preparation for commitment to the actual plan.

7. The primary care pediatric nurse practitioner provides patient teaching for children newly diagnosed

with irritable bowel syndrome (IBS). At which stage of development will children be able to

understand the link between stress and the symptoms of the disease?

a. Concrete-operational stage

b. Formal-operational stage

c. Pre-conceptual stage

d. Sensorimotor stage

ANS: B

In the formal-operational stage, children can understand how the body works and how illness may be

related to the body and the environment. It is late in this stage when children can conceptualize the mind

and body interactions of illness. In the concrete-operational stage, children do not yet distinguish between

the body and the mind. The pre-conceptual stage is characterized by a perception that people must be near

the cause of an illness. The sensorimotor stage, causes are not considered.

8. The primary care pediatric nurse practitioner is counseling an obese 16-year-old client about weight

management. The adolescent says, "I know I need to lose weight, but I don't want to give up all my

favorite foods." When using motivational interviewing techniques, how will the nurse practitioner

respond?

a. "Do you think there are any foods you could limit or do without for a while?"

b. "I hear you telling me that you really don't have a desire to lose weight."

c. "If you can't give up these foods, you won't see the benefits of weight loss."

d. "In the long run, the sacrifices you make today will improve your health."

ANS: A

Motivational interviewing (MI) uses persuasion, rather than coercion, drawing out the individual's

motivation for change in order to build a collaborative partnership between the client and the counselor.

This adolescent has indicated an understanding of the need to lose weight but doesn't want to give up

favorite foods. The PNP asks if there are any foods, allowing the client to choose possible options. In

answer B, the PNP does not acknowledge the client's motivations. In the other two answers, the PNP

doesn't allow choices.

9. The primary care pediatric nurse practitioner is working with a 12-year-old female who has poor

diabetes control. The child tells the nurse practitioner that the parent forgets to remind her to check

her blood sugars. Which action is correct?

a. Assess the parent's knowledge about diabetes management.

b. Help the child develop a strategy to remember without parental prompts.

c. Refer to a social worker to help the family overcome obstacles to care.

d. Remind the child's parent about the importance of good diabetes control.

ANS: B

When adherence is a concern, the PNP should work with the family or the child to develop intervention

strategies appropriate to the skills, needs, and desires of the parents and children. A 12-year-old child is

old enough to take responsibility for checking blood glucose, so the PNP can work with her. The other

options may be used if the situation does not improve.

10. The primary care pediatric nurse practitioner is performing a focused problem assessment on a child

who has asthma and learns that one of the child's parents smokes around the child in spite of being

advised against this. The nurse practitioner recognizes this as a possible alteration in which functional

health pattern?

a. Cognitive-perceptual

b. Health perception

c. Role-relationship

d. Values-beliefs

ANS: B

The health perception-health management pattern describes client perceptions of personal health and

health behaviors and includes the belief that there is a relationship between health status and health

practices. The cognitive-perceptual pattern describes sensory-perceptual and cognition patterns. The role-

relationship pattern describes patterns of roles and responsibilities of the client and other family members.

The values-beliefs pattern identifies the beliefs that influence daily living, decision making, and meaning

of life.

11. The parent of a newborn has quit smoking cigarettes within the past month and reports feeling fidgety.

Using a "reframing" technique, how will the primary care pediatric nurse practitioner respond?

a. Explore ways that the parent can use this extra energy to do things for the baby.

b. Remind the parent that this is a normal, temporary part of nicotine withdrawal.

c. Suggest that the parent take up exercise to enjoy the benefits of not smoking.

d. Tell the parent that, over time, these symptoms of withdrawal will subside.

ANS: A

Reframing is a counseling strategy that uses the context of an experience to give it a new meaning,

creating a frame of reference that focuses on a desired outcome instead of the current problem. The

withdrawal symptoms associated with tobacco cessation are uncomfortable, but the PNP can suggest

channeling this nervous energy into positive action for the baby. Telling the parent that the symptoms of

withdrawal are temporary or normal does not reframe the perception. Suggesting exercise may be

beneficial, but does not reframe the situation.

12. The primary care pediatric nurse practitioner is counseling a school-age child about asthma

management strategies. The child states that it is "too much trouble" to remember to use an inhaled

corticosteroid medication twice daily and reports feeling fine, in spite of exhibiting expiratory

wheezes. Which action uses the health belief and self-efficacy model to teach this child about asthma

management?

a. Asking the child to try to use the inhaler at least once daily

b. Discussing whether the child wants to participate in athletics

c. Obtaining pre- and post-treatment spirometry testing

d. Providing written information about inhaled corticosteroids

ANS: C

In the health belief model, clients need to believe that taking some action will reduce the risk of

symptoms and that the benefits of the action will outweigh the costs or effort. Demonstrating pre- and

post-treatment spirometry measures can help the child see that symptoms are reversible. Asking the child

to make one change may be part of the transtheoretical model, in which small behavior changes may

precede commitment to the actual plan. Discussing athletics may be useful when using the health

promotion model to encourage the client to participate in behaviors that will promote healthy activities,

such as sports. Providing written information is not part of any of the health behavior models.

1. 1. The primary care pediatric nurse practitioner is examining a newborn who is

breastfeeding and notes the presence of an ankyloglossia. What will the nurse practitioner

do next?

a. a. Ask the mother if the infant has any feeding difficulties.

b. b. Refer the infant for a possible frenulectomy.

c. c. Schedule an appointment with a lactation consultant.

d. d. Suggest that the mother feed breast milk by bottle.

ANS: A

Infants with ankyloglossia may have difficulty feeding if the tongue does not extend well. The

PNP should first assess feeding difficulties and then may refer for a lactation consultant or

consider a frenulectomy.

1. 2. The mother of a 2-month-old infant tells the primary care pediatric nurse

practitioner that she is afraid her breast milk is "drying up" because her baby never seems

satisfied and wants to nurse all the time. Which action is correct?

a. a. Recommend pumping her breasts after feedings.

b. b. Refer the mother to a lactation consultant.

c. c. Suggest supplementation with formula.

d. d. Weigh the infant to assess for a growth spurt.

ANS: D

Infants have growth spurts about every 3 to 4 weeks that increase their breast milk needs. Until

the mother's milk supply catches up, the infant will act hungry and want to nurse more

frequently. The PNP should evaluate for this growth spurt and then instruct the mother to feed

her baby more often to increase her milk supply. Since the infant is hungry, the infant should

nurse. It is not necessary to refer for a lactation consultation or to supplement with formula.

1. 3. The primary care pediatric nurse practitioner is performing an assessment on a 1-

week-old newborn with a slightly elevated bilirubin who is breastfeeding well and who has

gained 30 grams in the past 24 hours. The infant is stooling and voiding well. The nurse

practitioner suspects breast milk jaundice. Which action is correct?

a. a. Order home phototherapy and closely monitor bilirubin levels.

b. b. Reassure the mother that the bilirubin level will drop in a few days.

c. c. Recheck the serum bilirubin and infant's weight in 24 hours.

d. d. Recommend that the mother pump her breast milk for a couple of days.

ANS: C

Infants with breast milk jaundice who are gaining weight and thriving should continue to

breastfeed and be monitored for the development of pathologic jaundice. It is not necessary to

order phototherapy or discontinue breastfeeding unless pathologic jaundice is present. The

bilirubin may remain elevated up to 3 months.