PNCB CPNP-PC Exam Questions

Correct answer: Affordable Care Act of 2010 (ACA)

Provisions in the ACA address coverage and access (including insurance benefits for children), prevention of insurance companies from limiting or denying coverage due to preexisting medical conditions, oral health infrastructure and surveillance, the dental health workforce, cost-sharing restrictions, public health grants, and a requirement to review dental provider reimbursement rates.

Correct answer: Neglect

Neglect is defined as "failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child's health, safety, and well-being are threatened with harm." 

Neglect is the most common form of child maltreatment in the US, and the consequences are lifelong, extending well into adulthood. Early recognition of child neglect is critical. The earlier neglect is experienced, the more likely the child will have negative consequences.

Recent literature has shown causal relationships between children experiencing adverse events in childhood and adult morbidities and chronic illness, such as heart disease, depression, and mental disorders. 

Correct answer: Ureteropelvic junction obstruction

The most common cause of abdominal masses in the newborn period is hydronephrosis, a significant dilation of one or both kidneys, likely caused by an obstruction of the ureteropelvic junction. If spontaneous resolution does not occur by 6 to 12 months of age, or if symptoms arise or persist, surgical repair may be necessary. The longer the obstruction lasts, the less likely renal function will return to normal.

Wilms tumors and urolithiasis, although possible, are extremely rare in newborns. With renal vein thrombosis, sudden onset of gross hematuria may be noted, along with a firm, flank mass.

Correct answer: Type II

Fractures of the long bones can produce permanent deformities in children if the fracture occurs through the growth plate. The outcomes depend on the location, type, age of the child, status of the blood supply to the physis, and the treatment of the fracture. The Salter-Harris classification is based on the mechanism of injury, the relationship of the fracture line to the layers of the physis, and the prognosis with respect to subsequent growth disturbance. There are five classifications that can be remembered by the mnemonic SALTR:

• Type I: Slipped; the fracture plane passes all the way through the growth plate, not involving bone, and the prognosis is good.
• Type II: Above; the fracture passes across most of the growth plate and up through the metaphysis, and the prognosis is good. Type II is by far the most common type of growth plate fracture, with up to 75% of cases falling into this category.
• Type III: Lower; the fracture plane passes some distance along the growth plate and down through the epiphysis. The prognosis is poorer as the proliferative and reserve zones are interrupted.
• Type IV: Through or transverse or together; the fracture plane passes directly through the metaphysis, growth plate and down through the epiphysis. There is a poor prognosis as the proliferative and reserve zones are interrupted.
• Type V: Ruined or rammed; crushing type injury that does not displace the growth plate but damages it by direct compression. These are rare and difficult to diagnose initially due to the lack of radiologic signs and are the worst prognosis, requiring anatomic reduction to prevent articular incongruity and osseous bridging across the physis.

Correct answer: Dextro-transposition of the great arteries (d-TGA)

The cyanotic heart diseases in children are as follows:

• Truncus arteriosus
• Transposition of the great arteries
• Tricuspid atresia
• Tetralogy of Fallot
• Total anomalous pulmonary venous return

All of these diseases begin with the letter 'T' and can be remembered easily in that regard. With d-TGA, there is incomplete separation and migration of the truncus arteriosus during fetal development. The aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle. The aorta then receives the deoxygenated systemic venous blood and returns it to the systemic arteries, while the pulmonary artery receives the oxygenated pulmonary venous blood and returns it to the pulmonary circulation. Cyanosis is evident immediately after birth (within 1 hour to 1 day). Management involves referral to pediatric cardiology, and arterial switch surgery is usually performed in the first few days of life if possible.

Correct answer: Remove the information or document the dispute in the patient's record

Providers should use the diagnosis that best guides understanding of etiology and management of the patient. However, patients have the right to request removal or correction of any erroneous information documented in their electronic health record. If their request is denied, the dispute should be documented in the record by the nurse practitioner.

Seeking independent corroboration could constitute a violation of the patient's rights to privacy. The medical record can be changed when requested by the patient and should not be shared unless the patient authorizes it. The patient has the right to his medical records at any time and may request a change or removal of any incorrect or inaccurate information, and if erroneous, the information should be corrected.

Correct answer: Weight loss: common 

First-line medications for uncomplicated ADHD are the stimulants methylphenidate, and amphetamine compounds, which are equally effective and available in a wide variety of forms. 

Common adverse effects of stimulants include decreased appetite, weight loss, anorexia, insomnia, GI upset (nausea, stomach-ache), and headache. With time, these symptoms often resolve but must be monitored closely. 

Concerns about the effect of stimulants on growth exist, but a recent study showed this medication is not associated with any difference in adult height or growth fluctuations.

Correct answer: A 28-month-old child with unilateral AOM without severe symptoms 

Many changes have been made in the treatment of AOM because of the increasing rate of antibiotic-resistant bacteria related to the injudicious use of antibiotics. Treatment is based on the child's age, illness severity, and the certainty of diagnosis. Treatment guidelines for AOM include:

• Any child with moderate/severe bulging TM with otorrhea not associated with AOM
• Any child with mild bulging of the TM with recent (<48 hours) onset pain (holding, tugging, etc.) or intensely erythematous TM
• Babies 6 months old or older with severe signs of AOM (fever >102.2F [39C], otalgia for at least 48 hours)
• Any child 6-23 months old with acute bilateral otitis media without severe symptoms, without fever, and sick less than 48 hours

In the following diagnoses of AOM, clinical discretion is used as to whether or not to treat. The pediatric nurse practitioner may provide a prescription or "watch and wait" with close follow-up:

• Young children with unilateral AOM without severe symptoms and fever <102.2F [39C]
• Children 24 months old or older without severe symptoms
• Children not treated and no improvement in 48 to 72 hours

Correct answer: Calcium and vitamin D supplementation with laboratory monitoring

Laboratory monitoring to confirm vitamin D deficiency, known as rickets, is initially warranted, along with supplementation of both calcium and vitamin D. Phosphorous supplementation may also be indicated. Maintenance therapy generally consists of lower doses of vitamin D.

Correct answer: Nitroglycerin administration

TOF is a combination of four anatomic cardiac defects resulting in right ventricular outflow tract obstruction. Dyspnea and cyanosis are common complications of this condition, and "tet spells" may ensue. For these hypercyanotic episodes, the infant should be cradled in a knee-chest position, soothed, and given oxygen and morphine sulfate subcutaneously until the spell subsides. The knee-chest maneuver increases systemic vascular resistance, decreases right-to-left shunting, and increases pulmonary blood flow, hopefully alleviating symptoms. Morphine is given to reduce hyperpnea (reduces ventilatory drive). In extreme cases, anesthesia and ventilation may be necessary.

Nitroglycerin is not indicated in the management of "tet spells."

Correct answer: Increased lymphocytes 

Aseptic meningitis is an inflammatory process of the meninges, most often characterized by acute signs and symptoms of meningeal irritation (headache, stiff neck, fever); mononuclear CSF pleocytosis (predominance of monocytes, macrophages, and/or lymphocytes); a normal or, less frequently, elevated CSF protein concentration; normal or, less often, low CSF glucose concentration; and no organisms demonstrable by Gram satin or bacterial cultures. 

The most common cause is viral (not bacterial) infection. Up to 90% of cases are caused by enteroviruses and arboviruses. Symptoms vary, but headache and fever are predominating symptoms. 

Again, CSF findings include increased lymphocytes, normal glucose concentration, normal or slightly elevated protein, and negative bacterial antigen tests.

Correct answer: Neuroblastoma

A neuroblastoma is a solid tumor of unknown etiology that originates from neural crest tissue along the craniospinal axis. The majority of neuroblastomas develop in the abdomen, usually in the adrenal gland. It is the most commonly diagnosed neoplasm in neonates (extracranial solid malignancy), with about 600 new cases diagnosed each year. 

On rare occasions, neuroblastomas may regress without therapy (generally only those in children younger than 1 year old). Management most often involves a multidisciplinary approach, including surgical removal followed by radiation therapy or chemotherapy. The prognosis depends on the age of the child and stage of the tumor.

Teratomas, Wilms tumors, and soft-tissue sarcoma are less frequent types of neonatal neoplasms.

Correct answer: Gonorrhea and chlamydia

PID is an infection of a woman's reproductive organs. It is most commonly caused by chlamydia and gonorrhea but can be caused by other infections. Vaginal flora, other aerobic and anaerobic organisms, GBS, genital mycoplasma, and gram-negative bacteria are also implicated.

The CDC recommends presumptive treatment for sexually active young women if they experience pelvic or lower abdominal pain when no other cause of pain can be found. Women with PID should also be tested for HIV. 

Correct answer: Competition

Competition involves wanting to get your way no matter how it affects the other party. It is commonly a win-lose situation but may work to resolve conflict in an emergent scenario when a quick decision is needed.

The other answer choices are different styles of conflict negotiation or management.

Correct answer: Medical home model

Health delivery has been restructured to emphasize a patient-centered medical home model that is based strongly on relationship-centered care between provider and patient. This personalized approach is at the core of integrative medicine and also addresses 21st-century pediatric health care concerns and needs. It is care that is preventive, predictive, and personalized. With the medical home model, the focus becomes less on "curing diseases" and more on promoting health and healing, as well as preventing future disease. In this model, medical care also becomes less fractured, resulting in decreased costs, thus leading to fewer outside referrals while providing more continuity of care.

Correct answer: Respiratory depression

Treatment of acute, moderate to severe pain in the pediatric population with the use of opioids poses the risk of causing side effects and should be used with extreme caution. A plan to prevent or mitigate them is essential. Common side effects include nausea and vomiting, pruritus, and constipation. 

More serious side effects include sedation, respiratory depression, and urinary retention, which should be treated aggressively.

Correct answer: African 

Sickle cell disease has an autosomal recessive inheritance pattern. It is found most often in people of African descent but is also detected among ethnic groups from the Mediterranean, the Caribbean, Central and South America, and India. Owing to migration, it now occurs worldwide. 

Sickle cell trait occurs in 8% of African Americans, and approximately 1 in 400 African Americans has sickle cell disease. This incidence exceeds that of most other serious genetic disorders in children, including cystic fibrosis and hemophilia. 

Correct answer: Type 1 diabetes mellitus (T1DM)

Type 1 diabetes mellitus (T1DM) is caused by autoimmune destruction of pancreatic beta cells thought to be triggered by a preceding environmental event in genetically susceptible individuals. The destroyed beta cells result in deficient insulin secretion, reduced biologic effectiveness, or both. Glucose levels then become elevated in the blood, and as a result, diabetes ensues. 

Polyuria and urinary incontinence can be the first symptoms of diabetes mellitus and are secondary to hyperglycemia and the osmotic diuresis resulting from chronic glycosuria. Urine testing (for glucose and ketones) and blood glucose measurements are generally sufficient to make the diagnosis.

Diagnostic studies for type 2 diabetes mellitus (T2DM) include urine testing and fasting blood sample for blood glucose, HbA_1c, lipid panel, TSH and free T₄, and insulin level. 

Children and adolescents with a BMI greater than the 85th percentile for age and gender (indicating obesity) should be screened for a number of comorbidities: prediabetes and type 2 diabetes, dyslipidemia with fasting lipid panel, AST and ALT levels, blood pressure measurement, obstructive sleep apnea, and PCOS, along with a free and total testosterone level.

Hypoglycemia requires a blood glucose measurement to diagnose, not urine testing. 

Correct answer: Kohlberg

Lawrence Kohlberg was a psychologist best known for his theories of moral development and socialization, emphasizing the process by which children learn the expectations and norms of their society and culture. Kohlberg's work primarily involved male participants. Kohlberg's stages include:

• Punishment avoidance and obedience
• Instrumental realistic orientation
• Good interpersonal relationships
• Maintaining social order
• Social contract and utilitarian orientation
• Universal principles

Freud is best known for his psychoanalytic theory in finding links between the conscious mind and the body through the unconscious mind. Descriptions of the id, ego, and superego were some of his most significant contributions.

Erikson described the stages of the individual throughout the lifespan, presenting problems within each stage that the individual seeks to master.

Piaget's theory of cognitive development is about how a child constructs a mental model of the world. According to Piaget, children are born with a very basic mental structure (genetically inherited and evolved) on which all subsequent learning and knowledge is based. He emphasized how children modify themselves depending on their environmental experiences and their stage-related competency level.  

Correct answer: Primary care

Rural care, as well as regional specialty care, can be provided via telemedicine. In addition, telemedicine allows patients to undergo rehab at home. In many cases, the families of these patients find it difficult to travel to a health care facility regardless of whether they are in an urban or rural setting. Examples of providing rehab services via telemedicine include conducting cognitive or psychiatric assessments, leading group therapy sessions, and providing patients with online resources. 

Primary care is generally best done in the traditional office visit via face-to-face context between patient and provider, especially as a new patient or if needing a thorough examination (i.e., school physical assessment).