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Quiz Session - Attempts With Random Questions

PNCB CPNP-PC Exam Questions

Page 6 of 25

101.

Of the following clinical findings, which are NOT likely to be associated with child abuse? 

  • Bruising over bony prominences

  • Soft-tissue injuries

  • Skeletal fractures

  • Superficial burns

Correct answer: Bruising over bony prominences

The most common overall manifestations of child abuse are soft-tissue injuries (bruises, abrasions, and lacerations), followed by skeletal fractures (spiral fractures of long bones), and burns (superficial or deep).

Bony prominence bruising (knees, shins, elbows, forehead) is much more likely to occur in the child from playing and accidently falling, not from physical abuse. However, if multiple bruises, abrasions, and/or lacerations are found upon assessment in a pattern, shape, outline, or image of an object (handprint, cord, or buckle shapes), or are found in sites other than over bony prominences, then physical abuse should be considered.

102.

What is the gold standard for diagnosis of cystic fibrosis (CF)? 

  • Pilocarpine iontophoresis sweat test

  • One or more of the following clinical features: chronic sinopulmonary disease, GI and nutritional abnormalities, salt loss syndrome, chronic metabolic alkalosis, and/or male urogenital abnormalities

  • Newborn screening

  • Pulmonary function tests

Correct answer: Pilocarpine iontophoresis sweat test

CF is a multisystem genetic disorder manifested by chronic obstructive pulmonary disease (COPD), GI disturbances, and exocrine dysfunction. It is the most common autosomal-recessive disease. It affects the sodium-chloride transport gene and impairs the lungs, exocrine pancreas, and the vas deferens. 

The sweat test is considered the gold standard for diagnosing CF. The child must have one or more of the clinical features of CF before ordering the sweat test. Newborn screening (NBS) is now done in all 50 states that may measure immunoreactive trypsinogen (IRT) in the newborn's blood. If IRT is elevated, sweat testing is performed. Pulmonary function tests (PFTs) are used to follow the clinical course.

In addition, the diagnosis of CF can be made in patients with clinical features of the disease if:

  • Sweat chloride is greater than 60 mmol/L
  • The concentration of sweat chloride is in the intermediate range of 30 to 59 mmol/L for infants younger than 6 months old, or 40 to 59 mmol/L for older individuals
  • The child has two disease-causing CFTR mutations

103.

Medical care and screening with a pediatric primary care provider should be arranged for a child refugee within how many days of entry into the community?

  • 90 days

  • 60 days

  • 30 days

  • 120 days

Correct answer: 90 days

The domestic health assessment must take place within 90 days of arrival; however, within 30 days is ideal. If an applicant has a medical waiver for entry, health care should be arranged sooner than 90 days. The CDC Division of Global Migration and Quarantine is responsible for notifying state and local health departments of new arrivals who need medical treatment and/or follow-up.

The first primary care visit with a pediatric provider for immigrants, including refugees and international adoptees, should include a review of all medical records, a medical history, a developmental assessment, a psychosocial assessment, a complete physical exam and measurements, and tiered laboratory testing based on country of origin and risk factors.

104.

Which of the following statements regarding childhood type 1 and type 2 diabetes mellitus is FALSE?

  • Islet autoimmunity is uncommon in type 1 diabetes and present in type 2 diabetes

  • Type 1 diabetes can occur at any age, whereas type 2 frequently occurs when the child is 10 years old or older

  • Obesity is clinically found in over 90% of cases of type 2 diabetes in a child, whereas it is not related to type 1 diabetes

  • Insulin sensitivity is normal in type 1 diabetes and decreased in type 2 diabetes

Correct answer: Islet autoimmunity is uncommon in type 1 diabetes and present in type 2 diabetes

Type 1 diabetes is caused by the autoimmune destruction of pancreatic beta cells in the islet of Langerhans and thought to be triggered by a preceding environmental event in genetically susceptible individuals.

The prevalence of type 2 diabetes in children ages 10 to 19 years old is 0.46 per 1000 youth, increasing by approximately 30% over the period from 2001 to 2009.

Type 2 diabetes is strongly associated with environmental factors, such as obesity, sedentary lifestyles, and high-calorie, high-fat diets and is associated with decreased insulin sensitivity.

105.

At what age is a child generally able to first laugh responsively?

  • 4-6 months

  • 2-4 months

  • 6-8 months

  • 9-12 months

Correct answer: 4-6 months

The ability to laugh responsively is an expressive language milestone generally achieved between 4 and 6 months old. At 4 months, the infant will spontaneously smile to get your attention, and chuckle (not yet a full laugh) when you try to make him or her laugh. By 6 months, s/he laughs aloud, begins to imitate sounds, has one-syllable utterances, vocalizes to toys and mirror image, and their face brightens to their own sounds. 

Between 4 and 6 months, social skills are increasing, and verbal skills become more obvious. Babbling increases, the infant experiments using vowel sounds (vocal play), coos, laughs quietly, and experiments with variations in tone and pitch, such as deep belly laughs and low-pitched chuckles.

106.

The child with which of the following conditions is MOST LIKELY to also have an anxiety disorder?

  • Fragile X syndrome

  • Epilepsy

  • Rett Syndrome

  • Prader-Willi syndrome (PWS)

Correct answer: Fragile X syndrome

Fragile X syndrome is the most commonly diagnosed genetic cause of intellectual disability (ID) in males. It affects 1 in 4,000 males and 1 in 8,000 females. It is found in all racial and ethnic groups and is the result of an inheritable unstable DNA in the FMR1 gene of the X chromosome. 

It is a genetic condition that causes a range of developmental delays and behavioral problems, including speech and language delays, cognitive deficits, attention difficulty, anxiety disorder, aggression, and autism.

Anxiety may be present in the other conditions listed but is not as common as with Fragile X syndrome.

107.

A 14-year-old male comes into the pediatric clinic for complaints of a rash. This patient was told by his wrestling coach that he needs a note from the doctor that he has been seen and treated for the rash, or that it is not contagious. He states that the rash is slightly itchy, but otherwise does not bother him much. He noticed it about 2 weeks ago and says it began as a single, round pink patch that was scaly with a raised border, and states he has been using an over-the-counter antifungal cream in case it was ringworm, but has not noticed much improvement. He reports not eating anything new or different that he can remember in the past several weeks. The rash is located on his back and wraps around his trunk horizontally. It is in a "Christmas tree" pattern, following the dermatome skin lines. He reports he has not had a history of illness and is an otherwise healthy adolescent. He is up-to-date on his vaccinations.

What is the MOST likely diagnosis?

  • Pityriasis rosea

  • Psoriasis

  • Stevens-Johnson syndrome (SJS)

  • Angioedema

Correct answer: Pityriasis rosea

Pityriasis rosea (meaning rose-colored flaking) is a common, mild, self-limiting rash that begins with a herald spot or patch. This herald spot occurs in 70% of presentations, and it typically presents on the trunk, upper arm, neck, or thigh. This disease most commonly occurs in adolescents, and up to 98% of cases result in lifelong immunity. 

Although the etiology has not been established, it is thought that it may be caused by human herpesvirus 6 or 7 (HHV-6 or HHV-7). It is minimally contagious and generally resolves spontaneously in 6 to 12 weeks. Recurrence is common. Management involves calamine lotion, tepid baths with Aveeno, antihistamines, and emollients as needed for itching. Oral erythromycin may expedite the resolution of the eruption.

108.

Which of the following is the MOST common cardiac arrhythmia in children?

  • Supraventricular tachycardias (SVTs)

  • Atrial flutter

  • Complete AV block

  • Atrial fibrillation

Correct answer: Supraventricular tachycardias (SVTs)

Arrhythmias can manifest as a primary disorder or as a consequence of a cardiac or other systemic disorder. Sinus tachycardia is caused by predisposing factors that increase cardiac output, such as fever, anxiety, infection, pain, and dehydration. 

SVTs are the most common pathologic arrhythmia in children. Diagnosis is usually made by capturing it on an ECG or by Holter monitor. Management includes vagal maneuvers, IV adenosine, or if necessary, synchronized cardioversion. Long-term management involves prevention of recurrence with beta-blockade, or digoxin therapy (as long as the patient does not have Wolff-Parkinson-White syndrome).

The other answer choices are rare in the pediatric population.

109.

In educating the adolescent patient and family about human papillomavirus (HPV), prevention occurs on a variety of levels and in a variety of ways. Reducing the number of new cases best occurs before sexual debut by delaying initiation of sexual intercourse. This recommendation is a:

  • Primary prevention strategy

  • Secondary prevention strategy

  • Tertiary prevention strategy

  • Cross-sectional prevention strategy

Correct answer: Primary prevention strategy 

Preventative medicine includes primary, secondary, and tertiary preventative measures, such as counseling, immunization, prophylaxis, and screening. Primary prevention includes efforts that keep disease processes from becoming established by either eliminating the causes or increasing individual resistance to disease. These strategies seek to reduce the number of new cases of sexually transmitted infections (STIs) by preventing the onset of the disease, best done before the patient is involved in sexual intercourse. If the patient has plans of becoming sexually active, the use of condoms and partner communication skills should be promoted.

Secondary prevention seeks to reduce the numbers of existing cases through early detection and prompt treatment. This is done through well-woman care and STI screening (recommended every 6 months for those at risk). The focus of secondary prevention is on efforts that interrupt the disease process before it becomes symptomatic or halt the process at its incipient stage to prevent complications. 

Tertiary prevention seeks to minimize or limit the physical and social consequences of symptomatic disease. This includes minimizing perinatal complications, infant morbidity and mortality rates, and reducing the frequency of pelvic inflammatory disease (PID) and its complications.

110.

When assessing a child that has been vomiting due to a viral illness, what is one of the MOST useful clinical signs of hydration status?

  • Capillary refill time (CRT)

  • Skin turgor

  • Tachypnea

  • Mental status

Correct answer: Capillary refill time (CRT)

One of the most useful clinical signs of hydration is CRT. A normal CRT is less than 2 seconds. 

CRT, skin turgor, and tachypnea, considered together, are most helpful in determining dehydration.

111.

Which of the following statements about tics and tic disorders is CORRECT in pediatric medicine?

  • Stress reduction and relaxation techniques may lessen the severity of and/or decrease tics

  • Stimulants help to lessen tics caused by tic disorders

  • Typically, ADHD emerges after the onset of tics

  • Guanfacine (Intuniv) and extended-release clonidine (Kapvay) are ineffective for treatment of tics

Correct answer: Stress reduction and relaxation techniques may lessen the severity of and/or decrease tics 

Although behavior management modalities are not as powerful as medication in reducing symptoms in tic disorders, these treatments are clearly effective. Other behavior management techniques include recognizing premonitory urges and using competing responses to "discharge" a tic. Behavior management exclusive of medication should be used if the child is younger than 6 years old, symptoms are mild, and/or DSM criteria have not been met to diagnose the disorder.

Stimulants may exacerbate anxiety disorders and thus worsen tics. Children with ADHD are more likely to have tics, and over half of children with Tourette syndrome or chronic tic disorder have coexisting ADHD. Typically, ADHD emerges before the onset of tics (not after). Extended-release guanfacine (Intuniv) and extended-release clonidine (Kapvay) are approved for treatment of ADHD, although evidence of efficacy is not as strong as for stimulants or atomoxetine (Strattera).

112.

Which of the following statements is FALSE of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)?

  • The ICD-10-CM provides therapeutic intervention codes for billing purposes

  • ICD-10-CM is designed to represent the primary phenomena of concern to practitioners

  • ICD-10-CM is broad in nature

  • The ICD-10-CM listings are recognized by many insurance carriers for billing purposes and have become the "currency" for much health care delivery in the U.S.

Correct answer: The ICD-10-CM provides therapeutic intervention codes for billing purposes 

The ICD-10-CM provides the lists of reimbursable diagnoses, whereas the Current Procedural Terminology (CPT) codes provide the therapeutic intervention codes.

The other answer choices are correct.

113.

You are seeing a 12-year-old female for her annual school physical exam. She has no complaints and no significant medical history. She enjoys school. Her vital signs are normal; she is 58 inches tall and weighs 150 pounds. She is at the 97th percentile for weight and the 37th percentile for height. Her BMI is 31.3, placing her above the 95th percentile for her age.

What would your next step in management be at this time regarding this patient's weight?

  • Obtain a fasting glucose, insulin and lipid levels, total cholesterol, and liver function tests for further evaluation of health status

  • Recommend eliminating sugary foods and returning for a follow-up in 6 months

  • Submit a referral to a comprehensive weight-loss program

  • Recommend a VLCD (very low-calorie diet), increased fiber intake, and encourage incorporating moderate-to-vigorous activity into her daily routine

Correct answer: Obtain a fasting glucose, insulin and lipid levels, total cholesterol, and liver function tests for further evaluation of health status

For a BMI of greater than 95% or if BMI is greater than 85% and other risk factors are present, such as family history of diabetes or cardiovascular disease, labwork should be obtained to assess for diabetes, hyperlipidemia, and metabolic syndrome in children 4 years or older.

You should also create a healthy eating plan including family-focused education, registered dietician counseling, and increased daily moderate-to-vigorous activity.

114.

You are treating an adolescent female for bipolar disorder with lithium pharmacologic therapy. When is the BEST time to draw plasma levels of lithium during drug therapy?

  • 12 hours after the last dose

  • 24 hours after the last dose

  • 8 hours after the last dose

  • 48 hours after the last dose

Correct answer: 12 hours after the last dose 

The use of lithium must be carefully monitored. Data strongly supports long-term maintenance of lithium to prevent relapse of bipolar symptoms. A blood sample should be obtained 12 hours after the last dose taken for the most accurate plasma level of lithium during drug therapy. Doing so ensures that the steady-state concentration has been met.

115.

A 5-month-old female with a diagnosed congenital heart defect, poor feeding, hypotonia, constipation, and recurrent otitis media is referred to a geneticist for developmental delay. Chromosome analysis is consistent with DiGeorge syndrome. 

This syndrome is caused by a deletion in which chromosomal region?

  • 22q11

  • 7q11

  • 5p

  • 15q11

Correct answer: 22q11

The patient in this scenario is exhibiting characteristics of DiGeorge syndrome (also known as velocardiofacial syndrome), caused by a deletion in chromosome 22q11.

Deletions in chromosomes 7q11 are associated with Williams syndrome. Deletions in 5p are associated with Cri-du-Chat syndrome, and Prader-Willi syndrome is caused by a deletion in 15q11 (deletion in the paternally-derived chromosome 15).

116.

You are seeing a 5-year-old male patient with complaints of abdominal pain and associated nausea over the past 24 hours. His mother reports a rash on his legs and buttocks that started several days ago, which she attributes to poison ivy. Upon exam, the patient is afebrile with diffuse abdominal pain upon palpation. There is no rebound tenderness or guarding present. The patient has palpable purpura to the legs and buttocks, with diffuse joint tenderness and erythema.

Based on these findings, what diagnostic study is MOST appropriate to obtain?

  • Urinalysis

  • Complete blood count (CBC)

  • A Gram stain of the lesion 

  • MRI of abdomen/pelvis

Correct answer: Urinalysis

This patient has a diagnosis of Henoch-Schonlein purpura (HSP), a leukoclastic vasculitis of the small vessels most commonly seen in children between 4 and 6 years old. HSP is usually a self-limited immunoglobulin A (IgA)-mediated vasculitis representing the most common vasculitis of childhood. It affects vessels in the skin, joints, gastrointestinal tract, and kidneys. 

With inflammation of the small blood vessels, extravasation of blood occurs into local tissue, resulting in a maculopapular or urticarial rash for the first 24 hours, followed by purpura. The rash, along with nondestructive arthritis and GI manifestations occur in 80% of children. 

The diagnosis of HSP is based on clinical findings, but a urinalysis must be done to check for hematuria and proteinuria (a common sign of nephritis) to rule out renal involvement, which is commonly found in patients with this condition. It should be repeated on follow-up due to the risk of renal disease. In addition, a creatinine and BUN level should be drawn to evaluate renal function. 

Laboratory testing is not necessary but can be of use to the clinician in excluding the infectious or hematological causes of purpura if the patient does not present with classic features. A Gram stain of the lesion is not usually needed, but if completed, the results are negative. An MRI of the abdomen/pelvis is not necessary for the diagnosis of HSP. 

117.

Drug therapy for dyslipidemia in the 14-year-old patient should NOT be considered in which of the following scenarios?

  • LDL concentration of 150 mg/dL with history of chronic kidney disease, despite 6 months of therapy focused on diet and lifestyle changes

  • LDL concentration of 200 mg/dL, despite 6 months of therapy focused on diet and lifestyle changes

  • LDL concentration of 170 mg/dL and positive family history of heart disease, despite 6 months of therapy focused on diet and lifestyle changes

  • LDL concentration of 160 mg/dL with a history of smoking and an HDL level of 30, despite 6 months of therapy focused on diet and lifestyle changes

Correct answer: LDL concentration of 150 mg/dL with history of chronic kidney disease, despite six months of therapy focused on diet and lifestyle changes

Drug therapy should be considered in children 8 years old or older who, after 6 to 12 months of lifestyle changes (diet and exercise), continue to have the following:

  • LDL concentration greater than 190 mg/dL or
  • LDL concentration between 160 and 190 mg/dL and a positive family history of premature CHD or two risk factors

Risk factors include: 

  • Smoking
  • Hypertension
  • HDL level of less than 35 mg/dL
  • Obesity (greater than 30% more than ideal body weight)
  • Diabetes mellitus
  • Physical inactivity
  • Male sex
  • Renal disease, lupus, rheumatoid arthritis, HIV infection, nephritic syndrome, Kawasaki disease (without current aneurysms).

118.

When assessing a 3-day-old newborn, you know that normal initial weight loss may be UP TO:

  • 10% of birth weight

  • 8% of birth weight

  • 6% of birth weight

  • 12% of birth weight

Correct answer: 10% of birth weight

Normal newborn infants lose 5% to 10% of their birth weight in their first few days of life. Many breastfed infants have regained their birth weight by 2 weeks, while others may take up to 3 to 4 weeks before a return to birth weight is achieved. Subsequently, they gain weight at a steady pace of about 1 ounce per day for the first 2 or 3 months; they gain at half to two-thirds that rate for the next 3 months and half to two thirds again for the next 6 months. This results in a doubling of birthweight by the age of 4-6 months and a tripling at about 1 year.

Weight loss of greater than 10% requires close monitoring and may need further evaluation and treatment. 

119.

A 13-year-old male presents to your pediatric clinic with complaints of left-sided hip and groin pain for several weeks. Upon physical examination, you note limited abduction and extension of the left leg and external rotation of the thigh when the hip is in a flexed position. The patient's x-ray reveals slippage of the femoral epiphysis.

Which of the following is the MOST common historical finding associated with this condition?

  • Obesity

  • Leukocytosis

  • Diabetes mellitus

  • Hypothyroidism

Correct answer: Obesity

Slipped capital femoral epiphysis (SCFE) is a medical term referring to a Salter-Harris type I fracture through the proximal femoral physis, or growth plate, which results in slippage of the overlying end of the femur (epiphysis). Stress around the hip causes a shear force to be applied at the growth plate. 

Normally, the head of the femur, called the capital, should sit squarely on the femoral neck. Abnormal movement along the growth plate results in the slip. The femoral epiphysis remains in the acetabulum, while the metaphysis moves in an anterior direction with external rotation.

SCFE is the most common hip disorder in adolescence. SCFEs usually cause groin pain on the affected side, but sometimes cause knee or hip/thigh pain. It generally occurs in obese adolescents with delayed skeletal maturation. SCFEs often occur in obese adolescent males, especially young African American males. 

Symptoms include the gradual, progressive onset of thigh or knee pain with a painful limp and limited hip motion. Management involves a multidisciplinary approach, including consultation with an orthopedic surgeon for surgical repair.

120.

Intravenous prostaglandin E1 (PGE1) is given in the treatment of many congenital heart defects (CHD), including Tetralogy of Fallot, to:

  • Maintain or reopen the ductus arteriosus

  • Minimize excessive left to right shunting

  • Lower pulmonary vascular resistance

  • Close the foramen ovale

Correct answer: Maintain or reopen the ductus arteriosus 

In neonates with severe pulmonary obstruction, the ductus arteriosus is maintained or reopened with PGE1 while awaiting more definitive repair or palliation.

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