PNCB CPNP-PC Exam Questions

Correct answer: Bed rest 

Treatment involves the following:

• Antibiotic therapy to eradicate GAS infection. Benzathine penicillin G therapy is the drug of choice unless there is an allergic history, then erythromycin is the drug of choice
• Anti-inflammatory therapy. Aspirin can be used for arthritis and carditis after the diagnosis is made. It is usually given only for 2 weeks and then tapered. Aspirin and steroids provide symptomatic relief. However, the risk of toxicity and/or Reye syndrome with aspirin use is always a concern and must be addressed with parents. There is an increasing use of NSAIDs to reduce the need for frequent dosing. Annual influenza immunization is critical for children on aspirin therapy.
• Chest radiographs, including ECG and echocardiography, as carditis generally develops within the first three weeks of symptoms

Bed rest is generally indicated only for children with congestive heart failure (CHF).

Correct answer: The ACA prevents private insurance companies from denying claims based on preexisting conditions

Patients previously denied private insurance coverage due to preexisting conditions can now access health insurance. Coverage varies from state to state, and the cost of coverage, copays, deductibles, and out-of-pocket limits will vary. However, the cap on annual and lifetime benefits has been removed, and young adults can stay on their parents' plan until they are 26 years old. 

If an individual has a preexisting condition, there must be 6 months (not 12) of no insurance before becoming eligible for health insurance. In addition, patients who have life-threatening conditions and have a life expectancy of fewer than 6 months (not 12) are eligible for hospice care without having to forgo potentially curative care.

Correct answer: Inspect school playgrounds

Primary prevention aims at preventing problems from occurring and maintaining wellness; it includes efforts that keep disease processes from becoming established by either eliminating the causes or increasing individual resistance to disease. Therefore, inspecting school playgrounds is an assessment approach used in primary prevention.

Testing is a secondary level of prevention, which aims at detecting problems early and promptly treating them. Report, monitor, and control of environmental hazards also qualifies as secondary prevention, while evaluating children with known exposure would be considered tertiary prevention as a treatment approach.

Correct answer: Affordable Care Act (ACA)

The ACA is the program that allows parents to provide insurance coverage for their children to the age of 26.

The ADA protects disabled Americans from discrimination because of their disability. COBRA allows Americans who change employment to continue health insurance coverage for a certain amount of time while they search for other employment. The Patient Protection Act is a part of the ACA.

Correct answer: The right to pain control

Included in the Patient's Bill of Rights is the right to pain control. The importance of effective pain management in children cannot be overemphasized. Both the American Academy of Pediatrics (AAP) and the American Pain Society (APS) reinforce the need for health care providers to treat pain and suffering in all infants, children, and adolescents. In addition, the Joint Commission recognizes pain now as "the fifth vital sign" and established standards requiring assessment of pain in all patients. All health care management plans should include the elimination of preventable pain and reduction of unpreventable pain.

Affordable healthcare and access to the latest medical technology are not included in the Patient's Bill of Rights. The right to sue is not directly included, although patients are entitled to submit complaints and/or grievances.

Correct answer: Side effects of a ketogenic diet usually involve abdominal pain and diarrhea 

The ketogenic diet is a valuable nonpharmacologic treatment option that should be considered for children with intractable epilepsy (particularly nonsurgical candidates), or as a first-line treatment for specific types of epilepsy (such as GLUT1 transporter deficiency). The diet is also considered when the side effects of anticonvulsant medications are intolerable, have failed, or when allergies preclude their administration. 

The ketogenic diet is a very rigid diet that allows for high ratios of fats to protein plus carbohydrates in order to transform the body's primary source of energy from glucose to ketones (ketosis). The traditional ketogenic diet ratio is 4:1, but more recently, lower ratios have been implemented successfully. 

The ideal child is between 2 and 5 years old because the desired steady state of ketosis is easier to maintain. Side effects usually involve abdominal pain and diarrhea (or constipation), vitamin and mineral deficiency, fatigue, slowed growth, and renal stones. This diet continues to show a higher degree of effectiveness than many medications.

Correct answer: Polymerase chain reaction (PCR)

As the incidence of varicella disease has decreased, many providers may be unfamiliar with the clinical presentation of the disease, especially in mild cases with few lesions. Diagnostic studies can play an important role in these instances. For both unvaccinated and vaccinated persons, the most reliable method of diagnosing VZV is the PCR (preferred) or DFA done from scrapings of a vesicle base during the first 3 to 4 days post-eruption.

Tzanck smears of lesions demonstrate multinucleated giant cells; however, these are not specific for VZV. 

A positive serologic test for varicella-zoster IgM antibody is also confirmatory. The virus can be cultured from vesicular fluid, CSF, and/or biopsy of tissue, but is less sensitive than that of the PCR. The WBC count is usually within normal limits. 

Correct answer: 16 to 18 weeks' gestation 

Echocardiography, or a sonogram of the heart, uses reflected sound waves to identify intracardiac structures and their motion. A fetal echo can diagnose CHD now as early as 16 to 18 weeks' gestation, and as early as 10 weeks' gestation if done via high-frequency transvaginal echocardiography. 

It can also diagnose arrhythmias and hemodynamic changes to the fetal heart.

Correct answer: Health belief model

Based on the health belief model, the nurse practitioner's role is to help patients understand unhealthy conditions, the effects if the patient does nothing, actions that can be taken to prevent problems, and the improved outcomes possible that can result from taking action. The nurse practitioner should strive to reinforce patients' beliefs that they can initiate coping behaviors that will benefit their health. Furthermore, the nurse practitioner should assist patients in mastering the skills to take effective action and provide resources when necessary.

Stages of change model, also called the transtheoretical model, describes the stages of change that individuals go through as they initiate behaviors to promote health. These stages include precontemplation, contemplation, preparation, action, and finally, maintenance. 

The health promotion model defines health as a positive dynamic state rather than simply the absence of disease, and focuses on health promotion rather than on disease prevention. The cognitive-perceptual factors include all the concepts in the health belief and self-efficacy models, locus of control notions, and individuals' definitions of health and their own health status estimates. 

Correct answer: Under GINA, health insurers cannot use a person's genetic information to set eligibility requirements, establish insurance premiums, or request genetic tests 

GINA was passed in 2008, with all aspects of the law in effect in November 2009. The intent of the legislation was to protect individuals from the misuse of genetic information in health insurance and employment and remove barriers to the use of genetic services.

Under GINA, employers cannot request, require, or purchase genetic information about an employee or family member, nor can they use genetic information in decisions about job hiring, firing, assignments, or promotions. GINA does not, however, provide protection when a condition is already diagnosed, even if said condition is genetic. Further, GINA does not apply to life, disability, or long-term insurers.

Protected genetic information includes family health history, carrier testing, prenatal genetic testing, predictive testing, and other assessments of genes, mutations, or chromosomal changes.

Correct answer: Hepatotoxicity can occur 

Valproate is an antiepileptic drug (AED) that acts by blocking sodium channels. Valproate is recommended as the first-line treatment of choice for most patients with initial onset JME. It is a broad spectrum antiseizure medication that controls all three seizure types in JME, and has the best established efficacy in JME. Although commonly used, valproate has a number of side effects, including weight gain, hair loss, tremors, GI symptoms, and hepatotoxicity.

Other AEDs may worsen seizures and should not be used in combination with valproate. Hypokalemia is not a side effect of valproate. Osteoporosis from vitamin D deficiency has been seen in patients taking valproate monotherapy. In addition, adolescent females taking valproate should be counseled on teratogenesis of the drug and the possibility of neural tube defects in a developing fetus.

Correct answer: Summarize key themes in the discussion 

When facilitating conflict resolution, the nurse practitioner should protect and respect each individual by focusing on the issue and not on individual personalities of the involved parties. Do not place blame. Both positive and negative feelings should be discussed openly to optimize the opportunity for both individuals to express all of their concerns. Summarize key themes in the discussion and assist in the creation of alternative solutions to the problem.

Correct answer: CPT code

The International Classification of Diseases, 10th Edition (ICD-10-CM), provides the lists of reimbursable diagnoses, while the Current Procedural Terminology (CPT) codes provide the therapeutic intervention codes. These are owned by the American Medical Association.

V-codes are modifiers that indicate the reason for a health care visit, but cannot be used for procedures. DRG, or Diagnosis Related Group, is a statistical system of classifying inpatient stays into groups for the purpose of payment.

Correct answer: CMV is a member of the herpesvirus family, and a majority of infected newborns are asymptomatic

CMV transmission to the infant occurs via the placenta, passage through an infected maternal genital tract, or postnatally by ingestion of CMV-positive human milk. Most perinatal CMV infections do not have long-term neurological effects on the fetus, but fetal damage is worse following an infection in the first half of pregnancy. About 0.5% to 1% of all live-born infants are infected in utero and excrete CMV at birth, and approximately 10% of these neonates will have severe systemic findings. As many as 90% of infected newborns are asymptomatic. 

The outcome of symptomatic congenital CMV infection is poor, with a 3% to 10% mortality rate, and up to 50% of children will have isolated sensorineural hearing loss. 

Proof of congenital infection requires obtaining specimens within 2 to 4 weeks (not 2 to 4 months) of birth. Viral isolation or a strongly positive test for serum IgM anti-CMV antibody, especially with a fourfold rise in titers, is considered diagnostic.

Correct answer: Amoxicillin (Amoxil, Wymox) divided every 12 hours for 10 days

A majority of the pneumonias in children under 4 years old are viral in nature. However, S. pneumoniae is the leading cause of bacterial (community-acquired) pneumonia in this age group. Although chest x-rays do not distinguish between viral and bacterial pneumonia, in this scenario the x-ray does show an infiltrate, so it is logical to treat with an antibiotic with antipneumoccal properties, such as high-dose amoxicillin, as bacterial pneumonia is suspected.

If C. pneumonia or M. pneumonia (community-acquired) is suspected, azithromycin is the appropriate choice. Erythromycin is reserved for a 2- to 3-month-old with suspected chlamydia, while Tamiflu is indicated in children with influenza.

Correct answer: Gender expression

The term "gender expression" refers to the outward expression of maleness or femaleness and does not necessarily correlate with sex assigned at birth or gender identity. It is characterized by the emergence of behaviors, attitudes, and feelings that are labeled as male, female, or neutral. This process begins at preschool age and continues into adulthood.

Gender identity is the internal perception of one's gender, or the knowledge of oneself as being male or female. Common identity labels include man, woman, gender queer, transgender, and more. Often confused with biological sex or sex assigned at birth, gender identity is self-determined. One's gender identity develops in stages according to age, stage, and cognitive development.

Gender assignment, or sex assigned at birth, generally occurs at birth based on genital appearance and is the keystone in many societies for future gender socialization (i.e., gender identity).

Gender or sexual orientation refers to an individual's feelings of sexual attraction and erotic potential, and one's attraction to the same or opposite sex.

Correct answer: You should prescribe appropriate contraceptives without parental consent 

Leading national healthcare associations endorse confidential health care for adolescents in accordance with state consent law regulations of minors. Providers who provide contraceptives and safer sex counseling to adolescents should assure the adolescent of the confidential nature of the relationship and provide opportunities for trust to develop. One-on-one time with teens is the standard of practice. It provides teens with regular opportunities to raise sexuality concerns and allows providers to give personalized information aimed at risk reduction.

Exceptions to the requirement to obtain parental consent prior to treating a minor include: contraceptives, abortion, drug and alcohol counseling, and prenatal care, among others. 

Adolescents should be counseled that abstinence is the most effective strategy for preventing pregnancy, STIs, and HIV/AIDS. However, it is a choice to become sexually active, and if that choice is made, the practitioner should counsel the adolescent on the responsibilities that may come with the decision to be sexually active. Open communication and respect for self and their partner will lead to choices that include protection from STIs and pregnancy.

Correct answer: Parental smoking

Some commonly implicated risk factors for the development of otitis media include:

• Genetic susceptibility
• Native Americans or Native Alaskans
• Non-Hispanic Caucasian
• Prematurity
• Younger than 2 years of age
• Unimmunized
• Day care attendance
• Parental smoking
• Male gender
• Environmental pollution exposure
• Feeding in a supine position/bottle-propping
• Breastfeeding for less than 6 months
• Autumn season

Correct answer: It is a screening instrument for substance abuse in the primary care setting 

The CRAFFT questionnaire is an appropriate screening instrument for substance abuse in the primary care setting; it is used with children under the age of 21, primarily among adolescent clinic patients. Positive responses to two or more items indicate a high likelihood for substance abuse and merits further evaluation and treatment.

Interviewing the adolescent with parents is a key strategy for obtaining information about etiologic factors and any recent changes in behavior, cognitive, emotion and overall health. However, it is essential to interview the adolescent alone as well at every visit to assess mental health and family issues (the patient needs to be alone when asking CRAFFT questions).

Correct answer: Bulimia 

Bulimia is an eating disorder characterized by bingeing and purging behaviors that occur at least once a week for at least 3 months. If a patient controls caloric intake through purging via vomiting, findings may include hypertrophic salivary glands, dental erosions secondary to gastric acid irritation, and abrasions or calluses on the dorsum of the hand secondary to manual induction of vomiting. This is referred to as Russell sign, which is cuts, calluses, and/or abrasions to knuckles from inducing vomiting, and is a common finding in patients with bulimia.