Practice questions Flashcards

Question

The process of professional privileging is BEST represented by which of the following? A. licensure by state board of nursing. B. authorization to provide specific services. C. certification by a national certifying body. D. verification of completion of an accredited graduate level educational program.

Answer 1

B. authorization to provide specific services.

Answer 2

A. fainting during exercise this is a specific cardiac sign that may be experienced prior to cardiac arrest.

Answer 3

B. coordination is initiated by the team currently providing pediatric care. Care coordination is vital for transition and per AAP guidelines, should be started by the PCP.

Answer 4

D. toxin exposure

Answer 5

A. AP and lateral decubitus chest radiograph Current guidelines recommend ap & lat cxr for children with CAP who are not improving with abx.

Answer 6

C. do you know what caused this bruise on your baby's scalp?

Answer 7

D. propranolol

Answer 8

D. venous pH greater than 7.30 pH must be closer to normal , serum ketones have cleared and the anion gap has closed before changing to Sq insulin

Answer 9

C. intussusception The classic exam finding of intussusception is a small sausage shaped right sided abdominal mass.

Answer 10

C. tidal volumes 6-8 ml/kg This child has pulmonary contusion. keep tidal volumes lower with hypercapnia to improve oxygenation and reduce ventilator induced lung injury.

Answer 11

A. hyponatremia and euvolemia

Answer 12

B. nutrition For burns > 30%, hypermetabolism occurs with gluconeogenesis, glycogenolysis, muscle breakdown, and bone loss.

Answer 13

B. indirect calorimetry measurement

Answer 14

A. 5-aminosalicylates ******

Answer 15

B. hyponatremic dehydration, sepsis, congenital adrenal hyperplasia When Na levels are low and K levels are elevated, CAH must be considered.

Answer 16

C. retroauricular erythema, edema and tenderness The mastoid is part of the temporal bone and the middle ear helps to facilitate mastoiditis

Answer 17

B. epidural hematoma arise from injury to the middle meningeal artery or from venous source. See initial lucid interval followed by rapid deterioration.

Answer 18

D. Vitamin K administration.

Answer 19

A. measles

Answer 20

B. arranging for imaging and prompt aspiration/biopsy. This is to differentiate between septic arthritis and osteomyelitis.

Answer 21

D. shiga toxin-producing Escherichia coli

Answer 22

B. potentially outgrow the problem within the first couple of years of life.

Answer 23

B. partial anomalous pulmonary venous return

Answer 24

D. to reduce the risk infective endocarditis, antibiotics need to be taken before certain dental procedures. Residual defects are not uncommon. dental work causes greatest risk for infective endocarditis.

Answer 25

A. anti-factor Xa levels

Answer 26

D. Lyme disease

Answer 27

A. temporary pacing Complete heart block from Lyme carditis

Answer 28

A. cardiac magnetic resonance imaging (CMRI) this is the gold standard ,

Answer 29

C. rehydrating gradually and initiating insulin infusion

Answer 30

A. initiate alprostadil prostaglandin should be started to re-establish systemic circulation by opening the PDA. Then echo can be done.

Answer 31

B. bradycardia with eye movement this is signs of muscle entrapment.

Answer 32

D. maternal group b streptococcus status

Answer 33

B. fatigued and at high risk for respiratory failure increased wob with PaO2 < 60mmHg & PaCO2 > 42mmHg indicates severe distress & pt is at high risk for resp failure. While he may need intubation, it should be avoided as much as possible.

Answer 34

C. non-invasive ventilation

Answer 35

C. Continuous inhaled SABA with ipratropium Pt now having severe asthma and so adding ipratropium, a anticholinergic when initial interventions are not successful It is a mucolytic and bronchodilator.

Answer 36

B. administering a fluid bolus to a child with hypovolemic shock

Answer 37

D. iron-deficiency anemia This is a microcytic anemia with low retic count and elevated red cell distribution width.

Answer 38

A. A 2 month old with bronchiolitis and frequent episodes of apnea

Answer 39

A. femur fracture Factor V leiden causes resistance to protein C & S resulting in a prothrombotic state. The concerning issue is related trauma to the limb and vascular injury with the fx. Pt is at risk for thrombosis & possible embolus.

Answer 40

B. penicillin prophylaxis until 5 years of age.

Answer 41

A. 1-2 weeks then again at 4-6 weeks.

Answer 42

A. bacterial tracehitis

Answer 43

D. evidence based practice this the practice of reviewing and analyzing current evidence on a topic by searching published literature. Once analyzed, it can be applied to specific clinical setting.

Answer 44

B. history

Answer 45

C. molecular genetic tests

Answer 46

C. obtain an abdominal ultrasound and a CBC To rule out appendicitis

Answer 47

D. Rocky mountain spotted fever

Answer 48

A. corticosteroids

Answer 49

B. Facial BiPap with IPAP of 12 and PEEP of 8 Management of a child with asthma includes bronchodilation and oxygenation. Wheezing occurs because of inflammation and narrowing of airways during an acute event. Patients with asthma can exhibit wheezing alone, wheezing with hypoxia or sometimes just hypoxia. This patient is experiencing hypoxia which indicates the need for oxygen and considers gas exchange occurring at the alveolar level. Introducing oxygen through narrowed airways may not be successful, so pressure is needed to improve gas exchange. BiPap or bilevel positive airway pressure assists in delivering oxygen with higher pressure during inhalation and lower pressure during exhalation.

Answer 50

B. Pneumonia Pneumonia, although not a common finding in children, can occur following a prolonged upper respiratory infection. A two-week history of fever and a cough followed by more invasive symptoms like wheezing and hypoxia can indicate pneumonia.

Answer 51

A. Mycoplasma

Answer 52

A. Intravenous Azithromycin Pneumonia can be caused by viral or bacterial etiologies. In school age children, the bacteria, mycoplasma is one of the leading causes. Mycoplasma is associated with low grade fever along with the prodrome of other symptoms as described in question A2. In teens, evidence indicates that illness can be more severe and require hospitalization including intensive care management. The patient in question A3 most likely has mycoplasma pneumonia and due to hypoxia and respiratory distress, they should be initially made NPO to limit respiratory symptoms, so intravenous administration would be best. Macrolide antibiotics include azithromycin, erythromycin, clarithromycin and others. Macrolides are recommended first line to treat mycoplasma pneumonia.

Answer 53

D. Lateral neck radiograph

Answer 54

A. Viral croup Croup, otherwise known as laryngotracheobronchitis, is a viral illness which affects the trachea, larynx and sometimes the lower airways including the bronchi of children, occurring mostly within the ages of 6 months and 6 years of life. Inflammation of the upper airways causes symptoms of “barky” cough and stridor. Croup is caused by viral processes, the most common being parainfluenza A and B, adenovirus, rhinovirus, RSV and others. Croup often occurs following a cold or upper respiratory infection and the progression of illness includes a peak time of symptoms. Clinical practice guidelines recommend one dose of dexamethasone of 0.6mg/kg. Other forms of corticosteroids have been used successfully, but dexamethasone has a longer half-life, resulting in longer effectiveness with one dose. Even though diagnostic studies are usually not necessary for children with croup that responds to supportive care or one dose of Decadron, a lateral neck film will illustrate the narrowed airway or “steeple sign” which is the classic finding.

Answer 55

D. Staphylococcus aureus, Group A streptococcus and Haemophilus influenzae Bacterial tracheitis can result from croup or develop independently with the same prodrome of illness. It is more serious than croup from a standpoint of concern for airway edema and requires treatment with antibiotics. Children with viral croup typically have no fever or low grade fever and children with bacterial tracheitis have higher fevers. The most common bacteria responsible for tracheitis include staphylococcus aureus, streptococcus species, Haemophilus influnezae and Moraxella catarrhalis.

Answer 56

A. Third generation cephalosporin like cefotaxime and vancomycin Treatment for bacterial tracheitis includes a third-generation cephalosporin like ceftriaxone or cefotaxime plus vancomycin or clindamycin, depending on the severity for broad spectrum gram + coverage.

Answer 57

B. AP (anterior-posterior) and left lateral decubitus A child who has been treated for pneumonia and symptoms either persist or worsen is at higher risk for development of a pleural effusion which is defined as an abnormal accumulation of fluid in the pleural space. An x-ray with an anterior-posterior view is best to indicate the presence of pneumonia and having the film taken in a lateral position allows layering of fluid, so assisting with diagnosis of a pleural effusion. Bedside ultrasound is another effective test to identify fluid in the pleural space.

Answer 58

B. Adenovirus Bronchiolitis can be caused by a variety of viral entities, with the most common etiology being RSV or Respiratory Syncytial virus. Other causes include adenovirus, Human Metapneumovirus and influenza.

Answer 59

C. Administer albuterol nebulizer treatment and obtain RVAP Children with asthma who have had previous intensive care admissions are at higher risk for critical illness when they develop symptoms. Wheezing without hypoxia usually responds to a bronchodilator, so beginning with albuterol is the NIH recommendation. Obtaining a respiratory viral panel will not change the course of illness but may assist in determining the potential for critical illness.

Answer 60

B. Pneumonia caused by streptococcus pneumoniae Bacterial causes of pneumonia in children vary based on age and symptoms. Higher fevers in children between the ages of 1 and 5 indicate organisms such as streptococcus pneumoniae and Haemophilus influenzae. For neonates, Group B streptococcus and gram -negative organisms like E.coli are more common.

Answer 61

B. Hypotension and decreased respiratory rate Magnesium sulfate is used for wheezing in children with asthma as it is believed to have a bronchodilator effect by blocking calcium channels in airway smooth muscles, leading to muscle relaxation. Recommended dosing includes one IV infusion of 25 – 50 mg/kg/dose. Side effects of magnesium include hypotension, muscle weakness which includes decreased respiratory rate and respiratory depression. Intravenous magnesium has a very short half-life, so administering one dose does not contribute to long term side effects.

Answer 62

B. Dexamethasone 0.6 mg/kg/dose The child’s symptoms and steeple sign indicated on the x-ray indicate croup, so treatment would follow recommendations of Dexamethasone 0.6mg/kg/dose administered orally, intravenously or subcutaneously once.

Answer 63

A. NPO, NP suction and increase high flow and oxygen

Answer 64

A. NPO, IV fluids of D5NS with 20meq KCL at maintenance A 3-week-old infant with bronchiolitis is at risk for developing severe disease. Based on anatomy and breathing mechanism, young infants are at higher risk for airway obstruction and in the case of RSV, obstruction from secretions. If the child is critically ill, NPO status for a short while is warranted. However, considering nutrition’s role in healing, adding calories to intake is imperative and should be started even through an NG tube as soon as possible. IV fluids should contain higher levels of sodium at maintenance rate.

Answer 65

B. IV ampicillin and chest tube placement for drainage of fluid Evidence-based recommendations for treating pneumonia inpatient include the use of penicillin based antibiotics. Pleural effusions can represent just fluid in the pleural space which can be easily drained with a chest tube placed at the bedside. If the fluid is loculated, meaning that fluid is trapped in pockets or by scar tissue and/or the presence of empyema, surgical intervention is needed. A VATS procedure (Video-assisted Thoracic Surgery) is the surgery of choice for this condition.

Answer 66

C. Pneumothorax

Answer 67

B. Short term observation in the hospital for additional signs of respiratory distress A spontaneous pneumothorax can occur for no underlying medical reason and often affects tall, thin young men, especially athletes. Air enters the pleural space, but will drain without intervention. Assessment and observation are the mainstays of management.

Answer 68

A. Trial on CPAP on the ventilator, monitor for spontaneous respiration and oxygenation and then extubate A child who receives sedation medications is at risk for depressed respiratory status as this child who received benzodiazepines for status epilepticus. There is no underlying respiratory disease, so weaning off the ventilator quickly should not be problematic. The best approach is to allow the child to breathe independently with some pressure support with the use of CPAP to be sure that he is awake and able to independently breathe, then extubate.

Answer 69

A. Change from volume control to pressure control and add pressure support Intubation of a child with asthma should be a last decision, but happens frequently, especially in hospitals and health areas where providers are not comfortable managing these children. Unfortunately, when providers without experience assess children with asthma, they are rightly concerned about breathing and choose intubation not realizing that first the endotracheal tube is another asthma trigger and once intubated the asthmatic lungs are not easy to manipulate. Due to inflammatory processes and obstructive nature of asthma, using volume ventilation can require increased pressures which will alarm on the ventilator BUT will also cause barotrauma and lung damage. Using pressure-controlled ventilation is a better option in which the provider can adjust the pressure. Adding pressure support, allows the patient to take independent breaths, but with some pressure added for ease of breathing and increased oxygenation.

Answer 70

B. Increase the PEEP and add pressure support Adding pressure support to synchronized ventilator settings adds depth to the breaths which are initiated by the patient. The pressure helps to further extend the alveoli resulting in improved gas exchange and lowered respiratory rate. PEEP, as previously described, improves oxygenation.

Answer 71

A. SIMV, rate 12, tidal volume 250, pressure support 5 Synchronized Intermittent Mandatory Ventilation (SIMV) is a form of mechanical ventilation which provides a supported mode of ventilation in many different situations. SIMV offers a mandatory breathing pattern based on setting a ventilator rate but allows the patient to initiate their own breaths. In a post-operative patient with healthy lungs, minimal ventilator settings will allow support, but comfort as the patient can breath independently.

Answer 72

D .Left lower lobe pneumonia and hyperinflation The x-ray for this patient indicates a 9 – 10 rib expansion when normal expansion should be no more than 7-8 on an anterior view x-ray. Hyperinflation can occur with asthma, when there is obstruction to air flow and also in the case of pneumonia when the inflammation and obstruction of the airways causes air-trapping.

Answer 73

B. Decrease the PEEP to 6 During mechanical ventilation, PEEP (Positive End Expiratory Pressure) expands alveoli and assists in increasing gas exchange to improve oxygenation. If a ventilated patient is hypoxic, increasing PEEP can help. As the patient in question 16 is improving with high oxygen saturations, decreasing the PEEP is the first intervention.

Answer 74

A. Botulism Botulism is caused by the botulinum toxin which results in serious illness for infants less than the age of 1. The illness is characterized by muscle weakness which can lead to paralysis and respiratory arrest. Botulism spores are found in honey and soil, however, sometimes the source cannot be identified. Initial symptoms include constipation, muscle weakness, weak cry with visible facial feature “drooping,” including eyelids (Ptosis). Rapid evaluation and treatment with Human Botulism Immune Globulin also known as BIG-IV and BabyBIG is the primary treatment.

Answer 75

B. Malaria Malaria is a parasitic infection that is transmitted from mosquitoes in some tropical areas/countries such as Africa. It is not contagious, but not unlikely for family members to be bitten by mosquitoes in same area. Malaria is a life-threatening illness characterized by fever, chills, headache, muscle aches and anemia. Malaria is diagnosed by blood smear, looking for parasites under microscope and antigen detection. It is preventable by taking medications prescribed prior to travel and treatable with specific anti-parasitics.

Answer 76

A. Obtain fungal cultures and start Amphotericin IV Patients who are immunocompromised as those receiving chemotherapy are at risk for opportunistic infections such as fungus. With febrile illness, when antibiotics are not effective it is important to repeat bacterial cultures but obtaining fungal cultures before or at the same time is essential. Treating for fungal infection while waiting for culture results is also warranted.

Answer 77

C. Elevated protein Viral illness can lead to viral meningitis, although rare. Neurological symptoms, including headache, weakness and gait disturbances can be included. Cerebral spinal fluid results include slightly elevated WBC and protein levels.

Answer 78

C. Leukemia Children with Down Syndrome are at higher risk for developing both acute lymphocytic and myeloid leukemias. This child has symptoms of viral illness, but also petechiae and lymphadenopathy raise increased concern for something more involved.

Answer 79

B. 3-year-old undergoing induction chemotherapy who is suspected of having a central line infection Cefipime is a 4th generation cephalosporin used to treat both gram positive and gram negative organisms with broad anti-bacterial coverage. It is recommended for use at high doses for children who are receiving chemotherapy and immunocompromised.

Answer 80

A. 5-year-old with staphylococcus skin infection Second generation cephalosporins include Cefuroxime, Cefprozil and Cefoxitin. They are used to treat a variety of infections including bone, joint, skin and soft tissue, respiratory and urinary tract. The patient with a staph skin infection is the most appropriate for this treatment. The other descriptions may have additional considerations to determine prior to antibiotic choice.

Answer 81

D. Group B Streptococcus, Escherichia coli, Listeria monocytogenes Newborns and infants up to the age of 2 – 3 months who develop meningitis usually test positive for Group B Streptococcus, Escherichia coli, or Listeria monocytogenes. There are other organisms that are possible, but these are the most common.

Answer 82

A. Ceftriaxone administered IV Aspiration pneumonia occurs when stomach contents enter the lungs. Children who are intubated have a higher risk of aspirating the longer they are ventilated. Hospital acquired infections may involve different organisms than those from the community, but common bacteria include pseudomonas and Acinetobacter, which are both gram negative. Klebsiella and E.coli are also possibilities. Other pathogens include Staphylococcus aureus and Streptococcus. Ceftriaxone is a 3rd generation cephalosporin which has broad spectrum coverage of both gram negative and gram-positive organisms.

Answer 83

C. Positive culture, treat with antibiotics to cover gram negative infection and follow organism identification Urosepsis often occurs as a hospital-acquired infection related to continued urinary catheterization, but can occur in the presence of a urinary tract infection. Positive urine cultures include colony counts of 100,000 CFU or greater. Urosepsis requires immediate appropriate antibiotic coverage, and critical care monitoring. Identification of the causative organism is important to be confident of antibiotic.

Answer 84

B. Place on oxygen, begin a full sepsis work up and start IV antibiotics

Answer 85

D. Hospital admission and IV antibiotics are needed until culture results are known A 4-week-old infant, who is hypothermic and hypoxic has a high probability of sepsis. Despite cold exposure, it is unlikely that other symptoms are from environmental causes, so hospital admission, a sepsis work-up and treatment with broad-coverage antibiotics are indicated. Antibiotic treatment will be dependent on clinical status, and culture results at 72 hours. Length of treatment with antibiotics is also dependent on culture results and patient status.

Answer 86

C. No diagnostic studies are warranted An infant beyond 2 – 3 months of age, may exhibit high fever with viral illness. Over time in the first year of life, infants will also lose maternal immunity, so it is more likely that they will acquire viral illnesses more easily. In early stages of illness, and with positive symptoms such as nasal congestion, there is no reason to complete diagnostic testing. If the illness progresses, symptoms worsen, etc., there may be reasons for testing.

Answer 87

B. Ampicillin, gentamycin and acyclovir. A neonate with fever and possibility of meningitis should be treated with broad spectrum antibiotics and acyclovir, which is coverage for HSV. The cerebrospinal fluid results indicate presence of red blood cells, a finding that is associated with HSV. Even though congenital HSV is uncommon and RBCs in CSF can indicate a traumatic procedure, it is important to be cautious.

Answer 88

B. Antibody testing for borelia burgdorferi For Lyme disease

Answer 89

A. Doxycycline or Amoxicillin PO Diagnostic evaluation for Lyme disease includes antibody testing for borelia burgdorferi, the organism responsible for this illness. Lyme disease is a tick-borne illness which is common in deer-infested areas like the northeast USA. Symptoms include the presence of a characteristic “bulls-eye” rash called erythema migrans, fever and headache. If the initial rash is missed, symptoms will continue to include fever, headache, fatigue, muscle aches and a more generalized rash. Treatment for Lyme disease in children includes doxycycline or amoxicillin. Rarely does Lyme disease require hospitalization.

Answer 90

B. Dehydration with Hypovolemic shock Hypovolemic shock is characterized by tachycardia, tachypnea, poor perfusion, lethargy or irritability. It often occurs as a result of vomiting and/or diarrhea in a young infant. Treatment includes fluid resuscitation, monitoring and managing cause of symptoms.

Answer 91

A. Newborn screening and stem cell transplant. Severe combined immunodeficiency disease is an inherited condition which is life limiting. It is diagnosed in newborn screening in all states of the US. Stem cell transplant is the recommended treatment and has had increased survival rates as a result.

Answer 92

C. Meningococcal meningitis Meningococcal meningitis is caused by Neisseria meningitidis which has been prevented for many years by the meningococcal vaccine dosing administered at age 11 and repeated at age 16. CSF results include elevated WBC count, low glucose and elevated protein levels. Meningococcal meningitis can be fatal and requires early identification and rapid treatment.

Answer 93

B. Clindamycin and incision and drainage after evaluation An erythematous lesion located in the sacral area is most likely positive for staphylococcus aureus, and MRSA should be considered for most patients. Drainage is the most important management. Antibiotic treatment can be regionalized based on organism resistance, but Clindamycin and Bactrim are the oral antibiotics of choice to treat MRSA.

Answer 94

A. Obtain blood and fungal cultures A child with CHD who has had recent surgical procedures could be at higher risk for Candidiasis, Aspergillosis among other fungal and opportunistic infections, so cultures should be obtained as the cause of fever may not be related to the otitis media.

Answer 95

B.Ultrasound to rule out pyloric stenosis

Answer 96

C.Metabolic alkalosis as typically found in pyloric stenosis Pyloric stenosis occurs typically in young infants between the ages of 2 and 8 weeks of life and presents with projectile emesis in between hunger and normal feedings. Due to recurrent vomiting, metabolic alkalosis often occurs because of loss of hydrochloric acid with emesis. The diagnosis of pyloric stenosis can easily be made by ultrasound of the abdomen.

Answer 97

C. Abdominal x-ray An abdominal x-ray is a quick and easy test to diagnose a bowel obstruction, perforation or presence of air or stool in the bowel. X-rays contain less radiation than CT imaging, so are safer for the patient. Bilious emesis is usually a finding that indicates a severe illness or injury, including a bowel obstruction or perforation, so rapid detection is especially important.

Answer 98

C. Meckel’s nuclear medicine scan and CBC Painless rectal bleeding is indicative or Meckel’s Diverticulum which is a congenital defect in the small intestine most often unknown to parents and/or patients. Symptoms can be gradual or acute, but do not usually result in significant anemia. A nuclear medicine, Meckel’s scan is the diagnostic gold standard test and surgical repair is always warranted.

Answer 99

A. Right lower quadrant pain, pain at Mcburney point and + Psoas sign Right lower quadrant pain, with rebound tenderness, pain at McBurney point and + Psoas sign are all signs of appendicitis. Patients can have varying additional symptoms to include fever, vomiting or anorexia, but cannot tolerate “jarring” or other acute movement without pain.

Answer 100

B. Toxic megacolon Toxic megacolon is a life-threatening complication of chronic inflammation and inflammatory bowel conditions like Crohn disease and ulcerative colitis. It occurs as a result of any disease-causing infectious colitis and involves dilatation of the bowel and causes systemic illness to include high fever, leukocytosis and anemia. Initial medical management with possible surgical intervention is management.

Answer 101

C. Chest and abdominal radiographs This child with chronic constipation experienced a bowel obstruction and perforation. X-rays offer visual documentation of endotracheal tube placement and obstruction or perforation of bowel.

Answer 102

B. Treatment with Methotrexate or Mercaptopurine Ulcerative colitis (UC) is an inflammatory disease of the colon which can cause pain, bleeding, stool urgency and nausea and vomiting. UC is treated in a stepwise fashion with the use of corticosteroids the mainstay of acute treatment, but also include aminosalicylates, immunomodulators and biologics, with surgical intervention always possible. Methotrexate is an anti-metabolite and immunosuppressive which is used to treat some cancers and also inflammatory diseases including UC and JIA. Mercaptopurine is also an immunomodulator medication used to regulate the immune system, especially in illnesses such as UC.

Answer 103

B. Obtain a CBC, coagulation studies and type and crossmatch while calling for GI consult

Answer 104

A. Initiate a proton pump inhibitor, Clarithromycin and Amoxicillin Gastrointestinal bleeding is not a common occurrence in children or teens, but can be an acute or critical situation if not identified and managed. After a complete history and physical examination, obtaining a CBC, coagulation studies and type and crossmatch for the potential of transfusion is warranted while calling for GI consult. Gastroenterology service will determine what additional testing is needed for the individual patient. Helicobacter Pylori is the most common infectious cause of GI bleeding and is managed with a proton pump inhibitor and usually 2 antibiotics which include clarithromycin and amoxicillin.

Answer 105

B. Offer 3 bottles of breastmilk with fortifier to equal 24 cal/ounce three times per day For this infant who was born preterm and still not at term, the use of 24 cal/oz formula or breastmilk is reasonable for weight gain. Of the offered options, fortifying breast milk makes sense to increase calories and continue to feed with breastmilk. Most likely, this infant was receiving some bottles throughout his short life, so switching between breast and bottle would make sense.

Answer 106

C. Begin trophic NGT feedings of infant formula 20 cal/oz at continuous rate of 5 ml/hr, increasing as tolerated Continuing nutrition with calories and protein is very important for healing, especially in acutely or critically ill patients. A preterm infant is also at risk for nutritional deficits to include failure to thrive. The most appropriate feeding plan for this infant should include beginning trophic feedings of formula at a continuous rate which decreases the volume in the stomach from bolus feeds and primes the gut, along with providing some nutrition. As the infant stabilizes, increasing the feedings is appropriate.

Answer 107

A. D5NS with 20 KCL/L at 46ml/hr Recommended maintenance fluids for a 27 lb, 2-year-old with a head injury who is NPO in the PICU include the use of glucose and .9% saline in a D5NS solution with potassium at calculated rate of 46 ml/hr.

Answer 108

B. Ileocecal junction Intussusception is a condition in which a section of the bowel telescopes on itself, resulting in pain and bleeding. The area of bowel almost always involved is the ileocecal junction. Treatment for intussusception involves the use of an air or barium enema with surgical back-up.

Answer 109

C. Na+ 128 meq/dL, K+ 2.8 meq/dL, Cl- 110 meq/dL, CO2 8 meq/l A bowel perforation will result in hyponatremia, hypokalemia and either metabolic acidosis or alkalosis. Additional abnormal lab results can include elevated lactate due to tissue hypoxia or ischemia and elevated inflammatory markers along with leukocytosis.

Answer 110

A 13-year-old who has a history of long QT syndrome Ondansetron is an anti-emetic drug historically used for nausea and vomiting in patients receiving chemotherapy. It is currently in use for nausea and vomiting in other conditions including gastroenteritis, but does has some contraindications for use. These include known allergy to the medication, prolonged or long QT syndrome and other cardiac conditions, liver impairment, and gastrointestinal obstruction.

Answer 111

C. Elevated AST/ALT, hypoglycemia and decreased urine output Liver failure is not a common occurrence in children, but findings include elevated liver enzymes to include AST and ALT, hypoglycemia and decreased urine output. Liver failure can occur with trauma, medical or surgical diagnoses, especially those that contribute to multi-system organ failure.

Answer 112

B. Hirschsprung disease Hirschsprung disease is a congenital condition which occurs when ganglion cells don’t fully develop, delaying the passing of stool through the intestines. It can occur in smaller or larger areas of bowel and delayed passing of meconium is one symptom. However, because of the differences in involvement of the cells, it can also be diagnosed later in the first year of life.

Answer 113

C. 500 mL Fluid deficit in children is calculated based on using a percentage of dehydration considering clinical findings or difference between current weight and a recent measured weight. In this case, the child’s pre-illness weight was 7.3 kg and he now weighs 6.8 kg which is a loss of 0.5kg. Multiply this by 1000 which equals 500ml deficit.

Answer 114

D. 108 This infant who currently weighs 3.2 kg is receiving 108 kcal/kg/day. To make this calculation, multiply the number of calories per hour X 24 hours then divide by 3.2 kg. (First, calculate the number of ml/day = 432, then divide by 30ml which is the number of ounces per day = 14.4, then multiply by 24 = 345, finally divide by 3.2 = 108)

Answer 115

D. NS 100 mL, and start D5 NS @ 20 mL/hr This dehydrated infant requires a fluid bolus first and then continue the fluids with glucose and normal saline at maintenance. A Na+ of 128 is low and needs to be increased to avoid seizures, so 0.9NS is isotonic and will assist in correcting this value.

Answer 116

B. 45 mL/hr Using the 4-2-1 Holliday-Segar calculation, the hourly IV rate at maintenance is 68 ml, than multiplied by 0.66 (2/3) = 45 ml/hr.

Answer 117

C. Attention deficit hyperactivity disorder (ADHD The diagnosis of attention deficit hyperactivity disorder (ADHD) can be challenging for those children who are not hyperactive, but exhibit findings such as staring into space and not paying attention. However, it is important not to ignore the possibility of a seizure disorder as absence seizures and some other types can present with staring. If the video-EEG is negative, re-evaluation is needed to consider a behavioral health problem.

Answer 118

B. There is a risk of subsequent seizures but it is difficult to determine prior to the event, as seizures occur as the fever is rising Simple febrile seizures typically occur in young children between the ages of 6 months and 5 years. They can be familial and recurrent so there would be a risk of subsequent events. However, as they usually do not pose concern for any permanent neurological problems, recurrence is not of concern. For parents and caregivers, though, seizures are frightening and they want to understand how to prevent them. Education that includes the fact that the seizure occur with the rise of temperature, not when the fever peaks, can assist in supporting a “wait and see” approach.

Answer 119

C.Administer a 10 mg dose of rectal midazolam and attempt IV placement Seizures that last longer than 5 minutes should be treated and benzodiazepines are recommended course of therapy. For this patient with a history of a seizure disorder treatment is warranted and the dose of 5mg of valium is less than 0.3 mg/kg/dose, so it is important to treat with appropriate dosing to treat seizure effectively. Midazolam is a shorter acting benzodiazepine and dose of 10 mg represents 0.3 mg/kg, which is appropriate. At that point, IV access is also important if medications are continued.

Answer 120

A. Obtain a Dilantin level in 12 hours prior to the next dose of Fosphenytoin and add a bolus dose if the level is low Fosphenytoin is a Dilantin prodrug which is given intravenously instead of Dilantin as it does not precipitate in glucose solutions as Dilantin can. Fosphenytoin and Dilantin will maintain therapeutic levels, but require serum measurements to make sure the level is between 10 and 20. Measuring a level prior to the next scheduled dose also allows information about frequency of dosing.

Answer 121

C. Has the child been given honey recently?

Answer 122

A. Oxygenation, ventilation and administration of hypertonic saline Head injuries can result in increased intracranial pressure dependent on presence of hemorrhage or lesion and until imaging can be completed, it is important to limit additional potential for swelling. Hypertonic saline solution creates an osmotic gradient that causes free water to flow from the brain into circulation, thus decreasing fluid/pressure in the brain tissue. The use of hypertonic saline can improve cerebral perfusion along with oxygenation and aggressive ventilation.

Answer 123

C. Normal CT The head CT image in this question appears as a “smiling face” which is a classic normal head CT.

Answer 124

A.Subdural hematoma, surgical consultation immediately The white/gray area on the right side of the head CT in this image represents hemorrhage. Comparing the CT image in question 7 with question 8, it is evident that the bleeding is causing some pressure which is identified by the obscuring of the ventricles.

Answer 125

C. Obtain a stat head CT

Answer 126

A. Brain MRI takes about an hour, requires sedation, eliminates radiation exposure and offers better resolution Based on the presentation of this patient with unequal pupils and limited reaction to light can signal increased intracranial pressure or a brain lesion, so obtaining immediate imaging is important. A head CT can be done quickly (about 10 minutes) and does not require contrast to view solid lesions and/or blood formation. Most contemporary CT machines can also have radiation dosing decreased for pediatric patients. An MRI offers additional and more detailed views but may require sedation as the patient needs to be perfectly still, usually requires contrast injection and can take about an hour to complete. In a patient who has neurological abnormalities, sedation would not be considered safe.

Answer 127

C. Determine LOC with GCS, obtain detailed history of injury, complete motor, sensory, and muscle strength evaluation and obtain head and neck x-ray Trauma evaluation always includes beginning with airway (A), breathing (B) and circulation (C) and then continues with cervical spine evaluation, and disability (D). Determine LOC with GCS, obtain detailed history of injury, complete motor, sensory, and muscle strength evaluation and obtain head and neck x-ray

Answer 128

C. Administer IV hydralazine PRN Acute hypertension, such as that which results from the presence of a pheochromocytoma, can be managed with anti-hypertensive therapies, like hydralazine which can be titrated and administered as needed. Diuretics are documented as first-line treatment for hypertension, but affect fluid status and may not work acutely as in this situation. Completing a full cardiac work-up to include EKG and cardiology consult is also warranted.

Answer 129

B. Digoxin Pediatric heart failure can be seen in patients with congenital heart disease, cardiomyopathy, infectious and inflammatory diseases, metabolic disorders and renal failure. Although, rare, congestive heart failure in children carries high morbidity and mortality rates. Patients with congestive heart failure that is being managed long term or until surgical procedures do well with loop diuretics, such as Lasix. The addition of low dose Digoxin assists in increasing myocardial contractility and decreasing heart rate.

Answer 130

A. Enalapril Enalapril is an ACE (Angiotension-Converting Enzyme) inhibitor which is used to treat hypertension and heart failure. ACE normally converts angiotension I into angiotension II, which narrows blood vessels and increases BP. Enalapril blocks ACE, therefore resulting in relaxed blood vessels and lower BP. For the 15-year-old with documented hypertension, chronic kidney disease and type 2 diabetes, enalapril can slow the progression of kidney disease and does not have other significant side effects.

Answer 131

D. CRP, ESR, ALT, AST Kawasaki disease is a vasculitis that has a predilection for coronary arteries and is considering the leading cause of acquired heart disease in children. It is suspected that an infectious disease such as an upper respiratory infection starts a response that triggers the disease process. Symptoms of Kawasaki disease include multiple days (can be 1 – 4 weeks) of fever and patients will present with findings that are included in the diagnostic criteria for the illness. These include a generalized polymorphous exanthem, swelling with erythema of the hands and feet, cervical lymphadenopathy, bilateral conjunctivitis and other less common symptoms such as abdominal pain, vomiting or diarrhea, headache, rhinorrhea among others. Identification of Kawasaki disease is urgent for treatment to prevent CAD from occurring. The American Heart Association identified criteria for diagnosis based on clinical findings and symptoms so that treatment can be expedited. The AHA has also recommended lab testing along with echocardiography. Lab tests include inflammatory markers (CRP, ESR) and liver function tests, ALT and AST.

Answer 132

D. Decrease heart rate with after depolarization Long QT syndrome can result in fatal arrythmias and is not always identified before it causes sudden cardiac death. Medications classified as beta-blockers include Nadolol, Propranolol, Atenolol, Metaoprolol and others, with Nadolol and Propranolol preferred for the treatment of long QT syndrome. Beta-blockers slow the heart rate down, reduce the occurrence of early afterdepolarization, assisting in preventing arrythmias like ventricular tachycardia and also affect calcium channels in the heart, increasing the contraction of the heart.

Answer 133

A. Total Anomalous Pulmonary Venous Return The “snowman sign” is the most common description of the cardiac silhouette on x-ray seen in infants with TAPVR or Total Anomalous Pulmonary Venous Return which is a congenital heart defect occurring when the pulmonary veins bringing blood back from the lungs do not connect to the left atrium, but attach to the heart in a different pathway. Infants with TAPVR usually have an atrial septal defect which assists with circulation of oxygenated blood, but most require surgical intervention soon after birth.

Answer 134

A. Nitric oxide inhalation through ventilator circuit

Answer 135

A. Echocardiogram Pulmonary hypertension (PAH) can occur as a result of congenital heart disease, cardiac surgical procedures, respiratory illness and some genetic factors. The best methods for reducing pulmonary hypertension, especially following cardiac surgery include maintaining alkalosis, treatment with Nitric Oxide, which can be administered in an inhalation format, higher oxygenation and sildenafil, tadalafil and other medications, most of which are not approved for use in children. Diuretics can be helpful for fluid retention and right heart failure, but are not the first line solution and should not be used aggressively. Digoxin has been used for PAH but long term benefits are not established. Diagnostic study with documentation of PAH is an echocardiogram. Exercise stress testing is helpful to identify underlying mechanisms of exercise intolerance in patients with PAH, but should not be done in an acute illness.

Answer 136

B. Institute a vagal maneuver and then determine cause of high HR Supraventricular tachycardia is a narrow complex tachycardia with heart rates greater than 220/minute in infants and characterized by heart rates between 150 – 220/minute in adults. This patient has a pulse, but is symptomatic with shortness of breath. EKG monitoring should be completed first to determine the correct rhythm, followed by attempting a vagal maneuver. This patient may be dehydrated which could contribute to the condition, and starting IV fluids would be appropriate after attempting to slow the rate with a vagal maneuver and if adenosine is needed if the vagal maneuver is unsuccessful. Synchronized cardioversion is the last effort, not defibrillation which would be used for ventricular tachycardia.

Answer 137

A. Pericarditis

Answer 138

B. Cardiogenic shock Myocarditis is a serious, acute infection/inflammation of the myocardium of the heart which usually comes from an underlying viral infection. Children with myocarditis appear very ill and develop sudden cardiac failure with new murmur, gallop or arrythmia. Resting sinus tachycardia is the primary symptom of myocarditis which distinguishes this diagnosis from others, but children can also present with fever, lethargy and hypotension. The gold standard diagnosis of myocarditis is an endomyocardial biopsy, with MRI also being utilized in recent times. Children with myocarditis can develop cardiogenic shock which is demonstrated with poor perfusion, tachycardia, tachypnea, lactic acidosis due to inadequate oxygen delivery to tissues and multi-system organ failure. Treatment of myocarditis is supportive, to include critical interventions based on symptoms and findings, but patients can be critically ill with a poor prognosis.

Answer 139

A. Maintaining alkalosis and administration of nitric oxide. As mentioned in questions 7 and 8 the best methods to reduce pulmonary artery pressure include maintaining alkalosis and administration of nitric oxide. In the acute postoperative phase following cardiac surgery, measures to reduce pulmonary arterial pressure are the same.

Answer 140

A. Pericardial or pleural effusion, friction rub, elevated inflammatory markers. Post-pericardiotomy syndrome is an immune response which occurs days to months following surgical incision to the pericardium, mostly with cardiac surgery. Signs include muffled heart sounds, hypotension and jugular venous distention. This syndrome can also include fever, friction rub, pleuritic pain, pleural effusion and sometimes cardiac tamponade. Elevated inflammatory markers are noted with lab work.

Answer 141

C. Still’s murmur There are many types of murmurs which occur for different reasons, but in healthy children, murmurs are typically innocent. A Still’s murmur is described as a soft, mid-systolic murmur heard along left sternal border which is louder when the child is supine and disappears when the child is upright. Pulmonary ejection and a peripheral pulmonic stenosis (PPS) murmur are also considered innocent murmurs. The pulmonary ejection murmur is usually seen in older children, ages 8 – 14 and has a grating sound without radiation. A PPS murmur commonly presents in newborns and disappears by 3 – 6 months.

Answer 142

B. Valvular heart disease Symptoms of joint pain, rash and erythema marginatum several weeks after treatment for strep throat can be indicative of rheumatic heart disease, which is a collagen vascular disease of the connective tissue. This long-term problem occurs with untreated or undertreated strep throat because the infections trigger an immune response where antibodies attack the heart valves leading to inflammation and potential scarring. Rheumatic heart disease most commonly affects the mitral valve and then the aortic valve. These valves can leak with progressive damage over time and require replacement.

Answer 143

A. Place the child in the knee-chest position Tetralogy of Fallot is a cyanotic heart defect to include 4 components: ventricular septal defect, right ventricular outflow tract obstruction, overriding aorta and right ventricular hypertrophy. This defect appears on chest x-ray as a boot shaped heart. Young children with TOF can experience hypercyanotic events which include hyperpnea and agitation. The first management for these events is to place the child in a knee-chest position which adjusts pressure and blood flow. Ongoing symptoms may require medical management to include morphine.

Answer 144

B. Prostaglandin therapy to maintain patent ductus. Transposition of the great vessels is a cyanotic heart disease where the aorta and pulmonary artery are reversed in position. Prostaglandin is utilized to maintain the patent ductus arteriosus to support oxygenation.

Answer 145

C. Staged interventions will be required, the first one completed soon after birth. Hypoplastic left heart comprises 7 – 9% of all congenital heart disease, presenting with shock, respiratory distress and early heart failure. In order to maintain oxygenation from birth, the ductus arteriosus needs to remain patent, so prostaglandin therapy is indicated. Parents need to be aware of the high mortality and morbidity of this defect and that repair is staged with three procedures accomplished over time: The first is the Norwood/Sano procedure, second is a Bidirectional Glenn and the third a Fontan procedure.

Answer 146

A. Ketamine infusion as an anesthetic has bronchodilator properties. Ketamine is a centrally acting non-opioid anesthetic agent that is useful for sedation. It has properties that cause bronchial smooth muscle relaxation, which makes it useful for patients with asthma or other lung disease. Monitoring heart rate and BP is important with ketamine infusion as it can cause increases in HR and BP.

Answer 147

C. Ketamine and Midazolam Ketamine is a centrally acting non-steroidal anesthetic agent that has bronchodilation properties so works well for children with asthma and other respiratory disease. Midazolam is a short acting benzodiazepine which induces sedation and also has amnesic properties. Both of these medications together will work well for chest tube placement.

Answer 148

D. Intranasal Dexmedetomidine and child life support. Dexmedetomidine is a selective alpha-2 adrenergic agonist which helps patients relax and become drowsy before and during a procedure. In addition to providing sedation, it also has properties to relieve anxiety and mild pain without affecting breathing. This patient is obese and has potential for airway obstruction when asleep, along with potential difficulty with intubation, so minimal medications should be used. Child life support can be helpful in any situation to offer diversion and other activities for the patient to not focus on the procedure.

Answer 149

B. Fentanyl and Midazolam Fentanyl as analgesia and Midazolam for sedation can be titrated to provide effective support for a child undergoing a lumbar puncture. Both of these medications have shorter duration of effect, especially if compared to Morphine and Lorazepam.

Answer 150

B. Administer Diazepam for muscle spasm and re-evaluate Orthopedic procedures can cause significant muscle spasm, especially in the immediate and first few days post-operatively. Valium is a benzodiazepine which works for muscle relaxation by enhancing the effects of GABA, a neurotransmitter that inhibits muscle contractions, providing relief from spasms. If valium is not effective, closer evaluation would be necessary to be sure that the child is receiving the medications via epidural catheter, adjust the dosing of the fentanyl and assuring that the child is not experiencing compartment syndrome.

Answer 151

A. Gabapentin Neuropathic pain can result from nerve damage, disease of the nervous system or sometimes without etiology. There are different approaches to managing neuropathic pain from supportive care to topical analgesics like lidocaine patches to a wide range of other oral medications. Many of these recommended therapies do not have significant clinical trials or research to back their use, but gabapentin (Neurontin) has been used successfully for neuropathic pain by modulating activity of specific ion channels, like calcium and neurotransmitters in the nervous system to stabilize and reduce neuronal excitability.

Answer 152

C. Slower onset of action, but longer duration of effect, so should be titrated over time. Methadone is a medication used for withdrawal symptoms in patients who have been receiving opioids for pain and sedation over time. The half life for Methadone is variable, but long and can be from 8 to more than 50 hours. Methadone titration guidelines recommend starting at low doses and increasing slowly (over days) to get desired effects.

Answer 153

B. GI bleeding as NSAIDs inhibit platelet aggregation, especially in liver failure. Ketorolac is classified as a NSAID and is a prescription medication used to treat moderate to severe pain. It has been used successfully but cautiously for post-operative pain due to risk of bleeding and GI bleeding. NSAIDs inhibit platelet aggregation, especially in liver failure so with concerning liver function testing, additional caution is warranted.

Answer 154

A. Anesthesia risk is limited with easy pharnyx visualization for intubation and mild systemic disease based on scores reported. ASA refers to classification for potential anesthesia risks in surgery. The scales range from 1 for a patient with no systemic disease to 6 which is a patient with brain death being maintained for organ procurement. Mallampati scores are used to assess airway status for anesthesia based on predicted difficulty of endotracheal intubation. Scores are completed by viewing the patient with their mouth open to see which anatomical structures are visible. This patient has an ASA score of 2 which refers to mild systemic disease and Mallampati score is 1 which is full visualization and ease of intubation which presents mild anesthesia risk.

Answer 155

A. Frequent re-orientation, attempt to stabilize day/night activities and administer haloperidol. Delirium has been studied extensively in adult populations and more recently increased information is available for pediatric patients who also experience this phenomenon, especially in critical care units. Symptoms include changes in mental status, day/night disorientation, confusion, shifts in behavior, irritability and agitation among others. There are currently various rating scales and protocols for evaluating delirium along with recommendations for treatment. Addressing the underlying causes, attempting to re-orient the child, especially promoting appropriate sleep-wake cycles and using medication if supportive care is not sufficient. Atypical anti-psychotics like risperidone can be used for severe agitation and intravenous haloperidol, may also be used for severe symptoms.

Answer 156

D. Have child return tomorrow for BP check Hypertension is rare in young children and if found needs to be documented to occur on more than one occasion based on clinical practice guidelines by the American Academy of Pediatrics in 2017. Urinary tract infections can contribute to kidney damage which may result in hypertension, but this is also unlikely. The next important step for a child with high blood pressure is to have the child return for follow up and another BP check. Completing renal function testing is also reasonable, but not first on the list.

Answer 157

B. Pre-renal failure Pre-renal failure is the most common type in children and results from decreased blood flow to the kidneys for a variety of reasons, to include gastroenteritis, diabetes and DKA, hemorrhage and blood loss, altered cardiac output and others including effects of medications. Findings in pre-renal failure include hypotension, high urine osmolarity, low urine specific gravity, metabolic acidosis, hyperkalemia, hyperphosphatemia and hypocalcemia.

Answer 158

C. Nephrotic syndrome

Answer 159

B. Corticosteroids dosed for at least one month Nephrotic syndrome refers to damage to the endothelial surface, glomerular basement membrane and 85% of the time albuminuria and proteinuria are present with decreased urine output. Physical findings include edema, weight gain, fatigue and loss of appetite. This patient had post-strep glomerulonephritis which led to nephrotic syndrome. Treatment for nephrotic syndrome includes corticosteroids dosed for at least one month as first line management.

Answer 160

A. Lupus nephritis Lupus nephritis occurs when lupus autoantibodies affect and attach the kidneys resulting in renal failure. The condition often occurs within a few days of initial onset and diagnosis of lupus. A facial rash in the shape of a butterfly is a classic finding of lupus. Diagnosing lupus and following labs and symptoms will help to identify the presence of renal failure early. Dialysis may still be needed.

Answer 161

C. Hypervolemia, hyperkalemia and acidosis Continuous renal replacement therapy (CRRT) is used for managing fluid overload and renal failure. Indications for starting CRRT for the purpose of dialysis include hyperkalemia, severe fluid overload and/or metabolic acidosis, BUN > 70-100, confusion/encephalopathy, bradycardia and tamponade.

Answer 162

A. Hypocalcemia, hypokalemia, hypophosphatemia Hypocalcemia, hypokalemia, and hypophosphatemia are common abnormalities found while a patient is receiving CRRT.

Answer 163

C. Sodium is high based on high glucose levels and patient is in renal failure In DKA, high blood glucose and lower sodium levels are common based on effects of hyperglycemia and insulin deficiency. High levels of glucose results in water being pulled out of cells diluting circulating sodium and causing hyponatremia. Low sodium levels in this situation, however, usually do not cause seizures or other clinical problems.

Answer 164

C. Renal tubular necrosis (RTA) Renal tubular acidosis (RTA) is a non-anion gap hyperchloremic metabolic acidosis, occurring from different factors including, but not limited to genetic defects, medications, autoimmune illness and altered kidney function. Nephrolithiasis or kidney stones can occur as a result of increased calcium levels which are then related to calcium-induced interstitial and tubular damage which could be responsible for RTA, but there is not enough data to clearly associate the two illnesses, or make determinations of what causes what. The most important information from this question is the documentation of RTA as a non-anion gap hyperchloremic acidosis.

Answer 165

C. Retinoblastoma An asymmetrical red reflex noted in a newborn or young infant is cause for concern. Instead of the red reflex being present, a white or pinkish view, called leukocoria may be observed which is an indication of Retinoblastoma. If this observation is made, referral to ophthalmology is the first step in diagnosis.

Answer 166

C. Diagnose Immune Thrombocytopenia Purpura and have child follow up with PCP Immune Thrombocytopenia Purpura (ITP) is an autoimmune disorder which often follows a viral illness in children, with findings identified by parents or caregivers of bruising, easy bleeding especially from the mouth or gums and/or petechiae. Thrombocytopenia on CBC is the hallmark for diagnosis, but the illness is self-limited and will resolve without treatment, usually within a few months.

Answer 167

B. Therapeutic leukapheresis Children with leukemia can present with extremely high white blood cell counts and as treatment is initiated can lead to complications like leukostasis where WBCs can obstruct small blood vessels in the lungs and brain. Hyperleukocytosis, which usually refers to WBC counts of 100,000 and above, is a medical emergency and can require leukapheresis, a process which removes WBCs from circulating blood.

Answer 168

C. Exchange transfusion Children with sickle cell disease (SSD) have increased risk of stroke and annual screening with transcranial doppler ultrasound is recommended. However, some children do present with stroke symptoms which mimic those of adults to include headache, confusion, slurred speech and paresis. Exchange transfusion improves the viscosity of the blood, blood flow and oxygenation. Medications like alteplase or retaplase are not recommended for treatment in children with SSD and in most cases symptoms will resolve completely following exchange transfusion.

Answer 169

B. Lymphoma Lymphoma is considered a blood cell tumor cancer which is most common among young adult patients with pediatric age ranges from 15 - 21. Symptoms are often vague and missed or determined to be other diagnoses, but include lymphadenopathy, fever, night sweats, weight loss and fatigue. There are two main types of Lymphoma - Hodgkin and Non-Hodgkin, with prognosis for Hodgkin lymphoma higher than those with Non-Hodgkin, but overall good.

Answer 170

C. MRI of lesion and surgical consult Osteosarcomas are bone tumors common in adolescents and teens, also ages in which children are involved in sports, so pain is often considered resulting from injury. A plain x-ray is utilized to identify the lesion, location and appearance. An astute orthopedic surgeon can often determine the likelihood of cancer from appearance on the x-ray, but MRI studies are the gold standard for assessment of the lesion within the bone and surrounding tissues. Biopsy is the following step along with determination of need for surgery.

Answer 171

A. Referral to oncology specialty, continued work up for blood cell cancer and hospital admission A 3-year-old who presents with multiple bruises and petechiae, intermittent fever and weight loss with pancytopenia is highly suspect for an oncology diagnosis, most likely leukemia. Referral to oncology with continued work up for blood cell cancer and likely hospital admission would be the expected management at this point.

Answer 172

B. Typhlitis Typhlitis is a condition associated with neutropenia which involves inflammation of the cecum and colon in the large intestine, but can include findings in all areas of the GI tract, including oral ulcerations which is often the initial patient complaint. Abdominal pain and fever are classic based on infectious etiology along with diarrhea. Ultrasound and/or CT are common imaging for diagnosis and bowel rest, antibiotics and pain control are the main part of management.

Answer 173

B. Head CT Brain tumors are the second most common type of childhood cancer with many different configurations and areas of involvement. Symptoms of brain tumors can include multiple symptoms with headache and morning vomiting very characteristic. Other symptoms include vision changes, developmental delays, balance and coordination problems, speech and swallowing difficulties, seizures, changes in behavior and personality and others.

Answer 174

A. Airway protection Mediastinal tumors or lesions arise from a variety of etiology, but can present with Lymphoma diagnosis. Depending on the location of the lesion, high concern needs to be around airway management. In addition, for a child with a mediastinal mass, sedation for MRI or other procedures needs to be considered carefully utilizing anesthesia experts.

Answer 175

A. Pulmonary contusion Pulmonary contusion is essentially a bruise to the lungs which is caused by direct impact trauma to the chest. As a result of capillary damage, blood and fluid can collect in the lungs interfering with gas exchange, which will cause hypoxia. Treatment is supportive with oxygen, ventilation if needed and pain management. History of mechanism of injury and presence of hypoxia help to document this problem. Other findings such as bruising, tenderness or abnormal breath sounds also support the diagnosis. Chest x-ray can indicate patchy infiltrates or opacities, but this is not always diagnostic.

Answer 176

A. 20 ml/kg bolus of normal saline Fluid resuscitation means continuing to infuse normal saline boluses until the patient is stable. When outcome of injury is unknown, one important goal of care is to support the patient’s vital signs. Once fluid volume is assured and blood pressure continues to be low, a dopamine infusion may be indicated, but determining the cause of hypotension is most important at this point in a patient with trauma.

Answer 177

A. Spleen The spleen is the most common injured abdominal organ in pediatric blunt trauma. The spleen is a fragile, highly vascular organ located under the rib cage, so chest and abdominal trauma from a MVC, fall or sports injury is easily directed to this area.

Answer 178

B. Abdominal CT with contrast Hematuria following abdominal injury is often indicative of kidney damage. An abdominal CT with IV contrast is the best/gold standard imaging modality to diagnose a kidney laceration. Renal trauma is classified into 5 grades from mild contusion to fractured kidney and treatment ranges from observation to surgical repair.

Answer 179

A. Age of child, length of time submerged and what other treatment was done on the scene Submersion injuries are very common in young children who can drown in very little water. The young victim of a near drowning event who is successfully resuscitated at the scene has a higher positive prognosis. Factors that should be considered in a near drowning event are age of the child, as younger patients are documented to have better outcomes, effective initial resuscitation and the absence of pre-hospital cardiac arrest. Children who are submerged for 5 minutes or less have better outcomes.

Answer 180

B. Determination of fluid resuscitation and what level treatment center is needed Accurate estimation of burn surface area is important for determining the severity of the burn and treatment methods including appropriate fluid resuscitation. There are many different skin surface area calculators that can be used to estimate the affected burn surface areas, like the Rule of Nines, Palm method and Lund and Browder chart.

Answer 181

B. Carboxyhemoglobin level and venous blood gas in addition to burn treatment, children who are exposed to fire also have a risk for smoke inhalation which can result in carbon monoxide poisoning. Cough, respiratory distress or failure are some indications of smoke inhalation. It is also important to observe the face, especially around the mouth and nose for soot which is an indication of smoke inhalation. Laboratory testing should include carboxyhemoglobin levels which measure carbon monoxide and either venous or capillary blood gas to determine presence of respiratory failure. If a child has a high carboxyhemoglobin level, treatment includes hyperbaric oxygen therapy which is not available at every hospital.

Answer 182

C. Abdominal CT with IV contrast kidney, liver and spleen injuries are all best diagnosed with imaging including a CT with IV contrast. Liver lacerations are more common than kidney lacerations as the liver is much larger and takes up more space in the abdomen. Laboratory studies of ALT and AST are highly sensitive in predicting liver injury, so liver function studies along with a hemoglobin and hematocrit are important to monitor for suspected liver damage from trauma.

Answer 183

A. Introduce the concept of palliative care as the child can be referred for a life-limiting illness at any time. Patients who have a chronic illness that may be life-limiting at any time in the trajectory, are encouraged to be referred to a palliative care service. The palliative care team offers support for symptom management and emotional/social support for the patient and family members. This team can begin end of life preparation, if necessary, but can be involved for any amount of time as compared to hospice care which is dedicated to imminent death.

Answer 184

B. Managing excessive secretions as well as dyspnea. There are physical as well as psychological concerns at the end of life and in order to support a child at home, services need to include plans for medical, psychological, emotional and spiritual support for the patient. Comfort and quality of life are also key components. In most states hospice care is designated at the point when a medical provider considers aggressive treatment futile and expects the patient to die within 6 months to one year. Treatment decisions for children vary and can continue to include chemotherapy and others. As death becomes imminent, organs begin to fail and symptoms can include pain, nausea, vomiting, constipation, excessive nasal and oral secretions and difficulty breathing which can be of concern for caregivers. Hospice services provide medications and other supportive therapies to minimize these symptoms.

Answer 185

C. Prior to prescribing medications, it is important to determine cause of symptoms and then relate to the emetic pathway. Children who are actively dying can experience a variety of symptoms to include nausea and vomiting, but these symptoms are also associated with other medications and conditions, so prior to prescribing medications, it is important to determine cause of symptoms and then relate to the emetic pathway to determine best plans for management.

Answer 186

B. Consider adding Neurontin or Lamotrigine for neuropathic pain control. Patients who have amputations commonly complain of “phantom” pain. Children who undergo procedures to salvage a limb that contains cancer can experience the same sensations as bone is often resected. Neuropathic pain is often described in these scenarios and some anti-epileptics offer relief, like Neurontin and Lamotrigine.

Answer 187

D. Understand families’ wishes, but explore with them what they understand about the child’s condition. Families are often witness to trauma and injuries involving their children and in many hospitals are invited to be in the same room as resuscitation efforts continue. It is extremely difficult for families to make decisions about stopping CPR and need guidance from the medical team about the current status of the patient and the fact that continuing efforts will be futile. It is helpful to take families to a quiet area and have a conversation with appropriate supportive staff members available.

Answer 188

A. Hospice care provides comfort care, pain control and emotional support at the end of life. The primary difference between palliative care and hospice care is that palliative care can be obtained at any time when a patient has a life-limiting condition. Hospice care is typically reserved for patients who are actively dying or expected to die within 6 months to one year. State based health insurance often covers hospice services at 100% and this is another consideration when accessing this service for a child. It is also sometimes difficult to counsel families about hospice care based on their understanding of the disease process, but palliative care can often offer support to transition to end of life either inpatient or outpatient hospice services.

Answer 189

B. Introduce the topic of palliative care and call the palliative care team. The prognosis for a patient with AML who has already been treated for ALL is poor, although treatment options are often offered and utilized. Introducing the patient and family to the palliative care team allows another support mechanism as decisions are made regarding ongoing treatment and care.

Answer 190

C. Amenorrhea Children with anorexia nervosa usually present in adolescent and teen years and the problem can be associated with other health disorders including childhood obesity, mood disorders, personality traits or weight related concerns from family and peers, depending on the individual. Patients often have poor self-esteem and view themselves as overweight when they are thin. Many also have comorbid conditions including depression and anxiety. Physical symptoms of anorexia include amenorrhea in females, coarse hair growth on extremities, low heart rate and BP and signs of dehydration.

Answer 191

A. Was this a suicide attempt?

Answer 192

B. Evaluate the child for a mental health disorder, and refer to appropriate continuation of care. A teen who attempts an act of self-harm such as hanging in his home or overdosing medications needs to be evaluated for suicide ideation. In many cases, children who attempt self-harm, especially significant acts like hanging indicate that they need attention. If the child denies this activity as a suicide attempt, he still needs a full psychiatric evaluation.

Answer 193

B. Safety, trustworthiness and empowerment. Trauma informed care incorporates five core principles when providing care for patients who have experienced adverse childhood events and other devastating situations. The principles include safety, trustworthiness, choice, collaboration and empowerment. Integration of these principles into daily acute care practice assist in healing and developing resilience.

Answer 194

C. Substance abuse. Some common symptoms of substance abuse include secrecy, excuses or lying, aggression or withdrawal, mood changes, irritability, decline in school performance and a change in friends. Lack of participation in self-care, such as stopping needed medication may also occur, especially in the case of chronic illness.

Answer 195

A. Involve the teen in decision making, but stress the importance of support until his diabetes is stable Based on developmental level, teens view themselves as “invincible” and may not truly understand the consequences of actions. Children with chronic illness, like diabetes are forced to live a life different than others and will rebel, often using diabetes control as this mechanism. However, it is important that teens can participate in self-care and assist in making decisions for their health. Allowing some participation while remaining stern about expectations for health can help in this situation.

Answer 196

D. 17-OHP collected within the newborn screening test. Screening for 17-OHP, testing for congenital adrenal hyperplasia (CAH) is within the newborn screening process in every state in the US. CAH presents with electrolyte imbalances including hyperkalemia and hyponatremia due to deficiencies of cortisol and aldosterone.

Answer 197

B. Diabetic ketoacidosis, admit to a monitored bed for lab work-up, insulin drip, IV fluids and stabilization

Answer 198

A. BG is < 300 or dropping faster than 100 per hour. Children can present with new onset diabetes in diabetic ketoacidosis, which is characterized by hyperglycemia and acidosis. Symptoms of new onset diabetes include weight loss, dehydration and a history of polyuria, polydipsia and polyphagia. Electrolyte abnormalities include low serum pH, low bicarbonate level and high blood glucose. Other electrolytes may also be affected based on level of dehydration. Management includes admission to a monitored bed for lab work-up, insulin drip, IV fluids and stabilization. Lab work-up for a child with new onset diabetes will include many more tests including insulin level and thyroid studies. Hemoglobin A1-C should be obtained with any admission for DKA. As treatment with fluids, electrolyte replacement and insulin continue, glucose should be added to IV fluids when the BG is less than 300 or falling faster than 100 meq/dL per hour.

Answer 199

B. Syndrome of inappropriate anti-diuretic hormone Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH) can occur with a central nervous system disorder or illness such as status epilepticus or meningits. A first sign is decreased urine output despite fluid hydration. Electrolyte findings include low serum sodium, high serum osmolarity and high urine sodium. Treatment for SIADH includes restricting sodium and fluids, strict intake and output and diuretics as needed.

Answer 200

A. Peaked T-waves, prolonged QRS and shortened QT EKG changes indicative of hyperkalemia include peaked T-waves, prolonged QRS and shortened QT. For true hyperkalemia, treatment can include a combination of glucose and insulin, calcium or Sodium bicarbonate administered IV.

Answer 201

D. Initiate a vasopressin drip and titrate to urine output. Diabetes Insipidus (DI) can be genetic, congenital or acquired. In the presence of neurologic injury, tumor or infection among other acquired causes, DI will present with excessive urine output of greater than or equal to 4 ml/kg/hr, high serum sodium, high serum osmolarity, low urine osmolarity and specific gravity. Acute management of DI includes strict intake and output monitoring and the administration of intravenous vasopressin.

Answer 202

C. Vertical gene transfer. Vertical gene transfer is the process that occurs during transmission of genetic material from parents to their offspring during the fusion of gametes (sperm and egg). Bacteria also reproduce with vertical gene transfer through binary fission, where one cell divides into two identical cells.

Answer 203

A. Transformation Escherichia coli is easy to manipulate and is used in the production of pharmaceuticals including human insulin. Genetic engineering includes the insertion of the gene for human insulin into a bacterial plasmid, then introduced into E. coli cells. This process is called transformation. Some E. coli bacteria will take up the plasmid, incorporating the human insulin gene into their genome.

Answer 204

D. SSD is an autosomal recessive pattern in which a child must inherit a gene from both parents to have the disease Sickle cell disease (SSD) continues to be a complicated illness causing significant disability for both children and adults. SSD is an autosomal recessive pattern in which a child must inherit a gene from both parents to have the disease. Genetic counseling for couples planning to have children should include assessment of the potential for having a child with SSD if one or both parents either have the illness or carry the gene. Unfortunately, many people do not know if they are carriers of the sickle cell gene.

Answer 205

B. A boy from Mediterranean background who presents at 1 week of life with hemolytic anemia. G6PD deficiency, also called glucose-6-phosphate-dehydrogenase is a X-linked, genetic condition most often affecting males and people of mediterranean descent. Testing is included in most newborn screening panels as it is often asymptomatic but can cause hemolysis of red blood cells resulting in acute hemolytic anemia. G6PD can cause hyperbilirubinemia in the newborn period with jaundice as the presenting sign. There are many different types of triggers including medications and foods, historically fava beans. Treatment is supportive and can include red blood cell transfusions along with exchange transfusion.

Answer 206

C. CF is autosomal recessive, which means that the child must inherit 2 copies of the gene, one from each parent in order to have the disease. Cystic fibrosis is genetic disorder inherited as autosomal recessive, which means that the child must inherit 2 copies of the gene, one from each parent in order to have the disease. The disease is caused by mutations of both copies of the gene encoding the cystic fibrosis transmembrane conductance regulator. Individuals with a single working copy of the gene are carriers and do not have the illness but can pass it to children. Cystic fibrosis changes a protein that affects cells, tissues and glands that produce mucus causing it to be sticky and thick as compared to normal mucus and can cause obstruction to the airways, damage or infection. Testing for CF is found on the newborn screening panel and confirmed with a sweat test.

Answer 207

A. Non-accidental trauma from a twisting incident. An 8-month-old with bruising on his thigh and a spiral fracture which is unexplained by the injury needs to be considered child maltreatment until otherwise confirmed as an accidental injury. It is unlikely for an infant who is non-ambulatory to sustain a femur fracture which is usually caused by significant force.

Answer 208

B. Retinal exam by ophthalmologist. A young infant who presents with symptoms that do not seem to match the history is suspect for child maltreatment. A 4-month-old infant who presents with neurologic signs like lethargy and little to no response to painful stimuli should have a retinal exam by an ophthalmologist to determine if there are hemorrhages present. Retinal hemorrhages usually result from “shaking” as in “shaken baby syndrome.”

Answer 209

C. Inform parents of your concerns and complete a mandatory child abuse report Bruising in unusual areas, especially places where a child is not prone to injury is a high alert for potential child maltreatment. An evidence-based evaluation called the TEN-4 Bruise Clinical Decision Rule for Predicting Nonaccidental Trauma in Children Four Years and Younger offers guidelines for assessment of bruising in young children. Once obtaining the history of the injury, if the report does not match the visual assessment, that is an alert. Bruising on knees, lower legs and shins are common in children, but bruising on the torso, ears, neck or anywhere in an infant younger than 4 months of age is suspicion for child maltreatment. In most states, reporting suspected child abuse is mandatory, so informing the parents of your concerns and making a report is required. Including a social work evaluation is also helpful, but the report should occur early in the hospitalization when the assessment occurs.

Answer 210

A. Teen may be experiencing maltreatment at home and fears returning home. A teen who has a suicide attempt and is engaging in self-harm usually has an underlying mental health disorder and due to this admission, requires a psychological evaluation. However, the interest in staying inpatient and not returning home may indicate the basis of these problems which could include physical abuse, including sexual abuse. In most cases, teens would be opposed to inpatient admission.

Answer 211

A. Factitious disorder imposed on another. Factitious disorder imposed on another” is the current term previously known as “Munchausen by proxy” in which an adult or other person fabricates or induces illness or illness symptoms on another. In many cases, the adult, who is most often the mother of a young child, wants to gain personal attention or sympathy and the child will have strange symptoms that do not match a specific diagnosis. In obtaining history, the child has been hospitalized frequently, may see many different providers and has many tests, procedures and sometimes surgery. Symptoms are usually reported by the caretaker but not seen by health care providers.

Answer 212

C. Orbital cellulitis, treat with IV vancomycin and ceftriaxone, hospitalize until symptoms begin to resolve

Answer 213

C. Periorbital cellulitis /oral antibiotic for gram positive organism. Orbital cellulitis, also referred to as preseptal cellulitis is a concerning infection involving tissues around the orbit of the eye. Orbital cellulitis can cause vision impairment, eye pain as well as restricted movement in the affected eye. CDC recommendations include treatment with two broad spectrum antibiotics, such as IV vancomycin and ceftriaxone and hospitalize until symptoms begin to resolve. Differentiating between orbital and periorbital cellulitis is extremely important based on potential outcomes. Periorbital cellulitis involves the area around the orbit of the eye, primarily the eyelid and it is less toxic and does not cause significant pain, nor vision impairment. Periorbital cellulitis is typically caused by staphylococcus aureus or streptococcus pyogenes and responds to antibiotics with gram + coverage.

Answer 214

A. Brainstem auditory evoked response (BAER). A BAER, or brain stem auditory evoked response test determines electrical activity in the cochlea and auditory pathway in the brain. This is the recommended test for a child receiving ototoxic chemotherapy and can be done prior to referrals to specialists, especially if the child does not experience hearing loss during treatment.

Answer 215

A. Hydronephrosis on ultrasound. Pits or tags in the preauricular area may be associated with branchio-oto-renal syndrome. Children should be screened for renal abnormalities, so an ultrasound indicating hydronephrosis would not be surprising. These patients should also be screened for hearing loss.

Answer 216

B. Peritonsillar abscess

Answer 217

A. Needle drainage and oral antibiotic therapy. Peritonsillar abscess is a collection of infectious secretions in the peritonsillar space between the tonsillar capsule and superior constrictor muscle. This space is composed of loose tissue, so easily becomes abscess in the presence of infection, such as a strep throat. Typically this process is unilateral, so patients will complain of pain on one side of their throat along with difficulty swallowing and trismus is noted on exam. As the abscess increases in size, it results in muffled speech or the “hot potato” voice. Neck pain along with increased cervical lymph nodes may also be present. Fever, headache, malaise and nausea may also be symptoms. Treatment includes needle aspiration of the abscess and broad coverage antibiotic therapy to cover both gram + and gram organisms. Culture and sensitivity of the fluids can be accomplished with aspiration to document appropriate antibiotic coverage. If the patient is able to tolerate liquids by mouth and is not septic appearing, they can be discharged home and treated with oral antibiotics with follow up schedules.

Answer 218

C. Lateral neck x-ray. A retropharyngeal abscess is a bacterial infection which often follows an upper respiratory infection or croup in children less than the age of 5. Fever is the hallmark and children present ill-appearing with sore throat and sometimes with stridor. They may also have neck stiffness and visible swelling with tenderness on either side of the neck. A lateral x-ray is the first recommended study which will show soft tissue swelling posterior to the pharynx. CT or MRI imaging are considered next on the list. Treatment often includes surgical drainage and broad-spectrum antibiotics, often initiating in intravenous format with hospitalization and IV fluids.

Answer 219

B. Legg Calve Perthes disease. Legg-Calve-Perthes disease is a condition that affects children between the ages of 3 and 10 and occurs when blood flow to the femoral head is obstructed temporarily causing bone deterioration. Perthes disease causes pain and limping. Treatment can entail rest, the use of anti-inflammatory medications, physical therapy and surgery.

Answer 220

B. Arrange to remove the cast

Answer 221

C. Compartment syndrome. Compartment syndrome is a complication in orthopedics which occurs when pressure increases within a muscle compartment restricting blood flow. It is remembered with 5-Ps: Pain, Pallor, Paresthesia, Paralysis and Pulselessness. In a casted child, the first management strategy is to remove the external pressure of the cast and treat the event as an emergency.

Answer 222

C. Slipped Capital Femoral Epiphysis . Slipped Capital Femoral Epiphysis or SCFE is an orthopedic disorder affecting primarily overweight adolescent age children and involving a fracture through the epiphysis or growth plate of the head of the femur which moves out of place. It is diagnosed with x-ray and/or MRI and treated almost always with surgery.

Answer 223

C. Osteomyelitis

Answer 224

A. Surgical drainage and 3 – 4 weeks of antibiotic therapy for staphylococcus aureus). Osteomyelitis is an infection of the bone marrow occurring either spontaneously or as a result of an injury that causes skin disruption Symptoms include fever, chills, pain in affected area, nausea and vomiting, swelling and skin discoloration. Causative organism is most often staphylococcus aureus and treatment includes drainage and sometimes biopsy of the affected area with cultures obtained. Antibiotic therapy is aimed at the causative organism and can be 3 – 6 weeks in length with a combination of IV and oral routes.

Answer 225

B. Administer 3% saline bolus. A posterior spinal fusion is completed with the position prone and can take many hours. Potential complications of being in this position include respiratory and cardiac, compartment syndrome and visual impairment. It is appropriate to continue intubation and ventilation in this patient for stabilization over time. Aggressive fluid resuscitation is important during the procedure and post-operatively. Evaluating electrolytes indicates a low sodium of 128, which is best addressed by administering 3% saline, which is a hypertonic solution.

Answer 226

C. Risk of limb deformity or shortening. Children are at risk for fractures that involve the growth plate or physis of long bones, also known as Salter-Harris fractures. If this type of fracture is not managed properly, it can result in limb deformity or shortening.

Answer 227

C. Compartment syndrome and improper healing. A compound fracture, also known as an open fracture occurs when the bone pierces and protrudes through the skin. Compound fractures are graded based on severity and extent of soft tissue damage. Treatment consists of cleaning the wound, realigning and fixating the fractured bones which often includes surgical management.

Answer 228

D. Clavicular fracture falling from an ATV at high speed. A comminuted fracture is one in which the bone shatters or breaks into multiple pieces. The mechanism of injury is usually high impact from a motor vehicle or fall. Surgery to stabilize the bone fragments is usually required for healing to occur.

Answer 229

A. Notify poison control, administer activated charcoal and order IV N-acetylcysteine (NAC)

Answer 230

A. Rumack-Mathew Nomogram to assess timing of overdose and potential for liver failure

Answer 231

B. Access the most up to date and effective antidotes for specified ingestions. Acetaminophen ingestions remain high on the accidental list and also for patients who take overdoses intentionally. It is a substance sold OTC separately and is found in many other cold and sleep preparations, so easy access for children and teens. Large doses of Tylenol can result in liver failure to the extent that liver transplant is necessary. Approximately 50% of all reported cases of liver failure in the US result from Tylenol toxicity. Many children are asymptomatic with initial ingestion and then develop nausea, vomiting, diaphoresis, lethargy and malaise. As time elapses, symptoms worsen to include hypoglycemia, lactic acidosis and multi-system organ failure. Time is of essence in treatment, so despite knowledge of when the ingestion occurred, it is most important to notify poison control, administer activated charcoal and order IV N-acetylcysteine (NAC) as soon as possible. Both clinicians and poison control personnel use the Rumack-Mathew Nomogram to assess timing of overdose and potential for liver failure. Inputting acetaminophen drug levels into this nomogram along with timing of dose assist in predicting the possibility of liver failure. Notifying poison control in any case of potentially toxic exposure or ingestion is important to access the most up to date and effective antidotes for specified ingestions and receive guidance to diagnostic and treatment recommendations.

Answer 232

D. Ingesting bath salts

Answer 233

C. Benzodiazepines and IV fluid rehydration. Synthetic cathinones, also known as “Bath salts,” are dangerous stimulant drugs based on a chemical found in a specific plant type. This substance is taken to affect the central nervous system similarly to cocaine, methamphetamine and MDMA (Ecstasy). Some serious effects of the ingestion of bath salts include tachycardia, hypertension, hyperthermia, aggression and violent behavior. In addition, they cause neurologic effects of agitation, paranoia, with hallucination and delusions. In severe cases, bath salts can result in rhabdomyolysis with renal failure and multi-system organ failure leading to death. Treatment for bath salt ingestion includes the use of IV fluids and benzodiazepines to decrease acute agitation and reduce the risk for hyperthermia leading to rhabdomyolysis and resulting demise. Monitoring in the ED or critical care area is also needed until symptoms begin to resolve.

Answer 234

C. Acetaminophen Activated charcoal is recommended for its absorption and binding properties in the case of some substances that are ingested accidentally or intentionally for harm. Many medications taken in excess are on the list for the use of activated charcoal, but poison control should always be consulted prior to administration. Substances such as lye and bleach do not readily bind to activated charcoal and due to their corrosiveness could be more harmful if aspirated. Iron does not bind to activated charcoal.

Answer 235

D. Babysitter takes Metformin for Type 2 diabetes mellitus. Metformin is a an anti-diabetic drug used to control high blood sugar. Hypoglycemia can cause seizure activity, especially in a young child, so ingestion of metformin is a serious concern. In this case the child was given juice which counteracts the metformin action and may have assisted in improving the child’s status. Continued monitoring is import, though, as the half life of metformin is variable, but can be as long as several days.

Answer 236

B. Administer a bolus of normal saline and IV calcium. Diltiazem is a calcium channel blocker used to treat hypertension and other cardiac disorders. When ingested accidentally it will cause cardiac effects such as bradycardia and hypotension and hypocalcemia leading to altered neurologic status and seizures. Treatment for this overdose includes IV calcium and fluids along with ICU monitoring.

Answer 237

A. CNS agitation and seizures There are many types of essential oils which are primarily made from plants. However, based on the substance each one poses different side effects and potential toxicity. Many oils are safe with inhalation or topical use but if ingested can cause neurologic symptoms including seizures. Camphor, clove, wintergreen and wormwood oils can all cause seizures. Others affect liver function and if accidentally aspirated can cause aspiration pneumonia. It is important to counsel families to review toxicology profiles and store these solutions away from young children.

Answer 238

A. Urinalysis and renal ultrasound IgA vasculitis, formerly known as Henoch-Schonlein purpura is a systemic, immune complex-mediated, vasculitis characterized by purpura, arthritis and abdominal pain. There are no specific diagnostic tests to identify this disorder, but symptoms and findings are used to confirm disease These include abdominal pain, vomiting, presence of purpura, renal involvement and/or glomerulonephritis, along with others.

Answer 239

C. Eye exam for uveitis. Juvenile idiopathic arthritis is a chronic autoimmune disease which causes chronic joint pain, swelling and stiffness. JIA can affect one or more joints and presents with flare-ups. A concerning complication is uveítis, which can result in cataracts, glaucoma and blindness, so it is important that children are followed annually by opthalmology.

Answer 240

A. Order oral corticosteroids. Anaphylaxis or a hypersensitivity reaction can result from ingestion of food and/or medications and presents with a multitude of potential symptoms including rash and soft tissue swelling, hypotension, difficulty breathing with wheezing and nausea and vomiting. In addition to airway, breathing and circulation, the first line treatment for anaphylaxis is the administration of epinephrine which can be given subcutaneously at the first signs of reaction or intravenously. In this case, the child has significant facial swelling, so the next step would be to administer corticosteroids.

Answer 241

B. Testicular torsion Testicular torsion is a medical emergency which presents with acute testicular and at times, lower abdominal pain. A key physical finding is the absence of a cremasteric reflex and diagnosis can be made with color doppler ultrasound.

Answer 242

B. Urosepsis, obtain urinalysis, culture, CBC, blood culture and lactate. Urosepsis often occurs in a hospital setting where a child has a urinary catheter, but can also present in a child with a history of urinary tract infection (UTI), or with an undiagnosed UTI, such as a young infant. Symptoms of high fever, abdominal pain and lethargy are often present along with findings of shock: respiratory distress, tachycardia and hypotension. Obtaining a urinalysis with culture, CBC with differential, blood culture and lactate are helpful in determining definitive diagnosis.

Answer 243

C. Are you sexually active? A teen with a sexually transmitted infection can develop pelvic inflammatory disease which presents with diffuse, generalized abdominal pain, so it is important to ask if the girl is sexually active and to consider a list of differential diagnoses with PID included. It is rare to hospitalize teens with PID, as oral antibiotics work well, but there are situations when it is necessary to include PID with pregnancy, …

Answer 244

A. Escherichia Coli, Klebsiella, Enterococcus, Staphylococcus aureus. Urinary tract infections can be caused by a multitude of organisms, but in children the most common causes are Escherichia Coli, Klebsiella, Enterococcus, staphylococcus species. Other organisms include pseudomonas

Answer 245

A. Urine organic acids and ammonia level

Answer 246

B. Organic Acid disorder. Organic acid disorders present in the newborn period with poor feeding, lethargy, acidosis and ketosis with high ammonia levels. Diagnostic studies include urine organic acids and ammonia level. This disorder is included in the newborn screening testing in the US, but results of these tests are not always available early in the infant’s life, so recognition of symptoms is important.

Answer 247

B. Less active than usual, sticky oral mucosa, slightly diminished skin turgor and tachycardia. A 2-year-old exposed to excessive heat will be prone to dehydration. Physical signs of 10% dehydration include decreased activity, “sticky” oral mucosa, slightly diminished skin turgor and tachycardia.

Answer 248

A. Developmental delay, hearing loss, skeletal atrophy, short stature and coarsening of facial features. MucopolysaccharidosIs are liposomal storage disorders which include a deficiency of lisosomal enzymes leading to excessive tissue storage of lipid material or degradation and storage of mucopolysacharides. Clinical findings include developmental delay or regression, hepatomegaly, splenomegaly, hearing loss, ataxia, skeletal atrophy, short stature, coarse facial features and cardiac involvement. Diagnosis of this disorder is within the newborn screening process with treatment including replacement of enzymes.

Answer 249

D. Galactosemia. Galactosemia is a genetic disorder that prevents the body from producing galactose, which is a sugar found in lactose. Findings of illness usually occur in the first few weeks of life and include poor feeding, vomting, lethargy, jaundice and potential infection. Treatment of galactosemia is dietary elimination of lactose and galactose for life.

Answer 250

B. Mucus membrane involvement of the eyes. Stephens Johnson syndrome is considered a hypersensitivity reaction of the skin and mucus membranes which begins with a macular-papular rash that can develop into papules, vesicles and blisters. SJS has been associated with reaction to multiple different medications as well as to viral illness. Involvement of the eyes can include ulceration of the cornea which can result in vision loss. If mucus membranes of the eyes are affected, routine ophthalmologist evaluation and treatment is required beginning when the problem is identified.

Answer 251

D. Erythema Multiforme. Erythema Multiforme is a skin condition which includes a macular rash which is erythematous and itchy and often begins with presentation on the palms of his feet and hands and then spreads to other areas. Treatment is supportive and symptoms usually resolve spontaneously, but hospitalization and the need for IV fluids and other treatment is possible.

Answer 252

A. Toxic epidermal Necrosis (TEN). Toxic Epidermal Necrolysis (TEN) is a severe skin reaction triggered by certain medications or caused by infection. It causes blistering and peeling skin over most of the body surfaces. TEN is characterized by keratinocyte necrosis with separation of the epidermis from the underlying dermis which can result in sepsis and potentially death. Supportive care measures include hospitalization with IV fluids, pain management, wound care and nutrition.

Answer 253

C. Remove sutures, have patient take a deep breath and swiftly pull the tube, placing a Vaseline gauze at the site and secure. A chest tube is removed when there is no further need for its function. For pneumothorax, it is typically about 24 hours after the leak is no longer apparent and then a period of clamping to be sure the air leak does not return. For fluid drainage, it would be evident when the drainage slows and is no longer draining. To discontinue the chest tube, remove the sutures, have patient take a deep breath and swiftly pull the tube, placing a Vaseline gauze at the site and secure with a dressing.

Answer 254

B. Platelet count of 15,000 this am. Lumbar punctures (LP) are common procedures with very few risks and contraindications. A low platelet count poses a risk for bleeding at the needle insertion site. If an infant or child with respiratory distress requires an LP the procedure would be postponed if the patient’s airway is not stable. For a child with altered neurologic status, completing a head CT prior to the procedure is necessary.

Answer 255

B. Seldinger technique. A procedure used to insert an arterial line or central line by inserting a catheter and then using a guidewire to stabilize the vessel and place the final catheter is called the Seldinger technique. This procedure allows the provider to identify the vessel with a hollow needle, thread the catheter and remove the needle.

Answer 256

A. Two components including detailed history with 4 HPI elements, detailed exam with 6 systems, and high complexity medical decision making. Based on CMS guidelines for billing and coding for a hospitalized critically ill inpatient at a level 3 follow up, the PNP note must contain two components including detailed history with 4 HPI elements, detailed exam with 6 systems, and high complexity medical decision making or time based acute care of at least 35 minutes of patient provider care. The time-based care must be documented in the clinical note of the patient on that day.

Answer 257

A. Background data and information, a Fishbone diagram of the problem/s and runcharts to document intervention and outcome data over time. A formal quality improvement (QI) project utilizes background data and information to describe and document the problem, a Fishbone diagram of the problem/s and runcharts to document intervention and outcome data over time. Formal QI projects are based on cycles of improvement and intended goals and outcomes.

Answer 258

C. Specific risks of the CL to include bleeding and infection, ask for understanding and obtain signature. When obtaining a formal consent for a procedure, the nurse practitioner role is to fully describe the procedure and how it will be accomplished, discuss all potential side effects and/or risks and ask parents/guardian/patient to provide feedback to demonstrate their understanding of what will happen to the child. The nurse practitioner is responsible to sign as witness along with the designated parent or guardian. In most cases, another person, usually a bedside nurse will witness both signatures.

Answer 259

B. Credentialing

Answer 260

D. Credentialing Credentialing and privileging are processes that are linked, but different. Credentialing is the process of verifying a healthcare provider’s qualifications, such as their education, training, licensure and certifications. Privileging is a process which authorizes the health care provider to perform particular procedures within their scope of practice. This process considers what the job expectations are, recognizes previous training and experience of the health care provider to provide these procedures/skills and what resources will be needed at the facility to support the health care provider. In many states, the state board of nursing also participates in delineating a list of procedures which a nurse practitioner may be privileged to perform.

Answer 261

D. Randomized control trial. Evidence-based practice incorporates the use of the best available information to include an evidence pyramid outlining the quality of the evidence. Systematic reviews and Meta-analyses are highest on the list with randomized controlled coming next, then other methods of research, case studies and reports and the lowest level including expert opinion.

Answer 262

B. Nonmaleficence Non-Maleficence is a principal of ethics that means “do no harm.” In this case, repair or replacing the gastrostomy tube for this child may end up causing additional complications as well as pain and suffering.

Answer 263

A. Situation SBAR is an acronym for a structured communication method used in healthcare for both nurses and providers to share information about patient and patient care. S=Situation, B=Background, A=Assessment and R=Recommendation. The nurse practitioner providing the basic information about why she is calling, patient name and birthday is the situation.

Answer 264

D. Evaluate the patient and situation, discuss quality of life and anticipated recovery with parents. Discussing palliative and end of life care can be challenging, especially in a situation where they have not been addressed previously and the patient has had a life-limiting condition. If a patient is actively dying and does not have decisions for resuscitation, it is important to allow time for family/caregivers to make the best decisions despite the timing. In this situation, the nurse practitioner should evaluate the patient and situation, determining their own assessment of the quality of life and possibility for continued life, discuss quality of life and anticipated recovery with parents and make a mutual decision about ending life support.

Answer 265

C. Legally the PNP she should seek an educational program where she can obtain the missing acute care coursework. Based on the National Consensus Statement by the National Council of State Boards of Nursing an advanced practice nurse must have education, licensure to match their area of practice. However, some states do not adhere to this guidance and license nurse practitioners in different ways, such as “pediatric” vs pediatric acute and primary care. It is up to the NP to abide by the state rulings, so in this case the primary care PNP needs to obtain the acute care education and take the certification exam before engaging in acute care practice, despite previous experience.

Answer 266

B. Scope of practice Written statements that define expected knowledge, skills and roles of the acute care PNP are part of scope of practice which is listed within state boards of nursing. Some national nursing organizations recommend scope of practice and publish statements, but NPs are obliged to follow the scope within their state and license.

Answer 267

C. Agree to orient the fellow to the unit and patient environment, but expect that he will do his own assessment and notes. Nurse practitioners engage in educating other nurse practitioners as well as other members of the health care team. If asked to participate in education of another discipline, things like orientation to a unit or a team practice is general information, but patient care documentation needs to be done by the same person who provided the care. The NP in this situation should agree to orient the fellow to the unit and patient environment, but expect that he will do his own assessment and notes.

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