PRAC 6541
PRAC 6541 – Primary Care of Adolescents
and Children Practicum: Comprehensive
Review Examination – 200 Multiple-Choice
Questions with Evidence-Based Rationales
for Pediatric and Adolescent Primary Care
Certification Preparation
PRAC 6541 – Primary Care of Adolescents and Children Practicum
Comprehensive Examination
QUESTION 1
QUESTION:
A 4-year-old girl is brought to the clinic by her parents who are concerned because she is afraid of
the dark and insists on sleeping with a nightlight. She has no other behavioral concerns and is
developing normally. What is the most appropriate response to the parents?
A. This behavior is abnormal and requires immediate psychological referral
B. Reassure the parents that this is normal for her age and recommend continuing the nightlight
C. Prescribe low-dose melatonin to help with sleep initiation
D. Recommend behavioral extinction by keeping the lights off despite her protests
ANSWER:
B. Reassure the parents that this is normal for her age and recommend continuing the nightlight
RATIONALE:
Fear of the dark is a common and developmentally normal phenomenon in preschool-aged children
(3–5 years), representing typical fantasy thinking and imagination development. Parents should be
reassured that this is not pathological and that providing a nightlight is an appropriate, supportive
intervention. No psychological referral is needed for an isolated fear of the dark without other
concerns. Melatonin is not indicated for this issue, and behavioral extinction by keeping lights off
could increase anxiety and distress unnecessarily .
QUESTION 2
QUESTION:
A 6-year-old boy is unable to hop on one foot, ride a bicycle, or tie his shoes. His parents report he
has always been "clumsy" and was a late walker. He is doing well academically in first grade. What is
the most appropriate next step?
Page 1 of 86
, PRAC 6541
A. Reassure the parents that these skills typically develop by age 7-8
B. Refer for occupational therapy evaluation
C. Order a brain MRI
D. Diagnose developmental coordination disorder and initiate physical therapy
ANSWER:
B. Refer for occupational therapy evaluation
RATIONALE:
The inability to hop on one foot, ride a bicycle, and tie shoes at age 6 suggests possible
developmental coordination disorder (DCD). By age 6, most children have developed these gross and
fine motor skills. While DCD is a possibility, a formal evaluation by occupational therapy is the
appropriate next step for assessment and intervention planning. Reassurance without intervention
would delay needed services, and brain MRI is not indicated without neurological concerns.
Diagnosis should be made by a specialist following comprehensive evaluation .
QUESTION 3
QUESTION:
A 14-year-old girl presents for a well-child visit. She has not yet reached menarche. On examination,
she has breast development consistent with Tanner stage 3 and pubic hair at Tanner stage 3. Her
height and weight are appropriate for age. What is the most appropriate management?
A. Obtain a karyotype to rule out Turner syndrome
B. Reassure the patient and family and follow up in 6 months
C. Start estrogen therapy to induce menarche
D. Order a pelvic ultrasound to evaluate ovarian development
ANSWER:
B. Reassure the patient and family and follow up in 6 months
RATIONALE:
Menarche typically occurs approximately 2–2.5 years after thelarche (breast development), which
usually corresponds to Tanner stage 4 breast development. At Tanner stage 3 with appropriate
growth parameters and no other concerns, this represents normal pubertal progression.
Reassurance and continued monitoring are appropriate. A karyotype or estrogen therapy would be
indicated if there were signs of primary amenorrhea with lack of pubertal development or if
menarche had not occurred by age 16. A pelvic ultrasound is not routinely indicated in this scenario .
QUESTION 4
QUESTION:
A febrile 2-year-old presents with rhinorrhea, cough, and increased work of breathing. The
respiratory rate is 55 breaths per minute with subcostal retractions, and oxygen saturation is 89% on
room air. What is the most appropriate management?
A. Discharge home with amoxicillin and follow up in 24 hours
B. Admit to the hospital for oxygen therapy and supportive care
Page 2 of 86
, PRAC 6541
C. Obtain a chest x-ray before making a decision
D. Administer an albuterol nebulizer trial and reassess
ANSWER:
B. Admit to the hospital for oxygen therapy and supportive care
RATIONALE:
This patient demonstrates hypoxia (SpO2 < 90%), tachypnea, and increased work of breathing with
retractions, which are indications for hospital admission for bronchiolitis or pneumonia
management. Young age (2 years) with significant respiratory distress requires close monitoring and
supportive care, including oxygen therapy. Discharge home would be unsafe. Chest x-ray is not
routinely needed for bronchiolitis and can be obtained after admission if indicated. While albuterol
may be trialed, the primary concern is the hypoxia and work of breathing, which warrant admission .
QUESTION 5
QUESTION:
A 14-year-old reports a severe sore throat, fever, and fatigue. Examination reveals pharyngeal
erythema, tonsillar exudates, and tender anterior cervical lymphadenopathy. A rapid strep test is
negative. What is the most appropriate next step?
A. Treat with amoxicillin empirically
B. Obtain a throat culture
C. Order a Monospot test for infectious mononucleosis
D. No further testing; diagnose viral pharyngitis
ANSWER:
C. Order a Monospot test for infectious mononucleosis
RATIONALE:
In an adolescent with exudative pharyngitis, significant lymphadenopathy, fatigue, and a negative
rapid strep test, infectious mononucleosis (Epstein-Barr virus) should be strongly suspected. The
Monospot test has high specificity in adolescents and is the appropriate next step. Empirical
antibiotics are not indicated without confirmation of bacterial infection. A throat culture would be
appropriate if the rapid strep were positive or if the suspicion for GAS pharyngitis remained high
despite negative rapid test. Dismissing this as viral pharyngitis without further workup would miss
the diagnosis of mononucleosis .
QUESTION 6
QUESTION:
A 6-month-old infant presents with fever of 39.5°C (103.1°F), irritability, and a bulging fontanelle.
There are no focal neurological findings. What is the most appropriate next step?
A. Observe at home with antipyretics and return if symptoms worsen
B. Perform a lumbar puncture
C. Obtain a urinalysis
D. Order a chest x-ray
Page 3 of 86
, PRAC 6541
ANSWER:
B. Perform a lumbar puncture
RATIONALE:
A bulging fontanelle in a febrile infant is a concerning sign for meningitis and requires immediate
evaluation. Lumbar puncture is essential for diagnosis, even in the absence of other neurological
signs such as nuchal rigidity, which may be absent in infants. Observation at home would be unsafe.
While urinalysis may be part of a sepsis workup, the presence of a bulging fontanelle makes
meningitis the primary concern requiring LP. Chest x-ray is not indicated without respiratory
symptoms .
QUESTION 7
QUESTION:
A 2-year-old presents with fever of 40°C, tugging at the ears, and crying. Otoscopic examination
reveals a bulging, erythematous, and immobile tympanic membrane with purulent effusion. What is
the first-line antibiotic treatment?
A. Amoxicillin 80–90 mg/kg/day
B. Azithromycin
C. Amoxicillin-clavulanate
D. Cefdinir
ANSWER:
A. Amoxicillin 80–90 mg/kg/day
RATIONALE:
Acute otitis media (AOM) in children under 2 years or with severe symptoms is treated with high-
dose amoxicillin (80–90 mg/kg/day) as first-line therapy for 10 days. Amoxicillin provides excellent
coverage against Streptococcus pneumoniae, the most common pathogen. Azithromycin is not first-
line due to resistance concerns. Amoxicillin-clavulanate is reserved for treatment failures or if the
child has recently received antibiotics. Cefdinir is a second-line agent not typically used as first-line
therapy for AOM .
QUESTION 8
QUESTION:
A 4-year-old with acute otitis media has persistent fever and ear pain after 72 hours of amoxicillin
therapy. What is the most appropriate next step in management?
A. Continue amoxicillin for a full 10-day course
B. Switch to amoxicillin-clavulanate
C. Add ofloxacin otic drops
D. Refer for myringotomy
ANSWER:
B. Switch to amoxicillin-clavulanate
Page 4 of 86
PRAC 6541 – Primary Care of Adolescents
and Children Practicum: Comprehensive
Review Examination – 200 Multiple-Choice
Questions with Evidence-Based Rationales
for Pediatric and Adolescent Primary Care
Certification Preparation
PRAC 6541 – Primary Care of Adolescents and Children Practicum
Comprehensive Examination
QUESTION 1
QUESTION:
A 4-year-old girl is brought to the clinic by her parents who are concerned because she is afraid of
the dark and insists on sleeping with a nightlight. She has no other behavioral concerns and is
developing normally. What is the most appropriate response to the parents?
A. This behavior is abnormal and requires immediate psychological referral
B. Reassure the parents that this is normal for her age and recommend continuing the nightlight
C. Prescribe low-dose melatonin to help with sleep initiation
D. Recommend behavioral extinction by keeping the lights off despite her protests
ANSWER:
B. Reassure the parents that this is normal for her age and recommend continuing the nightlight
RATIONALE:
Fear of the dark is a common and developmentally normal phenomenon in preschool-aged children
(3–5 years), representing typical fantasy thinking and imagination development. Parents should be
reassured that this is not pathological and that providing a nightlight is an appropriate, supportive
intervention. No psychological referral is needed for an isolated fear of the dark without other
concerns. Melatonin is not indicated for this issue, and behavioral extinction by keeping lights off
could increase anxiety and distress unnecessarily .
QUESTION 2
QUESTION:
A 6-year-old boy is unable to hop on one foot, ride a bicycle, or tie his shoes. His parents report he
has always been "clumsy" and was a late walker. He is doing well academically in first grade. What is
the most appropriate next step?
Page 1 of 86
, PRAC 6541
A. Reassure the parents that these skills typically develop by age 7-8
B. Refer for occupational therapy evaluation
C. Order a brain MRI
D. Diagnose developmental coordination disorder and initiate physical therapy
ANSWER:
B. Refer for occupational therapy evaluation
RATIONALE:
The inability to hop on one foot, ride a bicycle, and tie shoes at age 6 suggests possible
developmental coordination disorder (DCD). By age 6, most children have developed these gross and
fine motor skills. While DCD is a possibility, a formal evaluation by occupational therapy is the
appropriate next step for assessment and intervention planning. Reassurance without intervention
would delay needed services, and brain MRI is not indicated without neurological concerns.
Diagnosis should be made by a specialist following comprehensive evaluation .
QUESTION 3
QUESTION:
A 14-year-old girl presents for a well-child visit. She has not yet reached menarche. On examination,
she has breast development consistent with Tanner stage 3 and pubic hair at Tanner stage 3. Her
height and weight are appropriate for age. What is the most appropriate management?
A. Obtain a karyotype to rule out Turner syndrome
B. Reassure the patient and family and follow up in 6 months
C. Start estrogen therapy to induce menarche
D. Order a pelvic ultrasound to evaluate ovarian development
ANSWER:
B. Reassure the patient and family and follow up in 6 months
RATIONALE:
Menarche typically occurs approximately 2–2.5 years after thelarche (breast development), which
usually corresponds to Tanner stage 4 breast development. At Tanner stage 3 with appropriate
growth parameters and no other concerns, this represents normal pubertal progression.
Reassurance and continued monitoring are appropriate. A karyotype or estrogen therapy would be
indicated if there were signs of primary amenorrhea with lack of pubertal development or if
menarche had not occurred by age 16. A pelvic ultrasound is not routinely indicated in this scenario .
QUESTION 4
QUESTION:
A febrile 2-year-old presents with rhinorrhea, cough, and increased work of breathing. The
respiratory rate is 55 breaths per minute with subcostal retractions, and oxygen saturation is 89% on
room air. What is the most appropriate management?
A. Discharge home with amoxicillin and follow up in 24 hours
B. Admit to the hospital for oxygen therapy and supportive care
Page 2 of 86
, PRAC 6541
C. Obtain a chest x-ray before making a decision
D. Administer an albuterol nebulizer trial and reassess
ANSWER:
B. Admit to the hospital for oxygen therapy and supportive care
RATIONALE:
This patient demonstrates hypoxia (SpO2 < 90%), tachypnea, and increased work of breathing with
retractions, which are indications for hospital admission for bronchiolitis or pneumonia
management. Young age (2 years) with significant respiratory distress requires close monitoring and
supportive care, including oxygen therapy. Discharge home would be unsafe. Chest x-ray is not
routinely needed for bronchiolitis and can be obtained after admission if indicated. While albuterol
may be trialed, the primary concern is the hypoxia and work of breathing, which warrant admission .
QUESTION 5
QUESTION:
A 14-year-old reports a severe sore throat, fever, and fatigue. Examination reveals pharyngeal
erythema, tonsillar exudates, and tender anterior cervical lymphadenopathy. A rapid strep test is
negative. What is the most appropriate next step?
A. Treat with amoxicillin empirically
B. Obtain a throat culture
C. Order a Monospot test for infectious mononucleosis
D. No further testing; diagnose viral pharyngitis
ANSWER:
C. Order a Monospot test for infectious mononucleosis
RATIONALE:
In an adolescent with exudative pharyngitis, significant lymphadenopathy, fatigue, and a negative
rapid strep test, infectious mononucleosis (Epstein-Barr virus) should be strongly suspected. The
Monospot test has high specificity in adolescents and is the appropriate next step. Empirical
antibiotics are not indicated without confirmation of bacterial infection. A throat culture would be
appropriate if the rapid strep were positive or if the suspicion for GAS pharyngitis remained high
despite negative rapid test. Dismissing this as viral pharyngitis without further workup would miss
the diagnosis of mononucleosis .
QUESTION 6
QUESTION:
A 6-month-old infant presents with fever of 39.5°C (103.1°F), irritability, and a bulging fontanelle.
There are no focal neurological findings. What is the most appropriate next step?
A. Observe at home with antipyretics and return if symptoms worsen
B. Perform a lumbar puncture
C. Obtain a urinalysis
D. Order a chest x-ray
Page 3 of 86
, PRAC 6541
ANSWER:
B. Perform a lumbar puncture
RATIONALE:
A bulging fontanelle in a febrile infant is a concerning sign for meningitis and requires immediate
evaluation. Lumbar puncture is essential for diagnosis, even in the absence of other neurological
signs such as nuchal rigidity, which may be absent in infants. Observation at home would be unsafe.
While urinalysis may be part of a sepsis workup, the presence of a bulging fontanelle makes
meningitis the primary concern requiring LP. Chest x-ray is not indicated without respiratory
symptoms .
QUESTION 7
QUESTION:
A 2-year-old presents with fever of 40°C, tugging at the ears, and crying. Otoscopic examination
reveals a bulging, erythematous, and immobile tympanic membrane with purulent effusion. What is
the first-line antibiotic treatment?
A. Amoxicillin 80–90 mg/kg/day
B. Azithromycin
C. Amoxicillin-clavulanate
D. Cefdinir
ANSWER:
A. Amoxicillin 80–90 mg/kg/day
RATIONALE:
Acute otitis media (AOM) in children under 2 years or with severe symptoms is treated with high-
dose amoxicillin (80–90 mg/kg/day) as first-line therapy for 10 days. Amoxicillin provides excellent
coverage against Streptococcus pneumoniae, the most common pathogen. Azithromycin is not first-
line due to resistance concerns. Amoxicillin-clavulanate is reserved for treatment failures or if the
child has recently received antibiotics. Cefdinir is a second-line agent not typically used as first-line
therapy for AOM .
QUESTION 8
QUESTION:
A 4-year-old with acute otitis media has persistent fever and ear pain after 72 hours of amoxicillin
therapy. What is the most appropriate next step in management?
A. Continue amoxicillin for a full 10-day course
B. Switch to amoxicillin-clavulanate
C. Add ofloxacin otic drops
D. Refer for myringotomy
ANSWER:
B. Switch to amoxicillin-clavulanate
Page 4 of 86
