PNP 6680 Midterm Exam | Questions, Answers and Rationales

PNP 6680 Midterm Exam | Questions, Answers and Rationales A 7-year-old is found to have a white mass behind the tympanic membrane on the right side during routine physical exam. Audiogram confirms a conductive hearing loss in the right ear. He has no history of previous ear surgery. Examination reveals a deep retraction pocket. What is your diagnosis? Group of answer choices A. Primary acquired cholesteatoma B. Secondary acquired cholesteatoma C. Glomus tympanicum D. Congenital cholesteatoma Rationale: Primary acquired cholesteatoma develops because of negative middle ear pressure which causes a retraction of the tympanic membrane, most frequently in the pars flaccida. There is an outbreak of shigella infection is the community. You suspect that your three -year-old patient has a severe shigella infection. Because this organism is particularly drug-resistant, which of the following antibiotics is MOST appropriate to treat this infection? A. Ceftriaxone (Rocephin) B. Amoxicillin (Amoxil, Moxatag) C. TMP-SMX (Bactrim, Sulfatrim) D. Ampicillin (Omnipen, Principen Rationale: Treatment of Shigella with antibiotics shortens the duration of bacterial shedding and clinical symptoms. Antibiotics are indicated if the disease is severe, or if the patient is immunocompromised. Resistant to antibiotics has been reported world-wide; in the absence of susceptibility testing, the use of IM ceftriaxone for 2-5 days for organism resistance is mot appropriate in this situation The Ishihara test is used to detect A. Streptococcal colonization B. the red reflex C. bone conduction of sound D. Color blindness Rationale: Visual testing for color sensitivity should occur at 4 year of age or before school entry. Difficulty or confusion when identifying colors may be related to cognitive learning differences and should alert parents and teachers. Color blindness is more prevalent in males. Testing should be completed with the Hardy-Rand-Rittler (HRR) test. The HRR test uses a series of symbols rather than numbers, which allows reliable testing to be don on young children. The Ishihara test, which uses a series of figures and letters composed of spots of certain colors, can be used on the older child. The child with a color vision deficit fails to see letter or figures of a certain color. Any child with hemihypertrophy and any child with aniridia should also be routinely screened for what condition A. Neurofibroamatosis B. Turner's Syndrome C. Tuberous Sclerosis D. Wilm's tumor Rationale: An important feature of Wilms tumor is the occurrence of associated congenital anomalies including renal abnormalities, such as cryptorchidism, hypospadias, duplication of the collecting system, ambiguous genitalia, hemihypertrophy, aniridia, cardiac abnormalities, and Beckwith-Wiedemann, Denys-Drash, and Perlman syndromes. Wilms tumor occurs with equal frequency in both sexes although males are diagnosed younger. There is a higher frequency in African Americans and a lower frequency in Asians. Please choose the correct definition for the condition sundowning: A. Downward deviation of the eyes associated with hydrocephalus, intracranial hemorrhage, other pathologic brain conditions, or early sign of cerebral palsy. B. Acute inflammation of palpebral and bulbar surfaces of the eye C. An acute or chronic irritation of the eyelid D. A cyst in the eyelid caused by inflation of the meibomian gland Rationale: Sundowning - Downward deviation of the eyes associated with hydrocephalus, intracranial hemorrhage, other pathologic brain conditions, or early sign of cerebral palsy; a sign of increased intracranial pressure when symptoms of lethargy, poor feeding, vomiting, bulging fontanel, or rapidly increasing head circumference are noted. A 5-year-old child is brought to the clinic with bilateral purulent discharge from both eyes. Physical findings include conjunctival redness, bilateral nasal discharge, and a bulging tympanic membrane in the left ear. Based on the history and physical examination the most common causative organism is: A. Adenovirus B. trachomatis C. Nontypeable Haemophilus influenzae D. Streptococcus pneumoniae Rationale: Review: Burns et al 6th Ed p 746 Non typeable H. influenza remains a common cause of AOM and it is the most common cause of otitis-conjunctivitis syndrome Please choose the correct definition for the condition chalazion: A. Solid intraocular tumor B. Most often first indication of systemic jaundice and liver disease in children and adolescents C. A cyst in the eyelid caused by inflammation of the meibomian gland D. Exophthalmia Rationale: Chalazion - A cyst in the eyelid caused by inflammation of the meibomian gland; usually painless and usually resolves spontaneously Please choose the correct definition for the condition congenital glaucoma: A. Causes ocular enlargement and visual impairment B. Solid intraocular tumor C. Inflammation of the episclera D. Downward deviation of the eyes associated with increased intracranial pressure Rationale: Congenital glaucoma - Symptoms of photophobia (sensitivity to bright light), epiphora (excessive tearing), and blepharospasm (eyelid squeezing), conjunctival injection, causes ocular enlargement and visual impairment. Please choose the correct definition for the condition Blepharitis: A. An infection of the sebaceous glands of Zeis at base of eyelashes B. Inflammation of the nasolacrimal sac C. An acute or chronic irritation of the eyelid D. Inflammation of the layer beneath conjunctiva, causing acute irritation and redness Rationale: Blepharitis - An acute or chronic irritation of the eyelid; may be caused by allergic conditions such as seborrhea, bacterial infections (staphylococcl), inflammation of meibomian glands, or parasities.Duderstadt, Pediatric Physical Examination 3rd Ed. P. 192 TABLE 12.4 EYE CONDITIONS Please choose the correct definition for the condition episcleritis: A. An infection of the sebacious glands of Zeis at base of eyelashes B. Solid intraocular tumor C. Inflammation of the layer beneath conjunctiva, causing acute irritation and redness of eyes D. Protrusion of the eye globe Rationale: Episcleritis - Inflammation of the episclera, layer beneath conjunctiva, causing acute irritation and redness of eyes, occurs in 2%-5% of children with inflammatory bowel disease (IBD), management with topical therapies and management of IBD. Please choose the correct definition for the condition exophthalmos: A. Proptosis B. Downward deviation of the eyes associated with hydrocephalus, intracranial hemorrhage, other pathologic brain conditions, or early sign of cerebral palsy. C. Inflammation of nasolacrimal sac D. Abnormal tearing pattern Rationale: Exophthalmos - Protrusion of the blobe, also known as exophthalmia or proptosis, may be unilateral (e.g., orbital tumor, orbital cellulitis, or a tretrobulbar hemorrhage) or bilateral (Graves disease or hyperthyroidism) Please choose the correct definition for the condition hordeolum: A. Overgrowth of conjunctival tissues extending from the lateral canthus to cornea B. An infection of the sebaceous glands of Zeis at base of eyelashes C. Symptoms of photophobia, epiphora, blepharospasm, conjunctival injection D. A cyst in the eyelid caused by inflammation of the meibomian gland Rationale: Hordeolum - Stye; An infection of the sebaceous glands of Zeis at base of eyelashes; can be external or internal. Internal stye or hordeolum is an infection of the meibomian sebaceous glands lining the inside of the eyelid. Please choose the correct definition for the condition lacrimal duct obstruction: A. Abnormal tearing pattern; upward pressure on lacrimal sac often yields mucoid discharge B. Causes ocular enlargement and visual impairment C. An acute of chronic irritation of the eyelid D. A cyst in the eyelid caused by inflammation of the meibomian gland Rationale: Lacrimal duct obstruction - Abnormal tearing pattern; upward pressure on lacrimal sac often yields mucoid discharge; massage of nasolacrimal duct with downward pressure on lacrimal sac may open duct to normal drainage by 6 months of age Please choose the correct definition for the condition pterygium: A. Overgrowth of conjunctival tissue extending from the lateral canthus to cornea B. Acute inflammation of palpebral and bulbar conjunctiva C. Downward deviation of the eyes associated with increased intracranial pressure D. Inflammation of nasolacrimal sac Rationale: Pterygium - Overgrowth of conjunctival tissue extending from the lateral canthus to cornea; begins in childhood with overexposure to sun and constant dust/environmental irritants Please choose the correct definition for the condition retinoblastoma: A. Solid intraocular tumor B. Acute inflammation of palpebral and bulbar conjunctive C. Symptoms of photophobia, epiphora, and blepharospasm, conjunctival injection D. A sign of increased intracranial pressure Rationale: Retinoblastoma - Solid intraocular tumor; presents as abnormal retinal or retinal light reflex in newborn or as white pupillary reflex in infant; can be associated with proptosis, protruding eye bulb Please choose the correct definition for the condition scleral icterus: A. Overgrowth of conjunctival tissue extending for the lateral canthus to cornea B. Swelling and redness around the lacrimal sac in the area of inner canthus C. Most often first indication of systemic jaundice and liver dysfunction in neonate D. Early sign of cerebral palsy Rationale: Scleral icterus - yellowish coloration of sclera extending to the cornea; most often first indication of systemic jaundice and liver dysfunction in neonate; often first sign of liver disease in children and adolescents Please choose the correct definition for the condition dacryocystitis: A. Inflammation of nasolacrimal sac B. Acute inflammation of palpebral and bulbar conjunctiva C. Overgrowth of conjunctival tissue extending from the lateral canthus to cornea D. Causes ocular enlargement and visual impairment Rationale: Dacryocystitis - Inflammation of nasolacrimal sac; swelling and redness occur around lacrimal sac in are of inner canthus This picture is an example of: A. Hypertropia B. Exotropia C. Esotropia D. Normal eye alignment Rationale: "An inward deviation of the eye is referred to as esotropia" Lillie is a 6-month-old girly who develops a persistent cough with progressively worsening paroxysms and cyanosis. There is occasional posttusive emesis. She is afebrile. Between coughing spells, the physical examination is normal. At this time, what would be the most important question to ask the family regarding Lillie's medical history? A. Immunizations B. Birth weight C. Family history of reactive airways disease D. Early infant deaths in relatives Rationale: This history is highly suggestive of pertussis. The clinical course is divided into three stages: 1. the catarrhal stage, 2-10 days in duration, characterized by rhinorrhea, lacrimation, and sometimes low-grade fever 2. the paroxysmal stage, lasting 1-6 weeks, during which there are intermittent episodes of coughing that may terminate with a forced inspiration against a partially closed glottis resulting in a "whoop" or may terminate with vomiting 3. the convalescent stage, lasting up to 6 months, during which the coughing episodes gradually resolve. Infants with pertussis often do not whoop because of their inability to generate sufficient inspiratory forces. Between episodes of cough, the examination is often normal. Of the choices given, the immunization status is of most importance. Lillie's white blood cell count is 32,000/mm3, with 80% lymphocytes and 2% mononuclear cells. What is the most appropriate next step at this time? A. Repeat the blood count in 24 hours B. Order a CBC with peripheral smear C. Treat symptomatically with humidifier and honey for the cough D. Prescribe oral azithromycin Rationale: Prescribe oral azithromycin - A high white blood count with a marked lymphocytosis is characteristic of pertussis. Therefore, prescribing a macrolide, specifically azithromycin, is the most appropriate choice. A repeat CBC is not needed to follow the treatment. Infact, antibiotics do not hasten the resolution of the illness but will decrease spread to other household members. Even so, all household contacts should also be treated prophylactically. Robin is a 6-year-old male known to have mild intermittent asthma. Hilar lymphadenopathy is noticed on the chest x-ray. Robin and his family live in rural Memphis on a farm with chickens. Tuberculin skin testing is negative and the family denies history of exposure to tuberculosis. You suspect histoplasmosis infection. What is the most likely mode of transmission of the spores? A. Skin inoculation B. Inhalation C. Oral ingestion D. Droplet inhalation Rationale: Histoplasma capsulatum is the most common primary systemic mycosis in the United States and most often occurs in the Ohio and Mississippi river valleys. The organism grows in moist soil and is facilitated by bird droppings. As in adults, the respiratory tract is the portal of entry for histoplasmosis in essentially all cases in children. Inoculation other than by inhalation is exceedingly rare, and person to person transmission does not occur. What is the major source of immunity conferred in breast milk? A. IgM B. IgA C. IgD D. Complement mediated Rationale: Human milk provides optimal nutrition for the growing infant. It contains lactose and other carbohydrates that are substrates for protective microflora, such aBifidobacterium and Lactobacillus spp. The major immunoglobulin present in breast milk is secretory IgA, and is available to act at the mucosal surface of the small intestine. Immunity is conferred against many specific enteropathogens and toxins. It also has been shown to inhibit binding ofH influenzae and S pneumoniaeto pharyngeal cells Camille is a 6-year-old-girl who is unimmunized and has a fever of 104 F (40 C) with crops of vesicles on the trunk along with scattered scabbed lesions. Which of the following infections is the likely diagnosis? A. Scabies B. HHV-6 C. Varicella D. Measles Rationale: Primary varicella infection (chickenpox) is most likely to present with a generalized, pruritic vesicular rash and fever. The typical exanthem appears first on the scalp, face, or trunk. New crops of lesions develop over a 1-7 day period. Progression from vesicle to pustule to crusted scab occurs quickly such that lesions of all stages are present after the first 48 hours#*) A 12-month-old child presents to your office for a well-child visit. The mother informs you that at the 6 month visit the child had fever of 101.6 and localized leg swelling after diphtheria-tetanus-acellular pertussis (DTaP) vaccine. She is worried if this vaccine should be withheld. Which of the following is a contraindication to receiving DTaP A. A preterm infant who is 8 weeks of age B. Encephalopathy within 7 days of previous dose C. A prior dose associated with temperature > 103.1 F (39.5 C) D. Family history of seizures Rationale: The use of a combined diptheria-tetanus-acellular pertussis (DTaP) vaccine is routine and is the method of choice for the primary immunization of infants and young children. There are two contraindications to pertussis immunization: an immediate anaphylactic reaction or encephalopathy within 7 days of a prior dose manifested by major alteration in consciousness or protracted generalized or focal seizures without recovery within 24 hours. A malnourished 3-year-old refugee child from Honduras has a positive tuberculin skin test (TST>10 for this age). Which of the following would be most concerning for extra-pulmonary disease? A. Fever B. Weight loss C. Hilar lymphadenopathy on roentograph D. Hepatosplenomegaly Rationale: Fever, cough, hilar lymphadenopathy, and elevated sedimentation rate are seen commonly in uncomplicated primary pulmonary tuberculosis. Hepatosplenomegaly is generally not seen in uncomplicated primary pulmonary tuberculosis, but does occur in more the 50% of children with disseminated disease. A 10-year-old child present to the clinic with a 2-day history of fever and newly noted altered mental status. His mother reports that he had been camping with his grandparents and sustained a "ton" of mosquito bites. Mosquitoes are recognized as vectors in the transmission of encephalitis of which of the following viruses? A. Arbovirus B. Mumps Virus C. Coxsackievirus D. Enterovirus Rationale: Mumps virus, enterovirus, and coxsackievirus are spread primarily by direct contact (eg, respiratory droplets, hands) and not through an arthropod vector. A number of viruses, notably the arboviruses, are spread by mosquito vectors, as well as ticks and sandflies. Examples in North America include eastern and western equine encephalitis, St. Louis encephalitis, and LaCrosse and West Nile encephalitis. Junior is a 12-year-old boy who presents to urgent care with a 2 week history of cough and wheeze. He doesn't have a history of asthma. Chest x-ray findings include bilateral patchy infiltrates. Oxygen saturation in normal. What is the most likely etiology of his pneumonia? A. Pneumocystis jiroveci B. Chlamydophila psittaci C. Mycoplasma pneumoniae D. Streptococcus pneumoniae Rationale: Mycoplasma pneumoniae has long been known to cause pneumonia, bronchitis, otitis media, myringitis bullosa, and nonspecific upper respiratory infection. This organism also has been recognized as a cause of various non-respiratory manifestations such as polymorphous mucocutaneous eruptions including Stevens-Johnson syndrome, encephalitis, and meningitis. Other neurologic manifestations reported with M pneumoniae infection include transverse myelitis, psychosis, poliomyelitis-like syndrome, and Guillain-Barre syndrome. Streptococcus pneumoniae and S aureus typically cause lobar pneumonia, oftentimes with empyema. While chest radiographs findings in M pneumoniae infection often include patchy alveolar infiltrates with small pleural effusion. Pneumocystis jiroveci is considered a pathogen in the immunocompromised host. It is wintertime and you have been seeing children of different ages in the clinic with upper respiratory symptoms. Which of the following children is most likely to have group A streptococcal infection? A. Tonsillitis, rash, and fever in a 5-year-old B. Fever, congestion, cough, and pharyngitis in a 3-year-old C. Cough and pharyngitis in a 15-year-old D. Exudative pharyngitis in a 1-year-old Rationale: Pharyngotonsillitis is the typical clinical manifestation of group A streptococcal infection. Scarlet fever is a syndrome of tonsillitis, fever, and rash caused by an erthrogenic toxin-producing streptococcus in a patient lacking antitoxin immunity. Streptococcal respiratory tract infections generally peak in children aged 5-11 years and winter predominance is generally noted. Patients younger than 3 years of age with exudative pharyngitis are more likely to have viral disease, as are older children who present with sore throat, cough, and/or rhinorrhea. You are a volunteer at a rural clinic in Haiti and examine a 6-year-old boy who has a temperature of 100F (38C), bilateral tender parotid swelling, and pain when you flex his neck. He has been complaining of a headache. His immunization history is unknown. What is the most likely cause of this child's infection? A. Leukemia B. Epstein-Barr Virus C. Cysticercosis D. Mumps Rationale: Mumps causes subclinical infection in one-third of cases. The most common manifestation is unilateral parotid swelling that becomes bilateral with a prodrome of headache, fever, abdominal pain, and anorexia. EBV infection typically manifests as exudative pharyngitis and cervical chain adenopathy. Leukemia may vary in presentation, but often presents with fever, hematologic abnormality, petechial rash, and nonspecific complaints. The initial sign of cysticercosis in children is oftentimes a seizure in an otherwise healthy child. How often should people who have had their initial tetanus immunizations receive a booster? A. 5 years B. It is life-long immunity C. 10 years D. 1 year Rationale: After the initial tetanus immunization, people should receive a tetanus immunization every 10 years. A tetanus immunization is necessary if it has been 5 years since the last tetanus immunization and the patient has a contaminated wound. Emmie, a 3-year-old girl presents with 6 days of fever; conjunctivitis; red, cracked lips; polymorphous rash; and an isolated 2 cm cervical lymph node. You diagnose Kawasaki syndrome based on clinical findings. Which of the following sequelae of Kawasaki syndrome is most common? A. Fulminate hepatitis B. Recurrent pericarditis C. Cerebral edema D. Coronary artery aneurysm Rationale: Kawasaki syndrome is a multi-system vasculitis which typically manifests with high, spiking fever for 5 or more days along with conjunctival injection, mucositis, polymorphous rash, changes in peripheral extremities, and single cervical lymph nodes swelling. Treatment with aspirin and intravenous immune globulin is indicated; without treatment, 20% of children develop coronary artery aneurysms. Fulminant hepatitis, recurrent pericarditis, cerebral edema, are not features of Kawasaki syndrome. Zamaria is a 3-year-old girl who returns to clinic with continued fever for 8 days, lymphadenopathy, splenomegaly, and numerous reactive or atypical lymphocytes on peripheral blood smear. The monospot test is negative. A likely cause of this clinical picture is infection with which of the following? A. Epstein-Barr virus B. Rubella virus C. Respiratory syncytial virus D. Adenovirus Rationale: The monospot tests for heterophile antibodies, which are rarely produced by children younger than 4 years. A negative result does not exclude EBV infection. Patients present with a typical clinical picture of lymphadenopathy, splenomegaly, and atypical (reactive) lymphocytes on peripheral blood smear. RSV and rubella infection are unlikely to cause atypical lymphocytosis or splenomegaly. Although both herpes and noncongenitally acquired rubella may present with lymphadenopathy, adnovirus typically causes an upper respiratory tract infection and pharyngoconjunctival fever. Junie is a 15-month-old girl who presents to your office with a mild fever, and an intense, red flushed cheeks with circumoral pallor. What is the most likely etiology of this febrile exanthem? A. Rubeola virus B. Parvovirus B19 C. Enterovirus 71 D. Coxsackievirus A16 Rationale: The clinical manifestations of human parvovirus B-19 include erythema infectiosum (Fifth's Disease), polyarthropathy syndrome (adults especially women), chronic anemia/pure red cell aplasia (immunocompromised hosts), transient aplastic crisis (sickle cell patients), and hydrops fetalis/congenital anemia (fetus). Erythema infectiosum is most commonly diagnosed and easily recognized. A distinctive rash featuring a "slapped cheek" appearance is noted that is often associated with circumoral pallor. Coxsackievirus A16 and enterovirus 71 are causes of hand-foot-and mouth syndrome. Enterovirus 71 is also associated with encephalitis. Adenovirus is not associated with a characteristic exanthem, however it may cause conjunctivitis. Rubeola virus is the causative agent of measles, and generally presents with a triad of cough, coryza, and conjunctivitis, as well as Koplik spots and rash. Piers, a 14-year-old boy, presents to clinic with a 2 week history of cough and rhinorrhea. He now has 2-day history of fever and frontal headache. On examination he is tender to palpation over his maxillary sinuses. You make the clinical diagnosis of acute sinusitis. He has no allergies to medication. What is the first-line therapy for this child? A. ceftriaxone B. clindamycin C. Amoxil or amoxicillin clavulanate. D. azithromycin Rationale: AAP Key action Statement 4 Diagnosis and Management of Acute Bacterial Sinusitis in Children:Clinicians should prescribe amoxicillin with or without clavulanate as first-line treatment when a decision has been made to initiate antibiotic treatment of acute bacterial sinusitis. Amoxicillin with or without clavulanate is the first-line therapyacute sinusitis in children without penicillin allergy. Initial therapy for acute sinusitis should be with an agent of the narrowest spectrum that is active against the likely pathogens, including M catarrhalis, H influenzae, and S pneumoniae. A 9-month-old presents to your clinic with 2-day history of temperature of 101.6 F (38.7 C) and fussiness. Mother reports that the infant has been pulling at his ear. On physical examination, you note an erythematous, bulging, right tympanic membrane with purulent effusion. You diagnose otitis media. What organism is the most likely cause of this infection? A. Pseudomonas aeruginosa B. Streptococcus pneumoniae C. Staphylococcus aureus D. Streptococcus pyogenes Rationale: Streptococcus pneumoniae is one of the most common causes of acute otitis media and of invasive bacterial infections in children. Nontypeable H influenzae is also a common cause, but since the advent of Hib vaccine H influenzae type B is rarely seen. Staphylococcus aureas andP aeruginosa cause complicated otitis media in patients with tympanostomy tubes. Pseudomonas aeruginosa is the most common cause of otitis externa. Streptococcus pyogenes can cause otitis media, however less frequently. A child with a history of cancer who has received chemotherapy comes to you for an MMR vaccine. How much time must elapse after chemotherapy for the child to receive this vaccine? A. 5 months B. 12 months C. 4 months D. 3 months Rationale: Certain drugs may cause immunosuppression. For instance, persons receiving cancer treatment with alkylating agents or antimetabolites, or radiation therapy should not be given live vaccines. Live vaccines can be given after chemotherapy has been discontinued for at least 3 months. Blake is in clinic 7/1/17 for his 2 month well baby checkup. His DOB is 5/1/17. His last immunization was his Hep B vaccine on 5/1/17. What immunizations should be recommended today? A. DTaP-IPV-Hib, PCV, and Rotavirus B. Hep B, DTaP-IPV-Hib, and Rotavirus C. Hep B, Hib, PCV, and Rotavirus D. Hep B-DTaP-IPV, Hib, PCV, and Rotavirus Rationale: See Immunization Schedule for 2 month vaccines. Maribel is in clinic 7/1/17or a checkup after entering foster care. Maribel is 20 months old and her immunization record is as follows: DOB 11/4/15. Hep B 11/4/15, 1/7/16, 9/5/16 DTaP 1/7/16, 4/1/16, 9/5/16 IPV 1/7/16, 4/1/16, 9/5/16 Hib 1/7/16, 4/1/16, 9/5/16 PCV 1/7/16, 4/1/16, 9/5/16 Rotavirus 1/7/16, 4/1/16 What immunizations do you recommend today? A. Hep B, DTaP, IPV, Hib, PCV, MMR, Varicella, Hep A B. Hep B, DTaP, IPV, Hib, PCV, MMR, Varicella, Hep A, Rotavirus C. DTaP, Hib, PCV, MMR, Varicella, Hep A D. DTaP, Hib, PCV, MMR, Varicella, Hep A, Rotavirus Choose an action that demonstrates elements of good outpatient antibiotic stewardship. A. Avoid delayed prescribing or watchful waiting of antibiotic prescribing B. Use evidence-based diagnostic criteria and treatment recommendations C. Do not waste time in self-evaluating antibiotic prescribing practices D. Do not display public commitments in support of antibiotic stewardship In teaching that antibiotics are of little benefit for viral infections, education for prescribers and patients that supports appropriate antibiotic use includes 2 of the following. Select the 2 most correct answers. A. Some mild bacterial infections may improve without antibiotics B. Use of probiotics and other complementary treatments to limit antibiotic use C. When to seek care for worsening symptoms D. The patient may shorten the course of antibiotics when symptoms improve Rationale: Outpatient antibiotic Use and Prescribing for the Pediatric Patient Please match the phase of disaster management to the action. A. Provide patients and their families with information of the importance of family preparedness. B. Participate is a disaster drill within your facility/clinic/office for various scenarios. C. Contact your community emergency headquarter to offer pediatric expertise. D. Critique the disaster response and identify opportunities for improvement. A. Prevention/Mitigation B. Preparedness C. Response D. Recovery If it is likely that the poqwer will be off to freezers and refrigerators storing vaccines longer than ___ hours, plan on moving vaccines to a safer location per AAP Preparedness Checklist for Pediatric Practices. Please fill in the blank with the correct answer. A. 24 hours B. 4 hours C. 1 hour D. 72 hours Rationale: "If it is likely that the power will be off for more than 4 hours, plan on moving vaccines to a safer location." Which of the following statements is a correct concerning the unique physiologic needs of children? A. Children breath less air per pound of body weight than adults. B. Children are safer because they are closer to the ground. C. Children are less prone to dehydration because they have less fluid in their bodies. D. Children have thinner skin and higher body surface area to mass ratio A 3-year-old child whose immunizations are up-to-date has been exposed to measles because of a localized outbreak among unvaccinated children. The parent reports that contact with infected children occurred within the last 2 days at a birthday party. What is the best course of action? A. Give antiviral medications at the first sign of symptoms. B. Reassure the parent that most exposed children will not get measles. C. Give the child a dose of immune globulin to mitigate the response. D. Administer the MMR vaccine to help prevent disease. Rationale: The measles vaccine can be given to those exposed if given within 72 hours of exposure. IG may be given in those without prior measles vaccine. Antiviral medications are not effective. Nine of 10 children who are unimmunized or under-immunized will contract the disease if exposed. A child is brought to the clinic with a fever, headache, malaise, and a red, annular macule surrounded by an area of clearing and a larger, erythematous annular ring. The child complains of itching at the site. What will the primary care pediatric nurse practitioner do to determine the diagnosis? A. Obtain a skin culture B. Order blood cultures C. Perform serologic testing D. Ask about recent tick bites Rationale: The presence of an erythema migrans rash with a positive history is diagnostic for Lyme disease, and no further testing is necessary. Because Borrelia burgdorferi is transmitted to humans through ticks, asking about recent tick bites is paramount to making this diagnosis. Skin and blood cultures are not indicated. Serology testing for IgG and IgM antibodies may be performed if the child is symptomatic without the characteristic EM rash. Borrelia burgdorferi (Bb), a spirochete, is the causative agent that is carried and transmitted to humans by infected species of Ixodes ticks. Lyme disease is the most commonly reported vector-borne infection in the United States and Europe and is a growing epidemic. Lyme disease can present with a variety of symptoms. Only 25% to 30% of people diagnosed recall having had a tick bite (Nichols and Windemuth, 2013). Classic Lyme disease can be divided into three stages: 1. Stage 1 (early localized disease): Generally within 1 to 2 weeks after the bite, a typical rash may appear at the inoculation site (range from 1 to 31 days; mean 10 days). Erythema migrans (EM) rash begins as a red, annular macule or papule at the site of the tick bite that progresses in 24 to 48 hours to being surrounded by a clearing and then a larger annular erythematous outer ring. It may appear as a "bull's-eye" and needs to be at least 5 cm in size to meet diagnostic criteria for EM (Fig. 24-5). Multiple lesions may occur in different sites; however, 10% of children in North America may not demonstrate EM (Sood and Krause, 2014). EM typically is warm and pruritic but not painful. The rash remains for a few weeks and fades even if untreated. In many cases, the rash does not follow this classic pattern but instead may resemble nummular eczema, tinea, granuloma annulare, an insect bite, or cellulitis; the rapid enlargement of erythema migrans helps distinguish it. Those without EM and 50% with EM may present with flu-like symptoms including fever, malaise, headache, arthralgia, myalgia, and stiff neck (Nichols and Windemuth, 2013). Without treatment, these symptoms, including the rash, may become intermittent, lasting for weeks to months. A 10-month-old infant has an erythematous, fluctuant, non-draining abscess on the right buttock after 10 days of treatment with amoxicillin for impetigo. What is the next step in managing this infant's care? A. Empiric treatment with clindamycin B. Culture of any superficial open surface wounds C. Consultation with a pediatric infectious disease specialist D. Incision and drainage of the abscess with culture Rationale: Non-draining, fluctuant abscesses should be incised, drained, and cultured to determine the causative organism. Consultation with an infectious disease specialist is necessary for seriously ill children, those who are immunocompromised, or those who have an increased risk for myocarditis. Superficial wounds should not be cultured because of the chance of sample contamination. Empiric treatment may be considered for severe infection, but many mild abscesses may not need antibiotic therapy after I&D. Recommended management strategies (Burns Fig. 24-6) include: • Incision and drainage (I& D) with culture is the treatment of choice for any non-draining but fluctuant abscess; antibiotics alone are ineffective (performing I& D prior to localization of pus is not effective and may promote more serious infection). Antibiotics are not needed after draining the abscess in mild cases. Consider empiric treatment