NURS 6541 Exam 4 | NURS 6541 / NRNP 6541 Primary Care of Adolescents & Children
| Actual Q&A with Rationale | Walden University
1. A 10-year-old boy with severe persistent asthma (on high-dose ICS/LABA and
montelukast) presents for a well-child visit. He has had two ED visits and one
hospitalization in the past year. His inhaler technique is poor, and his family uses a
wood-burning stove for heat. Which intervention is most likely to reduce his
exacerbation risk?
A. Increase ICS to maximum dose and add tiotropium
B. Refer to an asthma specialist and address home environmental triggers
C. Switch from LABA to a different bronchodilator
D. Prescribe an oral corticosteroid burst and follow up in 2 weeks
Correct Answer: B
Rationale: This child has poorly controlled asthma with environmental triggers (wood
stove). Specialty referral and environmental control are high-impact interventions.
Medication adjustment is important but secondary to mitigating triggers and improving
technique.
2. A 7-year-old girl with type 1 diabetes presents with HbA1c of 9.8%. She checks blood
glucose 2-3 times daily and admits to skipping insulin doses because "it hurts." Her
parents are divorced and share custody. Which approach is most likely to improve
adherence?
A. Switch to insulin pump therapy immediately
B. Involve a child life specialist and consider a collaborative behavior plan
C. Increase insulin doses to compensate for missed doses
D. Refer to endocrinology for inpatient management
Correct Answer: B
Rationale: Addressing needle phobia and family dynamics is essential. A behavior plan
and psychosocial support can improve adherence. Pump therapy may help but
requires motivation and education. Increasing doses is unsafe. Inpatient management is
not indicated.
3. A 14-year-old female with obesity (BMI 34) presents with irregular menses, hirsutism,
and acanthosis nigricans. Fasting glucose is 112 mg/dL, HbA1c 5.9%. Which is the most
appropriate initial pharmacotherapy?
A. Metformin 500 mg daily, titrate up
B. Oral contraceptive pills for cycle regulation
,C. Spironolactone for hirsutism
D. Orlistat for weight loss
Correct Answer: A
Rationale: This presentation is consistent with polycystic ovary syndrome (PCOS) and
prediabetes. Metformin improves insulin sensitivity, may restore ovulation, and slows
diabetes progression. OCPs are for cycle regulation but do not address metabolic risk.
Spironolactone and orlistat are second-line.
4. A 6-year-old boy with ADHD (on methylphenidate LA 20 mg daily) has lost weight
from the 50th to the 25th percentile over 6 months. He has poor appetite at lunch.
Which management change is most appropriate?
A. Discontinue methylphenidate and start guanfacine
B. Recommend high-calorie breakfast and dinner, and give medication after meals
C. Increase methylphenidate to 30 mg daily
D. Refer to a pediatric gastroenterologist
Correct Answer: B
Rationale: Stimulant-associated appetite suppression can be managed by timing
medication after meals and optimizing caloric intake at other times. Changing to a non-
stimulant is an option if weight loss is severe, but dietary strategies should be tried first.
Increasing dose may worsen appetite. GI referral is not indicated.
5. A 15-year-old male presents with acute onset of severe, colicky left testicular pain
and nausea. He has no fever. On exam, the left testicle is high-riding and swollen. What
is the most appropriate next step?
A. Obtain a testicular ultrasound with Doppler
B. Elevate the scrotum and apply ice
C. Prescribe antibiotics for epididymitis
D. Schedule surgical evaluation in 24 hours
Correct Answer: A
Rationale: Testicular torsion is a surgical emergency. Urgent Doppler ultrasound is
needed to assess blood flow. Immediate urology consultation is also critical. Elevation
and ice are for epididymitis. Antibiotics are inappropriate without confirmed infection.
Delay in surgery can result in testicular loss.
6. A 2-year-old child presents with a 3-day history of fever, vomiting, and diarrhea. He
has dry mucous membranes, sunken eyes, and no urine output for 8 hours. He is
lethargic. What is the most appropriate immediate management?
, A. Oral rehydration solution 20 mL/kg over 4 hours
B. IV normal saline bolus 20 mL/kg, then reassess
C. Antiemetic suppository and clear liquids
D. Start IV maintenance fluids and admit
Correct Answer: B
Rationale: This child has severe dehydration with lethargy. IV bolus is indicated for
rapid rehydration. Oral rehydration is not safe in lethargic patients. Antiemetics do not
address dehydration. Admission is needed after initial resuscitation.
7. A 12-year-old girl with a history of epilepsy (on lamotrigine) presents with a new-
onset, generalized, erythematous rash with target lesions and mucosal involvement. She
started lamotrigine 4 weeks ago. What is the most likely diagnosis?
A. Viral exanthem
B. Stevens-Johnson syndrome (SJS)
C. Urticaria
D. Scarlet fever
Correct Answer: B
Rationale: Lamotrigine carries a risk of SJS, especially during dose titration. The
combination of target lesions, mucosal involvement, and recent drug initiation is highly
concerning. Immediate discontinuation of lamotrigine and urgent referral are required.
Viral exanthem is less likely with mucosal involvement.
8. A 9-year-old boy with cystic fibrosis presents with increased cough, decreased
energy, and weight loss over 2 weeks. He has a fever of 38.5°C and O2 sat 93% on room
air. Sputum culture grows Pseudomonas aeruginosa. What is the most appropriate
initial management?
A. Start oral ciprofloxacin and monitor as an outpatient
B. Admit for IV antibiotics (e.g., ceftazidime and tobramycin)
C. Continue current airway clearance and add azithromycin
D. Refer to pulmonology clinic in 1 week
Correct Answer: B
Rationale: This is an acute pulmonary exacerbation in cystic fibrosis with
Pseudomonas. Admission for IV antibiotics (dual anti-pseudomonal coverage) is
standard. Oral ciprofloxacin alone is insufficient for moderate-to-severe exacerbations.
Delay can worsen lung function.
| Actual Q&A with Rationale | Walden University
1. A 10-year-old boy with severe persistent asthma (on high-dose ICS/LABA and
montelukast) presents for a well-child visit. He has had two ED visits and one
hospitalization in the past year. His inhaler technique is poor, and his family uses a
wood-burning stove for heat. Which intervention is most likely to reduce his
exacerbation risk?
A. Increase ICS to maximum dose and add tiotropium
B. Refer to an asthma specialist and address home environmental triggers
C. Switch from LABA to a different bronchodilator
D. Prescribe an oral corticosteroid burst and follow up in 2 weeks
Correct Answer: B
Rationale: This child has poorly controlled asthma with environmental triggers (wood
stove). Specialty referral and environmental control are high-impact interventions.
Medication adjustment is important but secondary to mitigating triggers and improving
technique.
2. A 7-year-old girl with type 1 diabetes presents with HbA1c of 9.8%. She checks blood
glucose 2-3 times daily and admits to skipping insulin doses because "it hurts." Her
parents are divorced and share custody. Which approach is most likely to improve
adherence?
A. Switch to insulin pump therapy immediately
B. Involve a child life specialist and consider a collaborative behavior plan
C. Increase insulin doses to compensate for missed doses
D. Refer to endocrinology for inpatient management
Correct Answer: B
Rationale: Addressing needle phobia and family dynamics is essential. A behavior plan
and psychosocial support can improve adherence. Pump therapy may help but
requires motivation and education. Increasing doses is unsafe. Inpatient management is
not indicated.
3. A 14-year-old female with obesity (BMI 34) presents with irregular menses, hirsutism,
and acanthosis nigricans. Fasting glucose is 112 mg/dL, HbA1c 5.9%. Which is the most
appropriate initial pharmacotherapy?
A. Metformin 500 mg daily, titrate up
B. Oral contraceptive pills for cycle regulation
,C. Spironolactone for hirsutism
D. Orlistat for weight loss
Correct Answer: A
Rationale: This presentation is consistent with polycystic ovary syndrome (PCOS) and
prediabetes. Metformin improves insulin sensitivity, may restore ovulation, and slows
diabetes progression. OCPs are for cycle regulation but do not address metabolic risk.
Spironolactone and orlistat are second-line.
4. A 6-year-old boy with ADHD (on methylphenidate LA 20 mg daily) has lost weight
from the 50th to the 25th percentile over 6 months. He has poor appetite at lunch.
Which management change is most appropriate?
A. Discontinue methylphenidate and start guanfacine
B. Recommend high-calorie breakfast and dinner, and give medication after meals
C. Increase methylphenidate to 30 mg daily
D. Refer to a pediatric gastroenterologist
Correct Answer: B
Rationale: Stimulant-associated appetite suppression can be managed by timing
medication after meals and optimizing caloric intake at other times. Changing to a non-
stimulant is an option if weight loss is severe, but dietary strategies should be tried first.
Increasing dose may worsen appetite. GI referral is not indicated.
5. A 15-year-old male presents with acute onset of severe, colicky left testicular pain
and nausea. He has no fever. On exam, the left testicle is high-riding and swollen. What
is the most appropriate next step?
A. Obtain a testicular ultrasound with Doppler
B. Elevate the scrotum and apply ice
C. Prescribe antibiotics for epididymitis
D. Schedule surgical evaluation in 24 hours
Correct Answer: A
Rationale: Testicular torsion is a surgical emergency. Urgent Doppler ultrasound is
needed to assess blood flow. Immediate urology consultation is also critical. Elevation
and ice are for epididymitis. Antibiotics are inappropriate without confirmed infection.
Delay in surgery can result in testicular loss.
6. A 2-year-old child presents with a 3-day history of fever, vomiting, and diarrhea. He
has dry mucous membranes, sunken eyes, and no urine output for 8 hours. He is
lethargic. What is the most appropriate immediate management?
, A. Oral rehydration solution 20 mL/kg over 4 hours
B. IV normal saline bolus 20 mL/kg, then reassess
C. Antiemetic suppository and clear liquids
D. Start IV maintenance fluids and admit
Correct Answer: B
Rationale: This child has severe dehydration with lethargy. IV bolus is indicated for
rapid rehydration. Oral rehydration is not safe in lethargic patients. Antiemetics do not
address dehydration. Admission is needed after initial resuscitation.
7. A 12-year-old girl with a history of epilepsy (on lamotrigine) presents with a new-
onset, generalized, erythematous rash with target lesions and mucosal involvement. She
started lamotrigine 4 weeks ago. What is the most likely diagnosis?
A. Viral exanthem
B. Stevens-Johnson syndrome (SJS)
C. Urticaria
D. Scarlet fever
Correct Answer: B
Rationale: Lamotrigine carries a risk of SJS, especially during dose titration. The
combination of target lesions, mucosal involvement, and recent drug initiation is highly
concerning. Immediate discontinuation of lamotrigine and urgent referral are required.
Viral exanthem is less likely with mucosal involvement.
8. A 9-year-old boy with cystic fibrosis presents with increased cough, decreased
energy, and weight loss over 2 weeks. He has a fever of 38.5°C and O2 sat 93% on room
air. Sputum culture grows Pseudomonas aeruginosa. What is the most appropriate
initial management?
A. Start oral ciprofloxacin and monitor as an outpatient
B. Admit for IV antibiotics (e.g., ceftazidime and tobramycin)
C. Continue current airway clearance and add azithromycin
D. Refer to pulmonology clinic in 1 week
Correct Answer: B
Rationale: This is an acute pulmonary exacerbation in cystic fibrosis with
Pseudomonas. Admission for IV antibiotics (dual anti-pseudomonal coverage) is
standard. Oral ciprofloxacin alone is insufficient for moderate-to-severe exacerbations.
Delay can worsen lung function.
