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AC PNP Pediatric Nurse Practitioner - Acute Care
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Which of the following best describes continuous renal replacement therapy (CCRT) A. Blood from an artery is circulated to a hemofilter using only arterial pressure and not a blood pump B. Blood is circulated by hydrostatic pressure through a semipermeable membrane C. Blood is pumped through a double-lumen venous catheter to a hemofilter D. A dialysate is used to increase clearance of uremic toxins - ANSWER-CCRT circulates the blood by hydrostatic pressure through a semipermeable membrane. It is used in critical care units because it can be instituted quickly. A. Blood is pumped through a double-lumen venous catheter to a hemofilter is continuous venovenous hemofiltration (CVVH) B. Use of a dialysate to increase clearance of uremic toxins is also a description of CVVH D. Blood from an artery circulated to a hemofilter using only arterial pressure and not a blood pump is an example of continuous arteriovenous hemofiltration (CAVH) Complications associated with dialysis include: A. Peritonitis B. Dysrhythmias C. Bleeding especially in females D. Anorexia - ANSWER-Correct Answer: Dysrhythmias. Hemodialysis can cause hypotension, muscle cramping and dysrhythmias during treatment A, B, C are all examples of complications of peritoneal dialysis. The difference in myocarditis and pericarditis is: A. Myocarditis is diagnosed by a myocardial biopsy B. Pericarditis is treated according to the cause and the type and extent of inflammation C. Pericarditis is caused by endocarditis D. Myocarditis requires pericardiocentesis - ANSWER-A. Diagnostic procedures for pericarditis are similar to those for endocarditis and myocarditis. The age, size and condition of the patient with pericarditis also determine treatment which may include: analgesics, anti-inflammatory drugs, restriction of activity, corticosteroids, and surgical intervention including percardiocentesis B. Performing a myocardial biopsy in a patient with suspected myocarditis would allow diagnosis but the procedure is so high risk due to the friability of the myocardium, it is not recommended C. Myocarditis may be a complication of endocarditis but is usually triggered by a viral infection such as influenza, coxsackie and HIV D. Pericarditis may require surgical intervention such as pericardiocentesis or removing fluid from the pericardial sac to relieve increasing pressure and diagnose causative agents. Acute tubular necrosis (ATN) occurs when a hypoxic condition causes renal ischemia that damages tubular cells of the glomeruli so they are unable to adequately filter the urine, leading to acute renal failure. Treatment of ATN includes: A. Loop diuretics B. Fluid restriction C. Antibiotics D. FFP for coagulopathy - ANSWER-Correct Answer: Loop diuretics
Explanation: A. Adequate fluid balance is necessary to perfuse the kidneys. Identifying and treating underlying cause is key C. Antibiotics including sulfonamides and streptomycin can cause ATN. Antibiotics should only be continued if infection is present D. Coagulopathy may develop if uremia is present. Uremia leads to destruction of platelets and bleeding. In Piaget's formal operational stage, development includes: A. Egocentrism B. Flexibility of thought C. Magical thinking D. Organization - ANSWER-Correct Answer: Flexibility of thought D. The formal operational stage of Piaget's theory of cognitive approach to development includes abstract thought and flexibility of thought. The age range a child begins to exhibit this is 12 years and older A. Magical thinking and B. Egocentrism are in the preoperational thinking stage; ages 2-7 years C. Organization is found in the concrete operational thinking which is 7-12 years of age The most common cause of bladder obstruction in the pediatric male patient is: A. Hypospadius B. Post urethral valve related issues C. Undescended testes D. Single kidney - ANSWER-Explanation: C. Post urethral valve issues are the most common cause of bladder obstruction in pediatric male patients. A, B, D. None of these GU or renal abnormalities cause bladder obstruction When doing Pulmonary Function Tests (PFTs), the NP recalls: A. Asthma is a form of restrictive lung disease B. Forced expiration is the best indicator of obstructive airway disease C. Forced expiration is the best indicator of restrictive airway disease D. A value is considered abnormal if it is less than 50% of your predicted value - ANSWER-Correct Answer: Forced expiration is the best indicator of obstructive airway disease Explanation: A. In PFT's, forced expiration is the best indicator of obstructive airway disease. Obstructive disease make the lungs contain too much air and take longer to empty. Changes in lung volumes and capacities are generally consistent with the pattern of impairment. With obstructive lung disease total lung capacity, functional residual capacity and residual lung volume increase. With obstructive lung diseases, these decrease. B. See explanation for A. C. A value is considered abnormal if it is less than 80% of your predicted value D. Asthma is a type of obstructive lung disease A child in the emergency department has point tenderness over the proximal tibia and an appropriate history of trauma. The radiograph show a fracture through the growth plate that extends in to the epiphysis and joint space. This type of fracture would be characterized as: A. Salter - Harris Type I B. Salter - Harris Type II C. Salter - Harris Type III D. Salter - Harris Type IV - ANSWER-Explanation: C. Salter - Harris type III is a fracture through the growth plate that extends into the epiphysis and into the joint space. They may require open reduction and fixation.
B. A child who is not immunocompromised should not contract pneumocystis carinii pneumonia C. Croup presents with a tight "barky" cough and is caused by a virus D. Strep pneumoniae - is many time preceded by a URI or OM. Their coughs are usually productive A patient with a history of hematemesis and melena is reported to have a clear gastric lavage. What additional diagnostic test should you consider? A. Meckel's scan B. Endoscopy C. Upper GI study D. KUB - ANSWER-Explanation: B. A history of bloody emesis (hematemesis) and dark tarry stools (melena) usually indicates recent GI hemorrhage, not a current hemorrhage. Approximately 50 ml of blood in the stomach can make stools tarry/black. Upper GI hemorrhage (above the Ligament of Treitz) can be diagnosed with endoscopy. A. UGI - is used to administer contrast medium and observe for reflux, not hemorrhage C. Meckels scan is a study unique to pediatrics used to diagnose Meckels diverticulum. It is the most common abnormality of the GI tract due to the vestigial remnant of the omphalomesenteric duct. It presents with painless bright red stools D. KUB (kidney, ureter and bladder) abdominal x-ray will not reveal active upper or lower GI bleeding. A known Cystic Fibrosis patient may need which of the following medications for control of known Pseudomonas infection. A. Antibiotics B. Inhaled Tobramycin C. Recombinant human deoxyribonuclease nebulized D. Physical therapy and vigorous vibration exercises - ANSWER-Correct Answer: Inhaled Tobramycin Explanation: A. Alternating months of regular inhaled tobramycin may be indicated for patients infected with Pseudomonas B. Nebulized recombinant human deoxyribonuclease breaks down thick DNA complexes present in mucus as a result of cell destruction and bacterial colonization C. Physical therapy and vigorous vibration exercises are the most fundamental therapies used in CF therapy. These are helpful in mobilizing secretions D. Antibiotics decrease the production of bacterial toxins, reduce inflammation and curb tissue destruction. Azithromycin has recently been added as a possible immune modifier Which of the following patients is at greatest risk for developing sepsis? Incorrect A. 5 year old requiring PICC for TPN secondary to ruptured appendix B. 2 year old with a PICC placed 24 days ago C. 5 year old patient with PIV placed for dehydration 72 hours ago D. 2 month old with central line placed < 2 weeks ago - ANSWER-Explanation: B. PICC's placed in a patient admitted to a PICU for greater than 21 days are at higher risk for developing a hospital acquired infection. The prolonged catheter dwell time can lead to catheter colonization and biofilm formation. A. Although PIV's pose a risk for infection, short term use is not highly likely to lead to sepsis C. Infants with central line placed less than 2 weeks are at risk for infection but not as high risk as patients admitted to PICU with PICC line in place greater than 21 days D. Adolescents with ruptured appendix who need a central line (short term) for nutrition purposes are at risk but lower risk than a patient admitted to a PICU with a PICC in place for greater than 21 days Two month old male presents with fever of 102F and fussiness. He has decreased urine output, but mild symptoms of dehydration. A full sepsis workup is completed and he needs to be started on antibiotics. Your orders include Ampicillin and Gentamycin. The following morning his urine culture
grows 50,000 CFU of E. coli. UA: Nitrites +, WBC 50, RBC 10, Bacteria 1+. Susceptibilities are Ampicillin resistant, Cefotaxime sensitive and Gentamycin sensitive. What do you do with your antibiotics? Incorrect A. Change to Sulfa drug B. Continue Gentamycin C. Continue Ampicillin and Gentamycin D. Discontinue antibiotics as this patient does not have a UTI - ANSWER-Correct Answer: Continue Gentamycin Explanation: A. Once an organism and its susceptibility pattern are known, antibiotic coverage may be adjusted. In this patient you would continue Gentamycin as the organism is susceptible to this medication. B. Discontinue Ampicillin if the organism is resistant to it. C. Sulfa drugs should not be administered to infants of this age A previously healthy 3 year old male, UTD on immunizations and a 1 week history of URI, presents to the ED with fever of 105 F, headache, altered mental status and neck stiffness. His LP showed WBC's of 3500, and gram stain of GPC pairs and chains. Which intial antibiotic therapy would you start? A. Vancomycin and Ceftriaxone B. Ampicillin and Gentamycin C. Acyclovir D. Cefotaxime and Gentamycin - ANSWER-Explanation: A. Given the emergence of resistant strains the recommended empiric therapy for infants and children older than 1 month of age with bacterial meningitis is 3rd generation cephalosporin AND vancomycin until final identification and susceptibility (Redbook, 2012) Answers B, C, and D are appropriate for children ages birth to 4 weeks of age A 4-year old presents to the ED with 1 day history of right leg pain and fever. He is also showing signs of difficulty breathing. He was found to have right tibia osteomyelitis, subperiosteal abscess and myositis. His chest xray also shows RLL consolidation. He was started on Vancomycin and Clindamycin. His blood culture was positive for MRSA as was his wound culture. Repeat blood culture, on hospital day 3, continued to grow MRSA. What else could you add given persistent blood cultures? A.High dose Penicillin B. Rifampin C. Ciprofloxcin D. Tetracycline - ANSWER-Explanation: B. Theoretical reasons for combination therapy with Vancomycin for S. aureus infection is to achieve bactericidal synergy. The weak bactericidal activity (tolerance) of vancomycin against some MRSA is associated with reduced therapeutic efficacy. Coadministration of certain antibiotics may help overcome some of these deficiencies by, for example, having more-favorable activity against biofilm colonies Answers A, C, and D are not useful antibiotic changes in the face of MRSA. If the culture grew MSSA, you would change the antibiotics to Oxacillin or Cefazolin A thirteen month old male is admitted in July with fever of 103 F and cough. His chest x-ray shows right sided pneumonia with an effusion. He does not attend daycare but his older brother was recently sick with fever and strep throat. His immunizations are up to date, he's had no travel outside the country and he has no known drug allergies. Due to persistent desaturations and the need to escalate care, he is transferred to the PICU. He is intubated shortly after arrival with plans to tap his effusion. After this procedure, which antibiotic would you plan to initiate? A. Ceftriaxone and Clindamycin B. Rifampin C. High dose penicillin
D. Type and Cross for potential transfusion - ANSWER-Explanation: A. Based on this patient's recent URI, presentation of rash on his lower extremities, GI cramping and proteinuria, he most likely has Henoch-Schonlein purpura (HSP). It is a form of vasculitis and typically presents with symptoms of skin, joint, gastrointestinal, and kidney disease. It peaks in the winter months. The classic rash is non- thrombocytopenic purpura localized to dependent areas of the body. Joint pain is very painful and gastrointestinal involvement includes colicky abdominal pain, vomiting and occasionally upper or lower GI bleeding. IgA-containing immune complexes are found within vessel walls. B. KUB may be necessary but not a priority C. Type and Cross is rarely needed and should only be ordered if patient is severely anemia with symptoms D. ANA and complement studies are ordered to diagnose systemic lupus erythematosus (SLE); CRP/ESR should be ordered but are included in Answer A. Which of the following regarding C3C4 levels is true? A. High C3C4 counts are indicative of increased CRP or acute inflammatory disease B. High C3 counts are indicative of autoimmune disease C. High C4 counts are indicative of acute glomerular nephritis D. Low C3C4 counts are indicative of tissue inflammation - ANSWER-Explanation: D. High C3C4 counts are indicative of increased CRP or acute inflammatory disease A. Low C3 indicates autoimmune disease, neonatal RDS, bacteremia, tissue injury or hepatitis B. Low C4 indicates DIC, acute glomerular nephritis, hepatitis or SLE C. High C3 C4 indicates CRP, acute inflammatory disease and tissue inflammation An 8 year old African American male was diagnosed with Sickle Cell disease as an infant. Which of the following tests should be added to his disease prevention plan at age 8? A. Hemoglobin electrophoresis B. Transcranial doppler evaluation C. Monthly PT/INR's D. Monthly PCN G IM - ANSWER-Explanation: C. Transcranial doppler evaluation is used for stroke prevention and should start at age 8. Other components of the SCD prevention plan include penicillin prophylaxis (daily oral dose), pneumococcal and meningococcal vaccine, and folic acid supplementation A. Monthly PT/INR's are required for patients on Coumadin or Warfarin therapy B. Monthly PCN G IM is not required for PCN prophylaxis (see rationale above) D. Hemoglobin electrophoresis is the gold standard for testing for SCD in the newborn period. A 15 year old presents to the cardiac clinic with complaints of shortness of breath on exertion. On exam you note 2+ peripheral edema, hepatosplenomegaly, and chest x-ray shows a CT ratio of > 50%. Approximately 1 month ago the patient had influenza. Treatment for this patient should include: A. Digoxin, Diuretics, Drug-screen B. Oxygen, diuretics, bed rest and aspirin C. Oxygen, antihypertensives, fluid resuscitation D. Bedrest, High-calorie diet and Potassium replacement - ANSWER-Explanation: A. Oxygen may be useful for patient's with low cardiac output related to heart failure; Diuretics are required to reduce peripheral and pulmonary edema, Bedrest decrease myocardial stress and Aspirin is extremely important because of the potential to develop clots in a heart that is not pumping or emptying well. B. Antihypertensives help decrease cardiac workload and may be added to the treatment plan, but fluid resuscitation on a patient in heart failure will only exacerbate the failure C. High-calorie diets are used in children with congenital heart defects and failure to provide adequate nutrition; Potassium replacements may be necessary after diuresis but not until you are certain of their serum K+ value and ability to void
D. Digoxin and Diuretics may be used in combination to promote contractility and fluid loss. A drug screen is appropriate but in this patient's presentation there is history of influenza which on occasion may invade the heart cells and cause damage leading to damage of the heart muscle The newborn with persistent hypoglycemia despite therapy should alert the PNP to: A. Be concerned for chromosomal abnormalities in the newborn B. Be concerned for inborn errors C. Be concerned about the mother's milk supply D. Be concerned about the mother's prenatal care - ANSWER-Explanation: Answer A. Inborn errors of metabolism such as galactosemia or persistent hyperinsulinemic hypoglycemia of infancy may cause persistent hypoglycemia in the newborn despite therapy A 3 year old is admitted for induction chemotherapy for Burkitt's Lymphoma. The PNP knows that to prevent Tumor Lysis Syndrome, the following should be added to her IVF orders: A. Phosphorous B. Sodium Bicarbonate C. Potassium D. Heparin - ANSWER-Explanation: Answer B. Tumor Lysis Syndrome is an electrolyte disturbance that develops due to rapid turnover of malignant cells. It's characterized by Hyperuricemia, Hyperkalemia, Hyperphosphatemia Prevention includes: Frequent Labwork (every 6 hours) Hyper K+ Hyper phos Hypo Na Treatment Allopurinol Bicarb in IVF (1.5 x maintenance = keep patient hydrated) Goal is to alkalinize urine Answer A. and Answer C. (see above) Answer D. Heparin, depending on the dose may be added to IV fluids to prevent clotting of a central line, but will not help TLS The use of an aminoglycosides in a patient with hepatic insufficiency may: A. Be safe as long as the kidneys work well B. Increase risk for nephrotoxicity in patients with cirrhosis C. Increase risk of leucopenia D. Increase risk of liver failure - ANSWER-Explanation: Answer B. Aminoglycosides are primarily excreted by the kidney. Answer A. In a patient with cirrhosis, aminoglycosides use may have increased risk for nephrotoxicity. Answer C. Leucopenia is an increase in the number of WBC's Answer D. Hepatic insufficiency and liver failure are similar Your postoperative patient who underwent VSD closure yesterday has a pericardial chest tube which has stopped draining. You are called to the bedside because he is in acute respiratory distress and anxious. Select most appropriate complication: A. Pleural effusion reaccumulation B. Pericardial effusion reaccumulation C. Hemothorax D. Pneumothorax - ANSWER-Explanation: Answer A. A tube in the pericardial space that has stopped draining can lead to reaccumulation of the fluid around the heart or cardiac tamponade where the
A 4 day old female infant presents to your ED in cardiogenic shock. She is afebrile, pale and unresponsive. She is placed on oxygen without any change in her saturations. CXR shows altered pulmonary vasculature and cardiomegaly. What drug might you start initially? A.Normal Saline B. Prostaglandin E C. Dopamine D. Versed - ANSWER-Explanation: Answer C. Congenital heart defects that result in ↓ blood flow to the lungs or ↓ systemic blood flow are dependent on the pulmonary systemic shunt from the patent ductus arteriosus to maintain pulmonary and systemic blood flow. Closure of the ductus arteriosus leads to worsening of obstruction to pulmonary blood flow with right to left shunt and cyanosis in right sided lesions and decreased systemic blood flow in left-sided obstructive lesions. Until CHD is ruled out PGE should be started. Answer A. Normal saline can be used for volume if needed Answer B. Dopamine can be used to help with contractility but will not be of use if PDA is necessary to provide systemic or pulmonary blood flow Answer D. Versed is a benzodiazepine and will not help with opening a ductus arteriosus. A 4 week old is brought to the ED by his parents for poor feeding. His parents report he acts hungry but after a few minutes sucking his bottle, he screams out and becomes diaphoretic. Their PCP has been treating him for GERD. You ask the parents to feed him and observe the reported behavior. He has a soft murmur and you order a chest x-ray which shows cardiomegaly. You order an ECG. What do you expect to find on the ECG? A. Atrial tachycardia B. Deep Q waves in leads V1 and AVL C. 1st degree AV block D. Peaked T-waves in all precordial leads - ANSWER-Explanation: Answerer C. The most likely diagnosis of this patient is anomalous coronary artery from the left pulmonary artery. Remember coronary arteries perfuse the myocardium during diastole. If an adult has a coronary related issue they experience chest pain, ischemia and sudden death. Infants will experience the same thing but usually during or shortly after starting a feed Signs of a patient with ALCAPA includes: Ischemia Heart failure Sudden death ECG - pathologic Q waves lead I and avF = infarction Answer A. first degree AV block is exhibited by prolonged PR interval Answer B. Atrial Tachycardia is evidenced by rapid atrial rate Answer D. Peaked T-waves is indicative of hyperkalemia You are the PNP seeing a 5 year old female patient who underwent Atrial Septal Defect (ASD) surgical closure one week ago. She presents for her postoperative appointment and appears anxious and will not lie flat on the exam table for your exam. Her parents also report fever, malaise and loss of appetite. Your immediate orders should include: A. Chest x-ray B. ECHOcardiogram C. CBC/diff D. Viral studies - ANSWER-Explanation: Answer B. Because this patient is refusing to lie flat and appears anxious, a quick look via echo can limit any delay in treatment that may be necessary. If the diagnosis of pericardial effusion is confirmed by ECHO you would need to evaluate the size and plan for treatment including hospital admission and: NSAIDS/anti-inflammatory actions Diuretics Pericardial tube placement
Answer A. CBC/diff may be important but will not help determine why she will not lie flat Answer C. Viral studies may also be important is she has s/s of respiratory illness, however based on her recent surgical history and echocardiogram is paramount Answer D. Chest x-ray would also be important but will only reveal an enlarged cardiac silhouette and will not show fluid in the pericardial sac. In a patient with suspected hemophilus, influenza B (HIB) infection, the antibiotic choices are? A. Amoxicillin p.o. B. Nafcillin I.M./I.V. C. Penicillin D. Rifampin p.o. - ANSWER-Correct Answer: Nafcillin I.M./I.V. Explanation: HIB is a bacterial disease that should be treated with an antibiotic. Haemophilus influenzae produces beta-lactamases, and is able to modify its penicillin-binding proteins. For this reason it has gained resistance to the penicillin family of antibiotics. Nafcillin IV/IM contains side groups that protect drugs from being inactivated by bacterial B lactamases. Answer A. Amoxicillin is inactivated by Beta Lactamases Answer B. Ampicillin IV could be used or Augmentin po in mild cases Answer C. Rifampin is not used for HIB In Piaget's formal operational stage, development includes: A. Egocentrism B. Flexibility of thought C. Magical thinking D. Organization - ANSWER-Explanation: D. The formal operational stage of Piaget's theory of cognitive approach to development includes abstract thought and flexibility of thought. The age range a child begins to exhibit this is 12 years and older A. Magical thinking and B. Egocentrism are in the preoperational thinking stage; ages 2-7 years C. Organization is found in the concrete operational thinking which is 7-12 years of age It is January 1, and you are seeing a 5 year old male who was recently diagnosed by his PCP with an URI. He presented to his PCP today with a skin rash on his lower extremities, joint inflammation, abdominal cramping, and fever. His PCP ordered a UA which showed proteinuria. He is being sent to the ED for further workup. Which diagnostic tests should you consider ordering? A. ANA, C3, C4 and CRP/ESR B. BUN, Creatinine, immunoglobulins, CRP/ESR, and platelets C. KUB to rule out pathology causing abdominal cramping D. Type and Cross for potential transfusion - ANSWER-B. BUN, Creatinine, immunoglobulins, CRP/ESR, and platelets Explanation: Based on this patient's recent URI, presentation of rash on his lower extremities, GI cramping and proteinuria, he most likely has Henoch-Schonlein purpura (HSP). It is a form of vasculitis and typically presents with symptoms of skin, joint, gastrointestinal, and kidney disease. It peaks in the winter months. The classic rash is non-thrombocytopenic purpura localized to dependent areas of the body. Joint pain is very painful and gastrointestinal involvement includes colicky abdominal pain, vomiting and occasionally upper or lower GI bleeding. IgA-containing immune complexes are found within vessel walls. KUB may be necessary but not a priority Type and Cross is rarely needed and should only be ordered if patient is severely anemia with symptoms ANA and complement studies are ordered to diagnose systemic lupus erythematosus (SLE); CRP/ESR should be ordered but are included in Answer A.
C. Hirschsprungs is congenital aganglionic megacolon and does not occur as an acute illness D. Hookworm larvae may be swallowed directly of penetrate the skin, migrate to the lungs, cough and be aspirated into the GI tract. Symptoms can be severe. Diarrhea may occur but there is often complaint of itching at the site of entry PEARLS of WISDOM: A transplant patient is immunocompromised. They are higher risk at contracting diseases most children will not have. If a cardiac transplant patient presents with abdominal symptoms, pain, nausea, vomiting or diarrhea, it is extremely important to rule out heart failure or transplant rejection. Symptoms of low cardiac output can cause GI symptoms in children. In this scenario her echocardiogram showed normal cardiac function. Once that is established, it is important to hydrate, send stool studies and monitor immunosuppressive therapy during the acute event. - ANSWER- A 12 year old female is admitted to the general pediatric floor with pneumonia. Her presenting symptoms include low-grade fever, myalgia, diarrhea and pharyngitis. On chest x-ray she has interstitial infiltrates. Her treatment plan should include: A. Tylenol and Motrin po every 4 hour, Augmentin, and maintenance IV fluids. B. IV NSAIDs or Tylenol po, Erythromycin and Maintenance IVF's or clear liquid diet C. Morphine, Tylenol suppositories, Ampicillin D. IV Toradol alternating with Tylenol suppository, regular diet for age and IV Clindamycin - ANSWER- Explanation: Community acquired pneumonia or Mycoplasma pneumonia is caused by pleomorphin microorganisms that interfere with the function of the cilia and produce hydrogen peroxide, which disrupts cell function. They also activate an inflammatory response. 3% of patients will develop a pneumonia affecting primarily children and young adults between the ages of 4 and 20. Occurs predominantly in the Fall. Symptoms include cough, fever, myalgia, diarrhea and pharyngitis Children who require IV hydration or monitoring for potential complications such as endocarditis, myocarditis or encephalitis may be admitted Treatment includes hydration, antipyretics, analgesics and antibiotics include macrolides (Erythromycin, Tetracycline, or Fluoroquinolone) A 6-year-old male who recently visited the mountains in Colorado develops fever, headache, muscle and joint pain. On physical exam you discover several large lymph nodes in his axilla, groin, and neck area and an erythematous ring-like rash with a clear center over his trunk and extremities. Based on his history and physical exam, which of the following treatments would you start? A. Doxycycline D. IV penicillin C. Oral amoxicillin D. IV ceftriaxone - ANSWER-Explanation: A. This patient's clinical presentation including the location of his recent vacation is consistent with Lyme disease. The management of Lyme disease is to eradicate the spirochete that causes the infection. He has early signs of the disease and should be treated with amoxicillin. B. Doxycycline should be avoided in children younger than 9 years because of concerns regarding permanent tooth discoloration. C. and D. IV antibiotics should be used only if the patient has symptoms or complications such as carditis or meningitis Of the following which is the optimal group to review the professionalism and clinical practice of an Advanced Practice Nurse? A. The hospital where the APN is privileged B. A Peer Review team comprised of like APN's C. The RN who works closely with the APN
D. The judicial system - ANSWER-Explanation: Answer C. There are 2 stated purposes of peer review: demonstration of professionalism and clinical competency. The American Nurses Association (ANA) defines nursing peer-review as a process for evaluating the care provided by an individual according to accepted standards. Peer Review Teams should look at nurses with similar rank and clinical expertise to help conduct these types of evaluations. Advanced practice nurses (APNs) should review one another's care. How does a new PNP receive Prescriptive Authority? A. Varies from State to State D. Hospital privileges ensure prescriptive authority C. Apply for DEA number D. Collaborative Practice Agreements outlines prescriptive authority - ANSWER-Explanation: Answer B. The PNP should review his/her state board requirements regarding prescriptive authority. Answer A. An application for a DEA number is a separate portion of prescriptive authority. Answer C. Hospital privileges determine credentialing Answer D. A collaborative practice agreement outlines medications which can be prescribed - not prescriptive authority In which of the following patients is circumcision contraindicated in? A.Infant born with undescended testes B. Infant born with congenital heart disease C. Infant born with cleft lip D. Infant born with hypospadias - ANSWER-Explanation: Answer D. In an infant born with hypospadias, the foreskin will probably be used in the repair of hypospadias A 16 year old well developed, well nourished female reports that she has not had a period in 2 months. She states she is not sexually active and prior to this had monthly periods. What do you do? A. Refer to eating disorder clinic B. Draw thyroids C. Send a urine-hct D. Send a drug screen - ANSWER-Explanation: Answer C. Many teenagers do not "comprehend" the term sexually active and are able to "deny" sexual activity in the face of possible pregnancy. Although there are many disorders which can lead to amenorrhea, the first test that should always be done is a pregnancy test. In a patient with DKA, what should you order when the blood glucose drops to 100 mg/dl - A. Correction of osmolality (GRADUAL to prevent Cerebral Edema) B. Administer K+ early after initial fluid replacement if there is adequate UOP C. Administer glucose when blood glucose levels are down to 300 mg/dl D. Initial fluid (isotonic saline) - ANSWER-Explanation: Answer C. Add 5% dextrose when blood glucose = 300 mg/dl; Add 10 % dextrose with blood glucose = 200 mg/dl Answer A. Isotonic Saline- treatment is with NS bolus 20 ml'kg, insulin drip at 0.1 units/kg/hr. You add glucose when serum glucose levels are 300 (see above) Answer B. check labs, vital signs and neuro checks every hours. Convert to subcutaneous insulin when pH and Bicarbonate are normalized Answer D. Administer potassium and phosphorous at this time too as cells are becoming hydrated An obese teenager presents with complaints of vomiting and pulsatile tinnitus. On exam she has bilateral papilledema. You order a CT scan and MRI, which are normal. What is the most likely cause?
Answer D. SIADH is low sodium and low osmolality making it harder for your body to release water A 10 year old male presents with a 1 month history of fever, weight loss, fatigue and pain in his right thigh. On exam you note painful localized swelling in the area of his right midproximal femur. What is the most likely diagnosis? A. Osteosarcoma B. Legg-Calve Perthes Disease C. Osgood-Schlater syndrome D. Ewings Sarcoma - ANSWER-Explanation: Answer C. Ewing's sarcoma tends to involve systemic symptoms such as fever, weight loss and fatigue. It is associated with an increased ESR. It usually involves the diaphyseal portion of the long bones. The most common sites are in the lower body including the midproximal femur and the bones of the pelvis. Answer A. Legg-Calve-Perthes patients are usually younger (4-8 years) Answer B. Osgood-Schlatter present with pain and swelling over the tibial tuberosity Answer D. Osteosarcoma involves tumors in long bones (humerus, femur and tibia). Common in adolescents and young adults. Gastroenteritis associated with Escherichia coli is associated with which of the following complications? A. Hemolytic Uremic Syndrome B. Cholera C. Failure to thrive D.. Appendicitis - ANSWER-Explanation: Answer C. Both Shigella dysenteriae and Escherichia coli (0157:H7) produce an enterotoxin associated with hemolytic uremic syndrome. This syndrome causes: hemolytic anemia, nephropathy and thrombocytopenia. Answer A. Failure to thrive occurs with giardiasis. Answer B. Cholera does not cause HUS Answer D. Appendicitis does not cause HUS A 15 year old male presents with mid abdominal pain radiating to back and fever. There is no history of recent trauma and he has been well until today. As the PNP you know to order the following labwork: A. Trypsinogen, lipase and amylase B. Renal ultrasound C. Drug screen D. CT scan of the head - ANSWER-Explanation: Answer C. Symptoms of pancreatitis are epigastric pain radiating to the back and fever. The lab tests to order include trypsinogen, lipase and amylase. Pancreatic enzymes can be elevated up to 4-6 times higher than normal althoug Amylase is least specific for pancreatitis as it's also produced in other areas of the body. Answer A. Drug Screen is not pertinent in this scenario Answer B. CT scan of the head will not reveal the cause of fever and pain Answer D. Renal Ultrasound is not pertinent unless the patient had signs or symptoms of UTI A 3 week old male infant present to the ED with a chief complaint of vomiting x 3-4 days. His mother describes the vomiting as "shooting out of his mouth." The emesis is non-bilious and non-bloody. His vital signs are stable, his abdomen is slightly distended and he has a firm, small, movable mass below his xiphoid process. His lab work shows: Na 135, K3.5, Cl 86, Bicarb 37, glucose 69. As the PNP you interpret these labs as: A. Hypochloremic alkalosis B. Hyperchloremic acidosis C. Moderate dehydration D. Nephrotic syndrome - ANSWER-Explanation: Answer A. Hypertrophic pyloric stenosis (HPS) Males>females
- family history Non bilious vomiting - projectile UGI - "string sign" olive shaped abdominal mass Visual inspection of abdomen - peristaltic waves from left to right Weight loss, FTT, dehydration Labs - hypokalemia, hypochloremia, metabolic alkalosis Treatment is Surgical consult - non emergent. Stablilize infant, improve hemodynamics (IVF's) to correct the hypochloremic alkalosis. With vomiting hydrogen ion loss leads to an elevation of serum bicarbonate, followed by a derease in serum cholride and development of hyppochloremic alkalosis NGT placement controversial - stimulates GI tract secretions Post op - ready for DC when the infant can tolerate 60ml's x 2 feedings. Answer B-Hyperchloremic acidosis occurs from a loss of bicarbonate with retention of chloride Answer C. Moderate dehydration - sodium and potassium levels are within normal limits Answer D. Nephrotic syndrome - usually diagnosed with serum and urine labs work and includes presence of protein in urine and low protein in the blood You receive a consult from a Pediatrician who states he has a 7 month old in his office who has "fallen off her growth curve." He also describes a IV/VI systolic ejection murmur heard best along her left sternal border. He wants to send her to the Cardiology clinic today. Upon arrival, you note a petite 7 month old female in no acute distress. Palpation of her chest is positive for a thrill. She also has hepatomegaly. You order an echocardiogram which diagnoses a large PDA. Before you can schedule this child for surgery, you need to: A. Inform the parents that their child has symptoms of congestive heart failure and needs to be started on B. Inform the parents their child needs to undergo cardiac catheterization to better define the defect some medications for this C. Inform the parents how to direct donate blood for their child D. Inform the parents that their child is gravely ill - ANSWER-Explanation: Answer C. Symptoms of congestive heart failure (CHF) develop from pulmonary over circulation and are exhibited by the patient's increased work of breathing, hepatomegaly, poor feeding and growth failure. Treatment may include: Digoxin for inotropy Lasix for diuretic effect After load reduction using ACE inhibitors (Enalapril, etc). Answer A. If the patient needs surgery, you may offer information on direct blood donation Answer B. Educate the parents on CHF and probable cause, however reassure them this can be reversed once the PDA is closed Answer D. Educate the parents cardiac catheterization will only be necessary if the patient qualifies for transcatheter device closure of her PDA What blood product do you administer for altered fibrinogen? A. Cryoprecipitate B. PRBC's C. LR D. Platelets - ANSWER-Explanation: Answer B. Cryoprecipitate contains Fibrinogen and plasma Answer A. PRBC's in packed red blood cells Answer C. LR is lactated ringers and is not a blood product Answer D. Platelets are thrombocytes involved in hemostasis Which of the following antibiotics are the best option for coverage of Pseudomonas aeruginosa positive pneumonia?
D. Claforan - ANSWER-Explanation: Although all the answers are 3rd generation cephalosporins, because the patient has cystic fibrosis, you must remember to cover for pseudomonas colonization. Ceftazidime is the best choice for this. You are the NP in the ED and are admitting a patient who has been a passenger involved in a MVC. Per EMS he has presumed head injury as there is a large scalp laceration noted. Which of the following drugs would you order on stand by for possible intubation in this patient? A. Vecuronium B. Ketamine C. Thiopental D. Propofol - ANSWER-Explanation: Answer B. Intubation drugs which can be used safely in a patient with presumed increased ICP include Thiopental. Answer A. Ketamine - increases ICP but also has bronchodilator effects. It may be used for induction in asthmatics requiring intubation due to its bronchodilation effects. Answer C. Propofol - decreases BP and cannot use in patients with egg allergies Answer D. Vecuronium - is a paralytic, not sedation medication After administration of Fentanyl, your patient develops chest wall rigidity. Your next course of action must include: A. Administration of Vecuronium B. Administration of Flumazenil C. Administration of Versed D. Administration of Narcan - ANSWER-Explanation: Chest wall rigidity after administration of Fentanyl requires a paralytic (Vecuronium) and adequate maintenance of the airway including bag, valve, mask ventilation or intubation. Answer C. Administration of Narcan is appropriate for opioid overdose. Answer D. Administration of Flumazenil is appropriate for benzodiazepine overdose or Versed overdose Answer A. Versed is a benzodiazepine You are the NP on-call for the PICU and are called by your patient's nurse that he has developed a blistery painful rash. He was recently started on Dilantin for seizure activity secondary to a head injury. What is your next course of action? A. Ensure the airway is secure and discontinue the Dilantin B. Give a 1 time dose of Benadryl 1 mg/kg C. Start IV Steroids D. Call ID for a consult - ANSWER-Correct Answer: Ensure the airway is secure and discontinue the Dilantin Explanation: This patient has Stevens Johnson Syndrome - erythema multifore major is a complication of some patients who have been started on sulfa drugs, dilantin, penicillin, or tegretol. In this type of question, the provider must recognize this as a major adverse reaction. SJS consists of mucocutaneous lesions that develop abruptly in clusters. It is managed like a burn including protection of the airway, fluid/electrolyte management and pain control You are in the ED when the grandparent run in and state, "my 2 year old granddaughter just took her grandfather's Metformin". The granddaughter is crying but otherwise appears fine. After you assess the child and find her stable, your next priority is: A. Order PICU bed STAT B. Order a set of labs including glucose, lactate and venous blood gas
C. Consult PICC team for line placement D. Consult Social Work for possible child neglect situation - ANSWER-Explanation: Metformin is used in Type 2 diabetes. It is an oral agent used to help the body properly respond to the amount of insulin it produces. It also decreases the amount of sugar your liver produces and your stomach/intestines absorb. In this scenario, the problem could occur later. You have to follow for possible hypoglycemia, lactic acidosis (most dangerous late occurring side effect), gap metabolic acidosis Symptoms of lactic acidosis: unusual tiredness, dizziness, severe drowsiness, chills, blue/cold skin, muscle pain, fast/difficult breathing, slow/irregular heartbeat, stomach pain with nausea, vomiting, or diarrhea Answer A. PICU admission is important, but not your first priority. Answer B. An IV line is important but not your first priority Answer C. SW should be consulted but again not your first priority A family presents to the ED with their 3 year old daughter who reportedly has taken an uncertain quantity of her mother's prenatal vitamins. As the PNP on call in the ED, you remember the best antidote would be: A. Deferoxamine methylate or DFO B. Syrup of Ipecac C. Activated Charcoal D. Gastric lavage - ANSWER-Explanation: Answer C. The specific antidote for iron ingestion is DFO - deferoxamine methylate -DFO acts as a chelating agent -Binds with iron and is excreted by kidneys -Anticipatory guidance includes telling families that urine may become reddish brown or "vin rose" during therapy Answer A. Activated charcoal does not absorb iron Answer B. Syrup of Ipecac is not used for poisonings Answer D. Iron tablets are radiopaque and may be visualized with abdominal radiography. If seen whole-bowel irrigation may be considered but not gastric lavage : An infant who is exclusively breast fed should begin receiving Vitamin D supplementation at_____________? A. Within the first few weeks of life B. Age 2 months C. Age 4 months D. Age 6 months - ANSWER-Explanation: D. Breastfed infants should receive oral vitamin D supplements in the first few weeks after birth to prevent rickets. Although rickets is rare in breast fed infants, it can occur. Dark skin infants and those exposed to limited sunlight in northern latitudes are particularly art risk. A previously healthy 3 year old male, UTD on immunizations and a 1 week history of URI, presents to the ED with fever of 105 F, headache, altered mental status and neck stiffness. His LP showed WBC's of 3500, and gram stain of GPC pairs and chains. Which intial antibiotic therapy would you start? A. Vancomycin and Ceftriaxone B. Ampicillin and Gentamycin C. Acyclovir D. Cefotaxime and Gentamycin - ANSWER-Explanation: A. Given the emergence of resistant strains the recommended empiric therapy for infants and children older than 1 month of age with bacterial meningitis is 3rd generation cephalosporin AND vancomycin until final identification and susceptibility (Redbook, 2012) Answers B, C, and D are appropriate for children ages birth to 4 weeks of age
