Pediatrics practice questions.

Answer

The key, and why

Two different abilities are on show here and only one of them has developed. Drawing up and giving an accurate dose is a concrete, rule-shaped task, and a school-age child of seven to eleven learns exactly that kind of task well. Reading shakiness and sweating as low blood glucose, and deciding that this is the moment to tell an adult, is a judgment about cause and effect that calls for abstract reasoning, and that arrives at around twelve years. So the teaching changes rather than the task. The child keeps the injection, which is a genuine competence and a source of confidence, and gains a short, concrete rule for the symptoms: if you feel shaky or sweaty, stop what you are doing, tell the nearest adult, and test. Rules work at this age in a way that an instruction to use judgment does not. The adults around the child carry the judgment in the meantime. The school nurse and the teachers are told what the symptoms look like in this child and where the fast-acting glucose is kept, and the parents keep oversight of the whole regimen even though the child gives the injection. Independence is handed over piece by piece as each piece is demonstrated, not all at once because one part of it looks fluent.

Each distractor

Option A blames the technique. The child gives an accurate dose at every visit, which is the part that is demonstrably working, and re-teaching technique would be the answer if the doses drawn up were wrong or the sites were being reused. Option B reads a correct injection as readiness to manage alone. Managing a condition means doing the task and knowing when something has gone wrong badly enough to get help, and waiting to be noticed while symptomatic is exactly the second half failing. Option C calls it regression and takes the task away. Regression would be a child who had this skill and lost it, often under stress or illness; this child has not lost anything, and removing a competence would cost confidence without adding safety.

The teaching point

carrying out a task and managing a condition are two different abilities. A school-age child learns concrete, rule-shaped tasks well, including an injection. Judging that a symptom needs help calls for abstract reasoning, at about twelve years. Give a school-age child a rule rather than a judgement: feel it, tell an adult, test. Adult oversight continues even when the child gives the injection alone.

Safety note

Shakiness and sweating in a child with diabetes are treated as low blood glucose until a reading says otherwise.

Answer

The key, and why

Sickle cell disease is an inherited blood disorder in which red blood cells become stiff and curved like a sickle (crescent) instead of round and flexible. Chest pain, fever, hypoxia and a new infiltrate on chest x-ray are the signs of acute chest syndrome, a leading cause of death in sickle cell disease. Sickling in the lung vessels, infection and fat emboli from bone marrow can all cause it, and it often develops during a pain crisis, especially when splinting and opioids lead to shallow breathing. The nurse reports it right away and expects oxygen, a chest x-ray, blood cultures, antibiotics and possibly a transfusion. Incentive spirometry every hour while awake helps prevent it.

Each distractor

Option A shows the pain is improving with treatment. Option C is expected. Chronic hemolysis causes jaundice and a low hemoglobin, often in the 7 to 9 g/dL range. Option D is expected. Sickling damages the kidney's ability to concentrate urine, and the client is receiving IV fluids.

The teaching point

ACUTE CHEST SYNDROME = CHEST PAIN + FEVER + HYPOXIA + new INFILTRATE = EMERGENCY. Prevent it with INCENTIVE SPIROMETRY every hour while awake.

Answer

The key, and why

A burn is an injury to the skin and deeper tissues caused by heat, chemicals, electricity or radiation. The rule of nines is built on adult body proportions. A toddler's head is far bigger for the body than an adult's, close to 18 to 20% of the body surface compared with 9% in an adult, and the legs are correspondingly smaller. Using the adult rule on a young child would underestimate a burn to the head and overestimate one to the legs. Charts such as the Lund and Browder chart adjust each area's percentage by age, so the estimate, and the fluid calculation built on it, is accurate. For small scattered burns, the child's own palm, including the fingers, is roughly 1% of the body surface and can be used as a quick measure. This matters more in children than in adults, because a child has less fluid in reserve and can go into burn shock with a smaller burn.

Each distractor

Option A is backwards. Children's skin is thinner, which is why a scald that would cause a partial-thickness burn in an adult can cause a full-thickness one in a child. Option B is untrue. The chart chosen depends on the client's age and proportions, not on what caused the burn. Option C is also backwards. Children lose fluid faster relative to their size and have smaller reserves.

The teaching point

CHILDREN = use an AGE-BASED chart such as Lund and Browder. A child's HEAD is a BIGGER share of the body. The LEGS are a smaller share. Child's PALM with fingers = about 1% of body surface. Children's skin is THINNER and they go into burn shock FASTER.

Answer

The key, and why

Toddlers swallow poisons more than any other age group, because they explore by putting things in their mouths and can now reach cupboards. The first question in any poisoning is whether the child is breathing, responsive and not having a seizure. This child is crying loudly and breathing normally, so the airway is open, and the next step is expert advice on this specific product. Poison Control, 1-800-222-1222 in the United States, is staffed around the clock and can tell the parent exactly what the product contains, whether treatment is needed and whether the child must go to the emergency department. Having the container to hand lets the parent read out the exact ingredients, and the container goes with the child if he is sent for care. If the child were unresponsive, not breathing or seizing, the parent would call 911 instead.

Each distractor

Option A induces vomiting, which is no longer recommended for any poisoning at home. A caustic cleaner burns the esophagus a second time on the way back up, and vomit can be inhaled into the lungs. Option B gives a home remedy before anyone knows what the product is. Fluids are sometimes advised, but only on Poison Control's instructions for that substance. Option C delays expert advice and may send the child to the wrong place. Poison Control can say whether he needs the emergency department, not a clinic.

The teaching point

CHILD swallowed something = check BREATHING and RESPONSIVENESS first. Breathing and alert = call POISON CONTROL, 1-800-222-1222, with the CONTAINER. Not breathing, unresponsive or seizing = call 911. NEVER induce VOMITING.

Answer

The key, and why

A 4-year-old thinks magically and illogically and can invent something far worse than the real procedure. Handing that child a long stretch of waiting time hands over the raw material for terror. Teaching on the morning of surgery, roughly two hours beforehand, gives enough warning that the child is not ambushed while leaving too little time for the imagination to build something monstrous out of it. The explanation is given in the future tense, describing what will happen, in words the child can picture. The nurse keeps it short, concrete and free of anything that sounds like cutting or taking out, and says plainly that the surgery is not a punishment. Parents stay in the room throughout, because separation is itself a major fear at this stage. Timing is a genuine intervention here rather than a matter of convenience. Preschool children admitted the night before and told nothing until morning cope better than children told days ahead, and the nurse who understands that will resist a parent's request to explain everything a week in advance and will explain why that request would backfire.

Each distractor

Option A is the timing for a school-age child of 7 to 11 years, whose concrete thinking makes a day or two of preparation useful without inviting fantasy. Given two days, a 4-year-old fills them with imagined disasters and arrives far more frightened. Option B is the approach for a child from birth to 2 years, who has no concept of time and is simply told what is happening while it happens. A 4-year-old can hold a short-term future and is frightened by being given no warning at all. Option C is preparation suited to an adolescent from about 12 years, who reasons abstractly and can use written material over a week without distortion. A week of waiting is precisely what makes a magical-thinking 4-year-old worse.

The teaching point

a 4-year-old is taught on the morning of a procedure, about two hours before. Days of notice give magical thinking time to invent something worse than the real thing. Teaching at this age is in the future tense, describing what will happen. Parents stay in the room, because separation is a leading fear from 3 to 6 years. Too little warning frightens a preschooler, and too much warning frightens one more.

Answer

The key, and why

The mouth is suctioned before the nose. Suctioning the nose first can make the infant gasp and breathe in the secretions that are still in the mouth. The parent squeezes the bulb before inserting it so the bulb does not push air and mucus deeper, and the tip is aimed at the side of the mouth along the cheek so it does not trigger the gag reflex. Using the bulb before feedings clears the nose, because a young infant breathes mainly through the nose and cannot feed well when it is blocked.

Each distractor

Option A is correct. Squeezing the bulb before insertion creates the suction on release and keeps air from being blown into the airway. Option C is correct. Placing the tip along the cheek avoids the back of the throat and the gag reflex. Option D is correct. Clearing the nose before a feeding helps the infant suck and breathe at the same time.

The teaching point

BULB SYRINGE = MOUTH before NOSE. SQUEEZE first, tip to the SIDE of the mouth, clear BEFORE feeds.

Answer

The key, and why

School-age children understand that a procedure is coming and often use stalling tactics, such as asking more questions, needing the bathroom or saying "wait, I'm not ready," to gain some control and put off the discomfort. The nurse gives honest information, offers limited choices, such as which finger to use, and sets a clear time to start.

Each distractor

Option A is a toddler, who reacts with physical resistance and crying rather than verbal stalling. Option C is a preschooler, who is likely to resist physically and may need to be held. Option D is an adolescent, who is more likely to want privacy and control than to stall.

The teaching point

SCHOOL-AGE = STALLING tactics. Give HONEST information, limited CHOICES, a clear start time. TODDLERS and PRESCHOOLERS = physical resistance; may need to be HELD.

Answer

The key, and why

School-age children think in concrete terms and want to understand what will happen and why. They benefit from preparation a few days ahead, with simple explanations, pictures or models of the body, a tour of the unit and the chance to handle equipment such as a mask. Honest information about what they will see, hear and feel reduces fear and helps them cooperate.

Each distractor

Option A is the timing used for toddlers and preschoolers, who have little sense of time. A school-age child needs a few days to process the information and ask questions. Option B uses play suited to a preschooler and gives too little time. Option D relies on reading alone, which suits an adolescent better. School-age children learn best with concrete, hands-on preparation and a person to talk to.

The teaching point

SCHOOL-AGE preparation = a FEW DAYS ahead, CONCRETE explanations, PICTURES, MODELS, TOURS. TODDLERS and PRESCHOOLERS = just BEFORE the procedure.

Answer

The key, and why

Digoxin for an infant is dosed in micrograms per kilogram. A usual maintenance dose for a 5 kg infant is about 5 mcg/kg, or 25 mcg, which is 0.025 mg. The prescription reads 0.25 mg, which is 250 mcg, ten times the expected dose. A misplaced decimal point is one of the most common and most dangerous errors in pediatric medication, and digoxin has a narrow margin between a therapeutic dose and a toxic one. A tenfold dose can cause severe bradycardia, heart block and fatal dysrhythmias in an infant. The nurse holds the medication and contacts the prescriber to clarify before anything is given.

Each distractor

Option B is enalapril, an ACE inhibitor that lowers the workload of the heart. A dose of 0.1 mg/kg falls within the usual infant range. Option C is expected care. A daily weight on the same scale at the same time is the most sensitive measure of fluid gained or lost in an infant with heart failure. Option D is furosemide 1 mg/kg per dose, a usual dose for an infant with heart failure.

The teaching point

Pediatric digoxin = MICROGRAMS per KG. A 5 kg infant gets about 25 MCG (0.025 mg), not 0.25 mg. Always CALCULATE the dose from the weight and CHECK it against the safe range before giving. DECIMAL errors = tenfold overdoses.

Safety note

A tenfold digoxin overdose in an infant can cause heart block and fatal dysrhythmias. Calculate every pediatric dose from the weight before giving it.

Answer

The key, and why

Hemophilia is inherited as an X-linked recessive trait. A carrier mother passes the affected X chromosome to half of her children. A son who receives it has hemophilia, so each son has a 50% chance of being affected. A daughter who receives it also gets a normal X chromosome from her father, so she is usually a carrier rather than affected, although some carriers have low factor levels and mild bleeding. An affected man passes his X chromosome to every daughter, so all of his daughters are carriers, and none of his sons are affected.

Each distractor

Option A is correct. Each son of a carrier mother has a 50% chance of hemophilia. Option B is correct. Each daughter of a carrier mother has a 50% chance of being a carrier. Option C is correct. An affected father gives his X chromosome to all of his daughters.

The teaching point

X-LINKED RECESSIVE = carrier MOTHER, affected SONS (50% each), carrier DAUGHTERS (50% each). Affected FATHER = ALL daughters carriers, NO affected sons.