Determine your understanding of the key topics in Module 4 with this Knowledge Check of 20 questions to answer. Like the other Knowledge Check formative assessments in the course, use this practice to help you prepare for the Final Exam this week and, looking ahead, to your Family Nurse Practitioner certification exam.
Note: With your Final Exam also this week, you are strongly encouraged to complete the Module 4 Knowledge Check at least 48 hours before you take the Final.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
Behavioral and Mental Health Issues
To prepare:
- Review Learning Resources from Weeks 10 and 11, using the topic list, below, as a guide.
- Module 4 Knowledge Check topics will include the following:
- Signs of behavioral issues
- Signs of mental health issues
- Child abuse/sexual abuse as factors in behavioral and mental health issues
- Diagnosis, treatment, and management of behavioral and mental health issues mental health issues
- Signs of musculoskeletal and neurologic conditions
- Sports-related concussions in children and adolescents
- Febrile seizures in young children
- Diagnosis, treatment, and management of musculoskeletal and neurologic conditions
- Socio-cultural considerations in treating/working with patients and families
- Evidence-based strategies for patient/family health promotion and education
Knowledge Check
You are required to answer 20 questions, randomly selected. You will have 1 attempt for each question. Each question is worth 1 point.
By Day 5 of Week 11
Complete and submit your Knowledge Check.
Question 1
Which of the following is most likely to be the victim of intentional injury?
A 2-week-old who rolled off the changing table.
A 9-month-old who had an unwitnessed fall at daycare.
A 6-month-old who fell off the bed and mom brought the infant immediately to the ED.
A 12-month-old with bruising to the shins.
CORRECT: A
A three-month old presents with signs of abusive head trauma. What additional findings may be present? (Select all that apply.)
Cervical injury secondary to hypoflexion
Skull fracture from blunt force trauma
Rib fractures from excessive squeezing of the torso
Lower extremity ligament tears
CORRECT: B
- Skull fracture from blunt force trauma
Chp 22–Abusive head trauma is the leading cause of death and disability in infants from physical abuse. The classic finding of AHT is subdural hematoma. Retinal hemorrhages are also common. Cervical spine injury can occur but is a result of hyperflexion. Skull fractures can be secondary to blunt force trauma. Rib fractures can also occur. Lower extremity injury is more likely to be metaphyseal injury.
CORRECT: C
- Rib fractures from excessive squeezing of the torso
Chp 22–Abusive head trauma is the leading cause of death and disability in infants from physical abuse. The classic finding of AHT is subdural hematoma. Retinal hemorrhages are also common. Cervical spine injury can occur but is a result of hyperflexion. Skull fractures can be secondary to blunt force trauma. Rib fractures can also occur. Lower extremity injury is more likely to be metaphyseal injury.
Question 3
“Use a consistent approach with behavioral cues both at home and at school.”
“Medications are the only intervention that can help with ADHD.”
A 14-year-old boy who is overweight develops a unilateral limp with pain in the hip and knee on the affected side. An exam reveals external rotation of the hip when flexed and pain associated with attempts to internally rotate the hip. What is most important initially when managing this child’s condition?Recommend seeing an orthopedic specialist as soon as possible.
Order imaging and refer the child to physical therapy to improve range of motion.
Provide information about weight loss to minimize further injury.
Place the child on crutches or in a wheelchair to prevent weight-bearing and refer to ED
CORRECT: D
- Place the child on crutches or in a wheelchair to prevent weight-bearing and refer to ED
Chp 40-This child’s age, history, and symptoms are consistent with slipped capital femoral epiphysis. The child should be placed on crutches or in a wheelchair to prevent weight bearing and referred to ED for urgent orthopedic consultation. Obesity is often part of the history and should be managed, but the immediate need is to prevent further damage to the hip. Imaging may confirm diagnosis but physical therapy may be part of treatment after the epiphysis is stabilized.
Question 5
The primary care nurse practitioner is performing an examination on a 5-year-old child who exhibits ritualistic behaviors, avoids contact with other children, and has limited speech. The parent reports having had concerns more than 2 years ago about autism but was told that it was too early to diagnose. What will the nurse practitioner do first?
Administer an M-CHAT screen to screen the child for communication and socialization delays.
Refer the child to a pediatric behavioral specialist to develop a plan of treatment and management.
Reassure the parent that if symptoms weren’t present earlier, the likelihood of autism is low.
Ask the parent to describe the child’s earlier behaviors from infancy through preschool.
CORRECT: D
- Ask the parent to describe the child’s earlier behaviors from infancy through preschool.
Chp 29–The DSM-5 criteria state that a patient must show symptoms from early childhood even if the symptoms are not recognized until later in life. The parent had noticed symptoms prior but was told not to worry; these symptoms should be evaluated in light of the current symptoms. The M-CHAT is used for infants and toddlers and not for school-age children. Autism symptoms are generally evident by age 3 years. The PNP should complete the assessment before making a referral.
Question 6
Apply ice packs to both knees and avoid activities that cause pain.
Refer to a pediatric orthopedic specialist to evaluate the need for surgery.
Begin quadriceps-stretching exercises now to prevent further injury.
Obtain radiographic studies to rule out fractures or ligament tears.
CORRECT: A
- Apply ice packs to both knees and avoid activities that cause pain.
Chp 40–The history of sports involving kicking a ball and the location and type of pain and swelling are consistent with Osgood-Schlatter disease (OSD). Management involves rest and ice and sometimes NSAIDs. Quadriceps-stretching exercises are not encouraged until the acute symptoms pass. Radiographic studies are not necessary. Referral is not indicated for OSD.
Question 7
The parent of a school-age child reports that the child becomes frustrated when unable to perform tasks well and often has temper tantrums and difficulty sleeping. Which disorder may be considered in this child?
Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS)
Obsessive-compulsive disorder (OCD)
Generalized anxiety disorder (GAD)
Separation anxiety disorder (SAD)
CORRECT: C
- Generalized anxiety disorder (GAD)
Chp 29–GAD is characterized by over-concern about competence, significant self-consciousness, irritability and tantrums, and poor sleep. OCD results in recurring thoughts, images, or impulses. Patients with PANDAS have OCD- and Tourette-like symptoms. SAD causes difficulties separating from caregivers and being away from home.
Question 8
A noted lack of back-and-forth conversation
Tolerance of flexibility with routines
Abnormal eye movements or body language
Fascination with light or movement
Question 9
A young adolescent female is observed to have mild unequal scapula prominences on gross examination while standing. In the Adams forward bending position, this inequality disappears. What will the primary care nurse practitioner do?
Refer to an orthopedic specialist for evaluation and possible bracing.
Discuss posture and exercise and ask about backpacks and books.
Obtain radiographic studies of the entire spine and neck.
Reassure the child’s parent that functional scoliosis will self-resolve.
CORRECT: B
- Discuss posture and exercise and ask about backpacks and books.
Chp 40–Unequal scapula noted on standing can denote scoliosis and deserves a more thorough physical assessment. Functional scoliosis can be diagnosed by assessing curves in the spine in the Adams forward bending position. Although it is relatively benign, functional scoliosis can progress to structural scoliosis if not treated, which can be done with physical therapy or other means, such as exercises or removing external forces (carrying heavy loads, heavy one-sided backpacks) that place unequal pressures on the spine, to prevent progression. Radiographs may be necessary if this worsens. This will not self-resolve but must be managed to prevent progression. Orthopedic referral is not necessary at this early, modifiable stage.
Question 10
A 13-year-old child has exhibited symptoms of mild depression for several weeks. The parent reports feeling relieved that the symptoms have passed but concerned that the child now seems to have boundless energy and an inability to sit still. What will the primary care nurse practitioner do?
Consult with a child psychiatrist to prescribe an antidepressant medication.
Refer the child to a child psychiatrist for evaluation of bipolar disorder.
Administer an ADHD diagnostic scale and consider an Attention-deficit/hyperactivity disorder (ADHD) medication.
Reassure the parent that this behavior is common after mild depressive symptoms
CORRECT: B
- Refer the child to a child psychiatrist for evaluation of bipolar disorder.
Chp 29–Children who have ADHD symptoms and depression should be evaluated by a child psychiatrist for bipolar disorder. Medications are not appropriate until the disorder is correctly diagnosed. Stimulant medications are not effective in treating bipolar disorder. Antidepressants may potentiate manic responses. Providers should carefully evaluate and refer any child treated for ADHD who does not respond to therapy or who experiences a sudden worsening of agitation while using ADHD medications.
Question 11
An adolescent has recently begun doing poorly in school and has stopped participating in sports and other extracurricular activities. During the history interview, the adolescent reports feeling tired, having difficulty concentrating, and experiencing a loss of appetite for the past few weeks but cannot attribute these changes to any major life event. Which is an important next step in managing this patient?
Referring the adolescent to a mental health specialist
Administering a diagnostic rating scale for depression
Determining suicidal ideation and risk of suicide
Considering a short-term trial of an antidepressant medication
CORRECT: C
- Determining suicidal ideation and risk of suicide
Chp 29–Because this adolescent exhibits clear signs of depression, the first goals of management are to determine suicidal risk and to intervene to prevent suicide since the risk of suicide is greatest during the first 4 weeks of a depressive episode. A diagnostic rating scale may help in diagnosing the depression but assessing suicide risk is a priority. Antidepressant medications may be useful but are best initiated by a mental health specialist. The initial response in adolescents should be to determine suicide risk to decide whether to admit to inpatient therapy or refer to a mental health specialist.
Question 12
A 14-year-old female comes to the clinic with amenorrhea for 3 months. A pregnancy test is negative. The adolescent’s body weight is at 82% of expected for height and age. The mother reports that her daughter often refuses to eat most foods and has an extreme fear of being “fat”. Which condition does the primary care nurse practitioner suspect?
Depression
Anorexia nervosa
Substance abuse
Bulimia nervosa
CORRECT: B
- Anorexia nervosa
Chp 29–Children with anorexia nervosa are usually underweight. Diagnostic criteria include food restriction leading to significantly low body weight based on sex, age, and height, intense fear of being “fat”, body dysmorphism and in the binge/purge type- frequent purging. Depression and substance abuse may be co-morbid conditions but these clinical signs are most associated with anorexia.
Question 13
A parent is concerned that a 12-month-old child is “bow-legged.” A physical examination reveals internal tibial torsion bilaterally. A radiograph reveals asymmetric bowing of the legs with an angle greater than 15 degrees. What is the correct action for the primary care pediatric nurse practitioner?
Order physical therapy to prevent progression of symptoms.
Refer to a pediatric orthopedic specialist for treatment.
Observe the child’s condition over time to assess progression.
Reassure the parent that the child will outgrow this deformity.
CORRECT: B
- Refer to a pediatric orthopedic specialist for treatment.
Chp 40–In Blount disease, the bowing is asymmetrical; children with this disorder need immediate referral to an orthopedist. Physiologic bowing may self-resolve and may be managed with observation, physical therapy, and reassurance
Question 14
The parent of a school-age girl reports that the child has difficulty getting ready for school and is often late because of a need to check and recheck whether her teeth are clean and her room light has been turned off. What will the primary care nurse practitioner recommend to this parent?
Medication management with an SSRI
Deferral of treatment until symptoms worsen
Cognitive-behavioral therapy
Referral to a child psychiatrist
CORRECT: C
- Cognitive-behavioral therapy
Chp 29–This child exhibits signs of obsessive-compulsive disorder (OCD). Cognitive-behavioral therapy is the first-line therapy for mild to moderate OCD. Children who have mild symptoms that do not interfere with their lives can defer treatment, but this is not the case in this situation. Medication and referral to a child psychiatrist are used for more severe symptoms.
Question 15
Recognize 5 colors and identify all letters in her name.
Empathize with others.
Counts to 4 and draws a person with three parts.
Accurately uses pronouns
Question 16
A newly divorced mother of a toddler reports that the child began having difficulty sleeping and nightmares along with exhibiting angry outbursts and tantrums 2 months prior. The primary care nurse practitioner learns that the child refuses to play with usual playmates and often spends time sitting quietly. What will the nurse practitioner do initially?
Consult with a child psychiatrist to prescribe medications.
Ask the mother about the child’s relationship with the father.
Recommend cognitive behavioral or psychodynamic therapy
Reassure the mother this is normal behavior following divorce.
CORRECT: B
- Ask the mother about the child’s relationship with the father.
Chp 29–The child exhibits signs of post traumatic stress disorder (PTSD). Because the parents are newly divorced, the PNP should evaluate the child’s previous interactions with the father to determine whether violence occurred. If PTSD is likely, referral to social service agencies may be warranted. Reassurance is not appropriate in this case.
Question 17
What anticipatory guidance is most appropriate to discuss regarding prevention of gun violence? (Select all that apply.)
Encourage parents to register all guns as required by their state
The safest homes are free of firearms
Encourage the parent to teach the child how to shoot a gun safely
If guns are in the home, they should be unloaded and store separately from ammunition
CORRECT: B
- The safest homes are free of firearms
Chp 21–Gun violence is the leading cause of pediatric mortality in the United States. The American Academy of Pediatrics recommends several strategies to help decrease risk of gun related deaths. Some strategies include not having firearms in the home, if there are guns in the home, they should be unloaded, locked up, and stored separately from the ammunition. Emphasis should also be placed on the risk of having a firearm in the home if there is a child at risk for mental health disorders living in the home. There is no recommendation regarding teaching children how to shoot firearms or recommending parents register guns.
CORRECT: D
- If guns are in the home, they should be unloaded and store separately from ammunition
Chp 21–Gun violence is the leading cause of pediatric mortality in the United States. The American Academy of Pediatrics recommends several strategies to help decrease risk of gun related deaths. Some strategies include not having firearms in the home, if there are guns in the home, they should be unloaded, locked up, and stored separately from the ammunition. Emphasis should also be placed on the risk of having a firearm in the home if there is a child at risk for mental health disorders living in the home. There is no recommendation regarding teaching children how to shoot firearms or recommending parents register guns.
Question 18
What is the most common cause of death among youth in the United States?
Gun violence-related death
Overdose
Motor vehicle crash
Drowning
CORRECT: A
- Gun violence related death
Chp 21–Historically, motor vehicle crashes were the leading cause of death in children over age one. However, gun violence has surpassed car crashes as number one cause of mortality among children and adolescents. Drowning remains an important preventable cause of death but not the leading cause. Suicide is almost a top cause of mortality but does not cause as many deaths as gun violence.
Question 19
An adolescent presents for a well visit. He is starting a new job which requires a urine drug screen. He went to a party about 3 weeks ago and drank alcohol and used “some drugs”. He wants to know if he will be able to “pass” his drug test. Which substance may be identified in the urine drug screen?
Alcohol
Lorazepam
Oxycodone
Marijuana
CORRECT: D
- Marijuana
Chp 29–Urine drug screens (UDS) only identify substance use and do not necessarily indicate substance abuse. Marijana may show up on a UDS for up to 30 days. Alcohol, opiates, cocaine, amphetamines, benzodiazepines generally do not show up on a UDS after a few hours to days.
Question 20
The primary care nurse practitioner is conducting a follow-up examination on a child who has recently begun taking a low-dose stimulant medication to treat attention-deficit/hyperactivity disorder (ADHD). The child’s school performance and home behaviors have improved. The child’s parent reports noticing a few tics, such a twitching of the eyelids, but the child is unaware of them and isn’t bothered by them. What will the nurse practitioner recommend?
Continuing the medication as prescribed
Adding an alpha-agonist medication
Stopping the medication immediately
Changing to a non-stimulant medication
CORRECT: A
- Continuing the medication as prescribed
Chp 29–Tics may occur as a side effect of stimulant medications but do not need to be discontinued if there is a net benefit and the symptoms are not disturbing to the child. It is not necessary to add an alpha-agonist, change to a non-stimulant medication, or stop the medication.
Behavioral and Mental Health Issues
Chp 22–There are several red flags for physical abuse. Some of which include inconsistent history, delayed medical treatment, a history that does not match the physical injury, or a history that does not match the child’s developmental age. The most worrisome scenario here is a 2-week-old who rolled off the changing table as 2-week-olds cannot roll over. A 12-month-old with bruising to the shins can be expected for this age group as the child begins to cruise and walk.
Question 2