PNCB CPNP-PC Exam Questions

Correct answer: Industry vs. inferiority

Erikson's theory of development describes the stages of the individual throughout the lifespan. Each stage represents problems that the person seeks to master. Erikson believed that if problems were not resolved, they would likely be revisited again in future stages of development. His stages are as follows:

• Birth to 12 months: Trust vs. mistrust
• 12 months to 3 years: Autonomy vs. shame and doubt
• 3 years to 6 years: Initiative vs. guilt
• 6 years to 11 years: Industry vs. inferiority
• 12 years to 17 years: Identity vs. role confusion
• 17 years to 30 years: Intimacy vs. isolation

In the 7-year-old child, industry vs. inferiority, also called the Latency stage, is taking place. The child is capable of learning, creating and accomplishing numerous new skills and knowledge, thus developing a sense of industry. This is also a very social stage of development, and if we experience unresolved feelings of inadequacy and inferiority among our peers, we can have serious problems regarding competence and self-esteem. The most significant relationship is with the school and the neighborhood. Parents are no longer the complete authorities they once were, although they are still important.

Correct answer: No individual belongs to only one culture

Culture is a complex, dynamic, learned pattern of behavior that is integral to the being of individuals and communities. One's ethnicity, gender, age, sexual orientation, spiritual practices, social, educational, and economic status, and geographic location all help shape an individual's cultural worldview. In addition, the degree to which one experiences discrimination or persecution also has a profound impact on one's beliefs and behaviors. No one belongs to only one culture. Rather, each person, family, and community represents a unique blend of overlapping cultures influencing perception, attitudes, and behavior.

An essentialist view of culture dominates in the health care literature today, and tends to oversimplify cultural information. Failure to address the diversity that exists within a cultural group results in ethnic groups being considered as all similar, when in fact, the variations within the group may be greater than the differences between cultural groups. Providers with these essentialist assumptions about cultural differences may have a false sense of competence. Instead of demonstrating respect as they intend, they may stereotype their patients, families, and communities in which they work.

Correct answer: Febrile seizures

Febrile seizures are the most common type of seizures in childhood and occur in up to 5% of children. They occur in conjunction with a fever (38 degrees C or higher). They are brief, generalized, clonic or tonic-clonic in nature, and can be either simple or complex. Simple febrile seizures last less than 15 minutes, while complex febrile seizures may last longer than 15 minutes and can have focal attributes. Febrile seizures typically occur between the ages of 6 months and 5 years (in association with a fever) in the absence of intracranial infection. 

The etiology of febrile seizures is unclear, with risk factors including family history of febrile seizures, or in those with predisposing factors, such as NICU stay >30 days, developmental delays, or day care attendance. 

Correct answer: Children with CGD eventually hit their growth spurt and generally reach normal adult height, although they may be slightly shorter compared to other family members

Children with CGD do eventually reach a normal adult height, often following the same growth patterns as their parents, but may be slightly short compared to other family members. It would be wrong to tell this patient that he will definitely reach the same height as his father; rather, reassuring him that he will, in fact, hit his growth spurt is appropriate. The other answer choices do not adequately address the question or provide reassurance, or are incorrect.

Correct answer: Mitochondrial inheritance

Mitochondrial inheritance is an inheritance pattern that arises from mitochondrial DNA (mtDNA). Mothers alone pass on mtDNA (i.e., matrilinear or maternal inheritance) because only egg cells contribute mitochondria to the developing embryo. Disorders that arise from mutations in mtDNA can appear in every generation, affecting both sexes, but mtDNA is inherited from the mother; thus, a mother will pass on the disease to all of her children.

Autosomal recessive inheritance is a type of single gene disorder that requires two copies of a mutated gene (one from each parent) located on one of the autosomal chromosomes (chromosome 1-22). Offspring who inherit only one abnormal gene in the pair are considered carriers. 

Autosomal dominant inheritance is a type of single gene disorder characterized by the inheritance of a single copy of a mutated gene located on one of the autosomal chormosomes (chromosome 1-22). The gene mutation is passed on from only one parent but results in an inherited disorder; the paired gene from the other parent is normal. The parent passing on the gene mutation typically has the disorder. 

In multifactorial inheritance, a combination of both genetic (with one or more contributing genes) and environmental factors are involved.

Correct answer: Rib fracture

Costochondritis is a common cause of chest pain in children and adolescents and involves an inflammatory process of one or more of the costochondral cartilages that causes localized tenderness and pain of the anterior chest wall. Most cases are idiopathic in nature, though trauma to the area and unaccustomed physical effort are factors known to cause costochondritis. 

Rib fractures are the key differential diagnosis if pain is associated with an injury. 

Childhood rheumatic diseases can also have complaints similar to costochondritis but generally have other characteristic physical findings. Vertebral osteomyelitis is a differential diagnosis of back pain. Clavicular fracture is not associated with costochondritis. 

Correct answer: Education of All Handicapped Children Act (Public Law 94-142)

Public Law 94-142 mandates appropriate education for all school-age children with developmental disabilities in the least restrictive environment. This law was amended by the IDEA in 2004 and 2008 to also cover children with special needs from birth to 3 years old. 

FAPE is a component of the IDEA and mandates that schools allow any child who needs specialized education services to receive them free of charge. Finally, Section 504 of the Rehabilitation Act of 1973 prevents discrimination, and also provides safeguards and support through reasonable accommodations in the school settings (such as ramps, assistive technology, and special seating arrangements).

Correct answer: Competing

Competing is a "win-lose" approach, where one acts very assertively in order to achieve their goals. There is no attempt made to cooperate with the other individual. This approach may be appropriate in an emergency situation when time is of the essence, or when you need quick, decisive action, when people are aware of and support the approach.

Accommodation involves cooperation to a high degree, even if it is at your own expense. Collaboration is where you partner or pair up with the other party to achieve both party's goals. Avoidance is when you simply avoid the issue. You aren’t helping the other party achieve their goals, and you aren’t assertively pursuing your own.

Correct answer: Erythema toxicum

Erythema toxicum is a benign self-limited eruption occurring primarily in healthy newborns in the first 24 to 48 hours. Up to 50% of newborns develop erythema toxicum, with a higher incidence in term than in preterm infants. This condition is characterized by yellow-white papules with a blotchy red base; it resolves within 2-3 weeks and is usually completely gone by 4 months of life. No treatment is required; the course is brief and transient.

An HSV rash is characterized by grouped vesicles on an erythematous base; the mother may have active lesions or a history of the disease. HSV is diagnosed via DFA or ELISA detection of HSV antigens, and acyclovir is given for treatment.

Transient neonatal pustular melanosis is a rash that is described best as vesicopustules that rupture easily and leave a halo of white scales around a central macule of hyperpigmentation, generally seen on the trunk, limbs, palms, and soles. There is no definitive diagnosis, and no treatment is necessary as a resolution is spontaneous.

Milia are multiple, firm, pearly, opalescent white papules scattered over the forehead, nose, and cheeks. Their intraoral counterparts are called Epstein pearls. Milia histologically represents superficial epidermal inclusion cysts filled with keratinous material associated with the developing pilosebaceous follicle. Milia exfoliate spontaneously in most newborns over the first few weeks of life and thus, no treatment is needed.

Correct answer: It is based on a biopsychosocial approach

Pediatric mental heath care has evolved from a medical model toward a more biopsychosocial approach that includes the concept of mind as expressed in behavior and adaptation to experience. This approach systematically considers biological, psychological, and social factors and their complex interactions in understanding health, mental illness, and health care delivery.

PCPs now recognize that the mind and the body are synergistic, not separate, and thus work together. Mental health concepts are now integrated into general nursing educational programs, resulting in national public awareness of the interrelationship of mental and physical health and well-being.

Correct answer: Bleeding gums, easy bruising, and slow wound healing 

These patients are likely deficient in vitamin C, which primarily comes from fruits and vegetables, especially citrus fruits, as well as broccoli, collard greens, spinach, tomatoes, potatoes, strawberries, and peppers. Scurvy may occur in patients with deficient vitamin C levels. Other signs include cracked lips, bleeding gums, slow wound healing, and easy bruising. 

Rickets would most likely be caused by a diet deficient in vitamin D (sources include sunlight and fortified food products, especially milk and fish). 

Anorexia and night blindness are signs of a deficit in vitamin A (sources come from liver, fish liver oils, fortified milk, eggs, red and orange vegetables, and dark green leafy vegetables). 

Muscle weakness, tachycardia, and confusion would likely be clinical findings in the child with a thiamin (vitamin B1) deficiency. Dietary sources include whole grains, brewer's yeast, legumes, seeds and nuts, fortified grain products, organ meats, and lean cuts of pork. 

Correct answer: Neisseria gonorrhoeae

Gonococcal conjunctivitis is the most serious cause of ophthalmia neonatorum (conjunctival infection or inflammation occurring in the first month of life). It is of particular concern because it produces a hyperacute, profusely purulent conjunctivitis that can lead to corneal perforation and blindness. It is less often seen in Western countries due to chemoprophylaxis but is still an important cause of ophthalmia neonatorum.

The other answer choices are all bacteria that can cause conjunctivitis in the newborn, but not as great of a risk as Neisseria gonorrhoeae.

Correct answer: An evidence review 

An evidence review is the most important aspect in developing evidence-based practice. Much of the basis for primary care practice is not yet evidence-based. Primary care would benefit from stronger scientific clinical research and review that could strengthen primary care principles and prevention.

Increased evidence in the primary healthcare domain would help to move the public dialogue toward a greater focus on primary prevention and away from a disease-focused healthcare system. 

Correct answer: Store substances

Physiologically, the kidneys serve to filter, clear, reabsorb, and secrete substances essential to the body's metabolism. The urinary system starts to form and excrete urine at just three months of gestational age, and glomerular filtration and renal blood flow become stable by 1 to 2 years old. The kidneys mature through infancy, although all measurable variables of kidney function approach adult values between 6 and 12 months old.

The bladder stores primarily urine, allowing urination to be infrequent and voluntary.

Correct answer: Pulls a pull toy; walks forward and backward; drinks from a cup; holds a spoon

• Typical 15-month-old: Pulls a pull toy; walks forward and backward; drinks from a cup; holds utensils, some attempt to use
• Typical 18-month-old: Aims and throws a ball; stacks up to six blocks; removes own socks; scribbles spontaneously
• Typical 24-month-old: Turns a doorknob; kicks a ball; climbs up on furniture; turns pages one at a time
• Typical 30-month-old: Walks on tiptoes; buttons large buttons; jumps with both feet; builds a tower with nine cubes

Correct answer: Screening for obstructive sleep apnea 

NF1 is a genetic, neurocutaneous disorder with multi-system involvement, including the brain, eyes, bones, and skin (skin and nervous system). It is characterized by multiple café au lait spots and neurofibromas (soft, fleshy growths) on or under the skin. Enlargement and deformation of bones and scoliosis may also occur. Occasionally, tumors may develop in the brain, on cranial nerves, or on the spinal cord. An estimated 4% to 8% of the NF1 population have an intellectual disability. Children with NFI are at high risk for learning disabilities involving math, writing, and reading skills, and may also have social deficits. 

Monitoring recommendations for primary care providers include:

• Monitor for growth using specialized growth charts (macrocephaly and short stature are common, and puberty growth spurt is reduced)
• Monitor for learning disabilities
• Annual ophthalmology screen (Lisch nodules, optic gliomas)
• Monitor blood pressure (hypertension) as a screen for renal artery stenosis, aortic stenosis, and pheochromocytoma (adult)
• Monitor for skeletal changes (tibial dysplasia, scoliosis, and increased risk for osteoporosis in adulthood)
• Advise use of sunscreen after 6 months of age (as sun will increase pigmentation of cafe-au-lait spots)

Obstructive sleep apnea is not likely to occur with this condition.

Correct answer: Every 2-3 years

Functional health problems are derived from Gordon's functional health patterns and are incorporated into the NANDA taxonomy terms, which is revised every 2-3 years.

These patterns provide a framework for thinking about the problems that nurses have always managed independently, and represent the universal health behavior patterns of all humans, regardless of culture, sex, age, or economic status.

Correct answer: Fever and cough

The hallmark of pneumonia is fever and cough, except in the neonate where there may be an absence of cough. 

Tachypnea and increased work of breathing may precede coughing. Cough, hypoxia, nasal flaring, retractions, rales, and rhonchi lung sounds are specific but not as sensitive for a pneumonia diagnosis.

Viral pneumonia tends to have an insidious onset that is associated with more wheezing than what is typically seen with bacterial pneumonia. On the other hand, lobar pneumonia (caused by pneumococcal pneumonia) generally presents with fever, cough, and decreased breath sounds in the area of the pneumonia.

Correct answer: Prescribe topical benzoyl peroxide gel daily plus a topical antibiotic twice a day

Medication for treatment of acne vulgaris should be effective but limited to avoid unnecessary adverse effects. Acne management is directed at modification of one or more of four primary factors that promote the development of acne, including:

• excess production of sebum
• abnormal desquamation of epithelial cells
• proliferation of P. acnes
• inflammation.

Medications commonly used in treating acne include topical retinoids, benzoyl peroxide, azelaic acid, and topical and oral antibiotics (as well as combination products). 

The patient in this scenario has mild papulopustular mixed with comedonal acne. Treatment involves choosing one of the following: benzoyl peroxide or adapalene (topical retinoid), plus a topical antibiotic twice a day (erythromycin, clindamycin). A minimum of 4 to 6 weeks of treatment is required before improvement is seen.

Correct answer: Paroxetine (Paxil)

Currently, there are only a few antidepressants the FDA approves for use in children and adolescents. Paroxetine should not be used in children and adolescents because of the 3.5-fold increased risk of suicide. A general rule of antidepressant dosing is to start low and slowly increase. It takes 4 to 6 weeks to see maximum response, but medication doses can be adjusted to improve response every 2 to 4 weeks, as long as significant side effects are absent. 

Activation (e.g., elevated energy without mood change) and mania can occur in patients secondary to treatment with antidepressants. Therefore, it is critical that parents be taught about symptoms that merit immediate evaluation. Close follow-up is recommended for all children and adolescents with depression, especially when symptoms are significant enough to merit pharmacotherapy.

Fluoxetine is FDA approved for children ages 8 and older who have anxiety, MDD, OCD, and selective mutism. Escitalopram is approved for children ages 7 and older with depression and/or anxiety. Sertraline is approved for children ages 6 and older who have MDD and/or OCD.