Test bank for MCQs in Pediatrics Review of Nelson
Textbook of Pediatrics 20 Edition
, Nelson Pediatrics Review(MCQs) 19 Edition
1. Which of the following statements regarding foster care is true?
□A permanency plan must be made for a child in foster care no later than 12 mo from the child's entry into care
□A minority of children in foster care have a history of abuse or neglect
□The mission of foster care is to safely care for children while providing services to families to promote reunification
□Most (>70%) of children in foster care are reunited with their families
■ A and C
description The mission of foster care is to provide for the health, safety, and well-being of children while assisting their
families with services to promote reunification. Children entering foster care have frequently experienced early childhood
trauma. More than 70% have a history of abuse, neglect, or both. Only about 50% of children achieve reunification. In the
USA, the Adoption and Safe Families Act (P.L. 105-89) passed in 1997 requires that a permanency plan be made for
each child no later than 12 mo after entry to foster care and that a petition to terminate parental rights typically must be filed
when a child has been in foster care for at least 15 of the previous 22 mo. (See Chapter 35, page 134, and e35-1.)
2. A 4 yr old girl is admitted to the hospital for her third evaluation for vaginal bleeding. The
mother noted bright red blood on the child's underwear. Previous examinations revealed a
normal 4 yr old girl, Tanner stage 1, with normal external genitalia. Pelvic ultrasound results
were normal, as was the serum estradiol level. The hemoglobin and platelet counts were
normal, as were the bleeding time and coagulation studies. Findings on pelvic examination
conducted under anesthesia also were normal. The next step in the examination is to:
■ Determine the blood type of the blood on the underwear
□Interrogate the father
□Isolate the parents and child
□Determine von Willebrand factor levels
, □Measure fibronectin in the vagina
description Consideration of factitious disorder by proxy should be triggered when the reported symptoms are repeatedly
noted by only one parent, appropriate testing fails to confirm a diagnosis, and seemingly appropriate treatment is ineffective.
At times, the child's symptoms, their course, or the response to treatment may be incompatible with any recognized disease.
Preverbal children are usually involved. Bleeding is a particularly common presentation. This may be caused by adding dyes
to samples, adding blood (e.g., from the mother) to the child's sample, or giving the child an anticoagulant (e.g., warfarin).
(See Chapter 37, page 146.)
3. Munchausen syndrome by proxy is characterized by all of the following EXCEPT:
□Mother who appears devoted and wins over members of care team
□Multiple hospitalizations and investigations without diagnosis
□Symptoms on history but not witnessed by medical team
■ Symptoms occurring in presence of different caregivers (e.g., while mother is out of town)
□Use of medications or toxins
description Symptoms in young children are mostly associated with proximity of the offending caregiver to the child. The
mother may present as a devoted or even model parent who forms close relationships with members of the health care
team. While appearing very interested in her child's condition, she may be relatively distant emotionally. (See Chapter 37,
page 146.)
4. Which statement is false?
■ Malnutrition is the second leading cause of acquired immune deficiency worldwide behind HIV infection
□Zinc is important in immune function and linear growth
□Kwashiorkor and marasmus are rare in developed countries
□The Western diet is associated with increased noncommunicable disease
description The significant global burden of malnutrition and undernutrition is the leading worldwide cause of acquired
immunodeficiency and the major underlying factor for morbidity and mortality globally for children <5 yr of age. Zinc is a
micronutrient that supports multiple metabolic functions in the body, is essential for normal immune functioning, and is
required to support linear growth; zinc deficiency is associated with impaired immune functioning and poor linear growth. In
parallel to the risk for nutrient and energy deficiencies, issues relating to excesses pose important challenges because of their
negative health effects, such as obesity or cardiovascular disease risk factors. The nutrition transition under way in the
, developing world from traditional diets to the Western diet has been associated with increases in noncommunicable
diseases, often coexisting with undernutrition and malnutrition, observed sometimes in the same communities or even the
same families. (See e41-1.)
5. Components of energy expenditure in children include:
□Thermal effect of food
□Basal metabolic rate
□Energy for physical activity
□Energy to support growth
■ All of the above
description The 3 components of energy expenditure in adults are the basal metabolic rate, the thermal effect of food
(energy required for digestion and absorption), and energy for physical activity. Additional energy intake and expenditure
are required to support growth and development for children. (See e41-4.)
6. Which of the following clinical scenarios increases the risk of vitamin A deficiency?
□Vegetarian diet
□Chronic intestinal disorders
□Zinc deficiency
■ B and C
□All of the above
description Vitamin A is an essential micronutrient because it cannot be biogenerated de novo by animals. It must be
obtained from plants in the form of provitamin-A carotenoids. In the USA, grains and vegetables supply approximately
55% and dairy and meat products supply approximately 30% of vitamin A intake from food. Vitamin A and the
provitamins-A are fat soluble, and their absorption depends on the presence of adequate lipid and protein within the meal.
Chronic intestinal disorders or lipid malabsorption syndromes can result in vitamin A deficiency. In developing countries,
subclinical or clinical zinc deficiency can increase the risk of vitamin A deficiency. There is also some evidence of marginal
zinc intakes in children in the USA. (See Chapter 45, page 188.)
7. Which statement about vitamin A toxicity is NOT true?
, □Excess vitamin A in utero can cause congenital malformations
□It may present as pseudotumor cerebri
■ An infant with a preference for carrots and butternut squash may develop toxicity
□It may cause fissures at the corners of the mouth, pruritus, and alopecia
□Symptoms subside rapidly after withdrawing the source of the vitamin
description Excessive intake of carotenoids is not associated with toxicity but can cause yellow coloration of the skin that
disappears when intake is reduced; this disorder (carotenemia) is especially likely to occur in children with liver disease,
diabetes mellitus, or hypothyroidism and in those who do not have enzymes that metabolize carotenoids. (See Chapter 45,
page 191.)
8. Which statement about vitamin E is false?
□The most common form of vitamin E is tocopherol
■ Premature infants given formula with a high content of polyunsaturated fatty acids and iron supplementation are protected
from deficiency
□Cholestatic liver disease increases the risk of deficiency
□Premature infants with vitamin E deficiency develop hemolysis, thrombocytosis, and edema
□Prolonged vitamin E deficiency causes a severe, progressive neurologic disorder
description Premature infants are particularly susceptible to vitamin E deficiency because there is significant transfer of
vitamin E during the last trimester of pregnancy. Vitamin E deficiency in premature infants causes thrombocytosis, edema,
and hemolysis, potentially causing anemia. The risk of symptomatic vitamin E deficiency was increased by the use of
formulas for premature infants that had a high content of polyunsaturated fatty acids (PUFAs). These formulas led to a high
content of PUFAs in red blood cell membranes, making them more susceptible to oxidative stress, which could be
ameliorated by vitamin E. Oxidative stress was augmented by aggressive use of iron supplementation; iron increases the
production of oxygen radicals. The incidence of hemolysis due to vitamin E deficiency in premature infants decreased
secondary to the use of formulas with a lower content of polyunsaturated fatty acids, less-aggressive use of iron, and
provision of adequate vitamin E. (See e49-1.)
9. Manifestations of hyperkalemia include all of the following EXCEPT:
, □Paresthesias
□Weakness
□Paralysis
□Wide QRS complex
■ Tetany
description The most important effects of hyperkalemia are due to the role of potassium in membrane polarization. The
cardiac conduction system is usually the dominant concern. Changes in the electrocardiogram (ECG) begin with peaking of
the T waves. This is followed, as the potassium level increases, by ST segment depression, an increased PR interval,
flattening of the P wave, and widening of the QRS complex. This process can eventually progress to ventricular fibrillation.
Asystole may also occur. Some patients have paresthesias, fasciculations, weakness, and even an ascending paralysis, but
cardiac toxicity usually precedes these clinical symptoms, emphasizing the danger of assuming that an absence of symptoms
implies an absence of danger. (See Chapter 52, page 221.)
10. Hyperkalemia may be associated with all of the following EXCEPT:
□Succinylcholine use
□Burns
□Trauma
□Chemotherapy
■ Metabolic alkalosis
□Digitalis toxicity
□Uremia
description Many causes of hyperkalemia result in metabolic acidosis; a metabolic acidosis worsens hyperkalemia through
the transcellular shift of potassium out of cells. Renal insufficiency is a common cause of the combination of metabolic
acidosis and hyperkalemia. This association is also seen in diseases associated with aldosterone insufficiency or aldosterone
resistance. (See Chapter 52, page 221.)
11. The best method to reduce the potassium level during hyperkalemia, by reducing the body
burden of potassium, is:
, □Sodium bicarbonate infusion
□Glucose and insulin infusion
□Calcium infusion
□Albuterol aerosol
■ Kayexalate enema
description Treatment of hyperkalemia has 2 basic goals: (1) to stabilize the heart to prevent life-threatening arrhythmias
and (2) to remove potassium from the body. The treatments that acutely prevent arrhythmias all have the advantage of
working quickly (within minutes) but do not remove potassium from the body. Calcium stabilizes the cell membrane of heart
cells, preventing arrhythmias. It is given intravenously over a few minutes, and its action is almost immediate. Several
medications cause potassium to move intracellularly and thus rapidly reduce the plasma level to prevent arrhythmias. These
include bicarbonate, insulin and glucose, and nebulized albuterol. However, these medicines do not remove potassium from
the body. To reduce the total body potassium, 3 options are available. In patients who are not anuric, a loop diuretic
increases renal excretion of potassium. A high dose may be required in a patient with significant renal insufficiency. Sodium
polystyrene sulfonate (Kayexalate) is an exchange resin that is given either rectally or orally. Sodium in the resin is
exchanged for body potassium, and the potassium-containing resin is then excreted from the body. Some patients require
dialysis for acute removal of potassium. Dialysis is often necessary if the patient has either severe renal failure or an
especially high rate of endogenous potassium release, as is sometimes present with tumor lysis syndrome or
rhabdomyolysis. (See Chapter 52, page 222.)
12. Clinical manifestations of hypokalemia include all of the following EXCEPT:
□ECG changes
□Paralysis
□Urinary retention
□Constipation
□Muscle cramps
■ Blurry vision
description The heart and skeletal muscle are especially vulnerable to hypokalemia. ECG changes include a flattened T
wave, a depressed ST segment, and the appearance of a U wave, which is located between the T wave (if still visible) and
the P wave. Ventricular fibrillation and torsades de pointes may occur, although usually only in the context of underlying
heart disease. The clinical consequences of hypokalemia in skeletal muscle include muscle weakness and cramps. Paralysis
is a possible complication, generally only at potassium levels <2.5 mEq/L. It usually starts in the legs and moves to the
arms. Respiratory paralysis may require mechanical ventilation. Some patients have rhabdomyolysis; the risk increases with
, exercise. Hypokalemia slows gastrointestinal motility. This effect manifests as constipation; with potassium levels <2.5
mEq/L, an ileus may occur. Hypokalemia impairs bladder function, potentially leading to urinary retention. (See Chapter
52, page 224.)
13. From the following list, choose the route(s) by which insensible water loss may occur: 1. Sweat,
2. Fecal loss, 3. Evaporative loss from skin, 4. Respiratory water loss, 5. Obligate water for
urinary solute excretion
□1 and 3
□1, 2, and 3
□3 only
■ 3 and 4
□2 and 5
description Water is a crucial component of maintenance fluid therapy because of the obligatory daily water losses. These
losses are both measurable (urine, stool) and not measurable (insensible losses from the skin and lungs). Failure to replace
these losses leads to a child who is thirsty, uncomfortable, and, ultimately, dehydrated. (See Chapter 53, page 242.)
14. Which of the following is a goal of maintenance fluids?
□Diminish protein degradation
□Prevent dehydration
■ Prevent hunger
□Prevent electrolyte derangements
□Prevent ketoacidosis
description The glucose in maintenance fluids provides approximately 20% of the normal caloric needs of the patient,
prevents the development of starvation ketoacidosis, and diminishes the protein degradation that would occur if the patient
received no calories. Glucose also provides added osmoles, thus avoiding the administration of hypotonic fluids that may
cause hemolysis. Maintenance fluids do not provide adequate calories, protein, fat, minerals, or vitamins. This fact is
typically not problematic for a patient receiving intravenous fluids for a few days. A patient receiving maintenance
intravenous fluids is receiving inadequate calories and will lose 0.5-1% of weight each day. Table 53-1 summarizes the
goals of maintenance fluids. (See Chapter 53, page 242.)
,15. Which patient has an elevated risk of hyponatremia with standard maintenance fluid therapy
(D5 ½ NS if >10 kg, D5 ¼ NS if <10 kg)?
□6 mo old NPO for elective hernia repair
□4 month old with bronchiolitis and poor oral intake
□13 yr old status post motor vehicle accident with multiple fractures, requiring treatment with narcotics and antiemetics
□8 yr old with nephrotic syndrome
□A and D
■ B, C, and D
description Patients who are producing antidiuretic hormone (ADH) may retain water, creating a risk of hyponatremia due
to water intoxication. Patients who may be producing ADH owing to subtle volume depletion or other mechanisms
(respiratory disease, stress, pain, nausea, medications such as narcotics) may be more safely treated with fluids that have a
higher sodium concentration, with a decrease in fluid rate, or with a combination of these strategies. Patients with persistent
ADH production due to an underlying disease process (syndrome of inappropriate ADH secretion [SIADH], congestive
heart failure, nephrotic syndrome, liver disease) should receive less than maintenance fluids. Treatment is individualized, and
careful monitoring is critical. Special caution is needed in patients who are known to have low-normal serum sodium
concentrations or hyponatremia. (See Chapter 52, page 243.)
16. In which patient is oral rehydration NOT indicated?
□2 yr old with moderate hypernatremic dehydration
□6 mo old with mild hyponatremic dehydration
■ 4 mo old with severe dehydration and normal serum sodium
□3 yr old with moderate dehydration and normal serum sodium
□A and C
description Dehydration, most often due to gastroenteritis, is a common problem in children. Most cases can be managed
with oral rehydration. Even children with mild to moderate hyponatremic or hypernatremic dehydration can be managed
with oral rehydration. The infant with severe dehydration is gravely ill. The decrease in blood pressure indicates that vital
organs may be receiving inadequate perfusion. Immediate and aggressive intervention is necessary. If possible, the child
with severe dehydration initially should receive intravenous therapy. (See Chapter 54, page 245.)
, 17. Which statement about pediatric poisoning is NOT true?
□Most poisonings among young children involve a single substance and are unintentional
□Poison prevention should be discussed at all well child visits beginning at 6 months
□Pediatric poisonings occur most frequently in the toddler and adolescent age ranges
■ The toddler age group experiences the majority of poisoning deaths
□Poison control centers are available via phone, 24-7, toll free
description Although the majority of exposures are in children <6 yr, only 2% of the reported deaths occur in this age
group. In addition to the exploratory nature of ingestions in young children, product safety measures, poison prevention
education, early recognition of exposures, and around-the-clock access to regionally based poison control centers all
contribute to the favorable outcomes in this age group. Exposures in the adolescent age group are primarily intentional
(suicide or abuse or misuse of substances) and thus often result in more severe toxicity. Adolescents (ages 13-19 yr)
accounted for 74 of the 108 poison-related pediatric deaths in 2008 reported to the National Poison Data System.
Pediatricians should be aware of the signs of drug abuse or suicidal ideation in this population and should aggressively
intervene. (See Chapter 58, page 250.)
18. Quantitative levels of certain medications are helpful in the management of acute poisonings.
For which of the following medications is this NOT true?
□Salicylates
□Acetaminophen
□Iron
□Carbon monoxide
■ Marijuana
description For select intoxications (salicylates, some anticonvulsants, acetaminophen, iron, digoxin, methanol, lithium,
theophylline, ethylene glycol, carbon monoxide), quantitative blood concentrations are integral to confirming the diagnosis
and formulating a treatment plan. For most exposures, quantitative measurement is not readily available and is not likely to
alter management. (See Chapter 58, page 253.)
19. The 4 principles of management of poisonings are what?
■ Decontamination, enhanced elimination, antidote, supportive care
