Question 1

A 2-year-old child has an acute diarrheal illness. The child is afebrile and, with oral rehydration measures, has remained well hydrated. The parent asks what can be done to help shorten the course of this illness. What will the primary care pediatric nurse practitioner recommend?

Accepted Answer

The primary care pediatric nurse practitioner may recommend the use of lactobacillus to help shorten the course of the illness. Lactobacillus may help to restore the balance of gut bacteria and reduce the severity of symptoms. However, it is important to note that the use of other medications such as loperamide or peppermint oil is not recommended for a 2-year-old child with acute diarrheal illness. Clear liquids and oral rehydration measures should be continued to maintain hydration.

Question 2

A 12-month-old infant exhibits poor weight gain after previously normal growth patterns. There is no history of vomiting, diarrhea, or irregular bowel movements, and the physical exam is normal. What is the next step in evaluating these findings?

Accepted Answer

The next step should be to assess the infant's feeding and stooling history as well as a 3-day diet history to evaluate potential nutritional issues. This information can help identify possible underlying causes of poor weight gain, such as inadequate nutrient intake or feeding difficulties. Further diagnostic testing, such as a swallow study or stool cultures, may be warranted depending on the results of this initial evaluation.

Question 3

A toddler is seen in the clinic after a 2-day history of intermittent vomiting and diarrhea. An assessment reveals an irritable child with dry mucous membranes, 3-second capillary refill, 2- second recoil of skin, mild tachycardia and tachypnea, and cool hands and feet. The child has had two wet diapers in the past 24 hours. What will the primary care pediatric nurse practitioner recommend?

Accepted Answer

The child's symptoms suggest dehydration and thus, the primary care pediatric nurse practitioner should recommend ORS (oral rehydration solution) with follow-up in 24 hours. Hospitalization may be considered for children with severe dehydration or those unable to tolerate ORS. Anti-diarrheal medication is contraindicated in children with diarrhea and should be avoided. Bolus of IV normal saline may be considered in children with severe dehydration but not in mild to moderate dehydration.

Question 4

A 9-year-old girl has a history of frequent vomiting and her mother has frequent migraine headaches. The child has recently begun having more frequent and prolonged episodes accompanied by headaches. An exam reveals abnormal eye movements and mild ataxia. What is the correct action?

Accepted Answer

The frequent vomiting, headaches, abnormal eye movements, and ataxia suggest that there may be an underlying neurological or gastrointestinal condition present. It is important to refer the child to a specialist who can perform a thorough workup and provide appropriate management.

Question 5

An 18-month-old child has a 1-day history of intermittent, cramping abdominal pain with non-bilious vomiting. The child is observed to scream and draw up his legs during pain episodes and becomes lethargic in between. The primary care pediatric nurse practitioner notes a small amount of bloody, mucous stool in the diaper. What is the most likely diagnosis?

Accepted Answer

The intermittent, cramping abdominal pain with vomiting, along with lethargy and drawing up of legs suggest abdominal pain. The presence of bloody, mucous stool suggests lower gastrointestinal bleeding. These symptoms, along with the age of the child, are highly suggestive of intussusception, which is a condition where a portion of the intestine telescopes or invaginates into another part, causing blockage and eventually decreasing blood flow, leading to ischemia and necrosis. Appendicitis typically presents with continuous abdominal pain, fever, and with a focus on the right lower quadrant of the abdomen. Gastroenteritis usually causes diarrhea, vomiting, and abdominal pain, but typically does not have bloody stool. Testicular torsion is a condition affecting the male genitalia and is not relevant for this child's symptoms.

Question 6

A 10-year-old child has had abdominal pain for 2 days, which began in the periumbilical area and then localized to the right lower quadrant. The child vomited once today and then experienced relief from pain followed by an increased fever. What is the likely diagnosis?

Accepted Answer

The onset of abdominal pain in the periumbilical area and then localizing to the right lower quadrant, along with vomiting and increased fever, are classical symptoms of appendicitis. The relief from pain after vomiting can also indicate perforation, which is a serious complication of appendicitis. Gastroenteritis, PID, and UTI typically present with different symptoms and would not explain this child's symptoms.

Question 7

A school-age child has a 3-month history of dull, aching epigastric pain that worsens with eating and awakens the child from sleep. A complete blood count shows a hemoglobin of 8 mg/dL. What is the next step in management?

Accepted Answer

The history and symptoms of epigastric pain worsened by eating and awakening the child from sleep, combined with a low hemoglobin, suggest a possible peptic ulcer or upper gastrointestinal bleeding. An EGD is the most appropriate next step in management to visualize the upper GI mucosa and potentially obtain biopsies for H. pylori testing or ruling out other underlying conditions. Administration of HRA or PPI medications and empiric therapy for H. pylori may be considered but should not be initiated without confirming the diagnosis through endoscopy. An upper GI series may also be considered, but EGD has better diagnostic yield and is preferred in cases of suspected peptic ulcer disease.

Question 8

An adolescent is diagnosed with functional abdominal pain (FAP). The child's symptoms worsen during stressful events, especially with school anxiety. What will be an important part of treatment for this child?

Accepted Answer

Teaching the child about the brain-gut interaction causing symptoms is important in the treatment of FAP. It helps the child understand that the pain is real, but is caused by stress and emotions rather than a physical problem. This knowledge can empower the child and help reduce anxiety around the pain. Lactose-free diet and lactobacillus supplements may be helpful in some cases of FAP, but are not always necessary. Histamine2-blockers are not indicated in the treatment of FAP. Informing the parents that the pain is not real is inappropriate and unhelpful.

Question 9

The parent of an infant experiencing colic asks about using a probiotic medication. What will the primary care pediatric nurse practitioner tell this parent?

Accepted Answer

Although there has been some studies on the use of probiotics to treat colic, the evidence is not conclusive. Therefore, the best answer is D. It is important for healthcare providers to provide accurate information to parents about the safety and effectiveness of treatments for their infants.

Question 10

A toddler who was born prematurely refuses most solid foods and has poor weight gain. A barium swallow study reveals a normal esophagus. What will the primary care pediatric nurse practitioner consider next to manage this child's nutritional needs?

Accepted Answer

A videofluoroscopy swallowing study is used to assess swallowing function and identify any aspiration or swallowing difficulties, which is important for managing feeding issues in a child with poor weight gain.

Question 11

A child is diagnosed with Crohn disease. What are likely complications for this child?

Accepted Answer

Intestinal obstruction with scarring and strictures is a common complication of Crohn disease due to chronic inflammation and damage to the intestinal wall. While some patients may require surgery, such as a colectomy, the other complications listed are less common.

Question 12

The parent of a 3-month-old reports that the infant arches and gags while feeding and spits up undigested formula frequently. The infant's weight gain has dropped to the 5th percentile from the 12th percentile. What is the best course of treatment for this infant?

Accepted Answer

The symptoms described are consistent with gastroesophageal reflux (GER) which can be managed with a trial of extensively hydrolyzed protein formula (EHF). EHF is easier for an infant's digestive system to break down and absorb, thereby reducing the likelihood of regurgitation and other GER-related symptoms. Acid suppression with a PPI or esophageal pH testing is typically reserved for more severe cases of GER. It is not appropriate to simply reassure the parent that the symptoms will resolve on their own as  the infant has experienced a drop in weight gain percentile.

Question 13

A school-age child has recurrent diarrhea with foul-smelling stools, excessive flatus, abdominal distension, and failure-to-thrive. A 2-week lactose-free trial failed to reduce symptoms. What is the next step in diagnosing this condition?

Accepted Answer

Serologic testing for celiac disease is the next step in diagnosing this condition, given the symptoms of recurrent diarrhea, foul-smelling stools, excessive flatus, abdominal distension, and failure-to-thrive, especially after a lactose-free trial failed to reduce symptoms. These are classic signs of celiac disease.

Question 14

A school-age child has had abdominal pain for 3 months that occurs once or twice weekly and is associated with a headache and occasional difficulty sleeping, often causing the child to stay home from school. The child does not have vomiting or diarrhea and is gaining weight normally. The physical exam is normal. According to Bishop, what is included in the initial diagnostic work-up for this child?

Accepted Answer

CFor a child presenting with chronic abdominal pain, a thorough initial diagnostic work-up is essential to rule out common causes and identify any underlying conditions. Choice A and C are correct because they include a range of tests that assess for inflammation, infection, and organ function, which are crucial in the initial evaluation of chronic abdominal pain in children. CBC (Complete Blood Count) and ESR (Erythrocyte Sedimentation Rate) can help identify inflammation or anemia. Amylase and lipase in choice A are important for evaluating pancreatic function. A UA (Urinalysis) can rule out urinary tract infections, which sometimes present with abdominal pain. Stool tests for ova, parasites, and culture in choice C are essential for identifying infections that could cause abdominal symptoms. These comprehensive approaches help in ruling out common and easily identifiable causes of abdominal pain.

Question 15

A 2-month-old infant cries up to 4 hours each day and, according to the parents, is inconsolable during crying episodes with fists and legs noted to be tense and stiff. The infant is breastfeeding frequently but is often fussy during feedings. The physical exam is normal and the infant is gaining weight normally. What will the primary care pediatric nurse practitioner recommend?

Accepted Answer

The infant's symptoms are consistent with colic, which can be exacerbated by certain foods in the mother's diet. The primary care pediatric nurse practitioner should recommend that the mother eliminate potentially offending foods, such as dairy and caffeine, from her diet for a trial period to see if there is improvement in the infant's symptoms. A complete work-up and medication treatment are not typically indicated for colic. Stopping breastfeeding and switching to a hydrolyzed formula would not address the underlying issue and could potentially lead to further feeding difficulties.

Question 16

A child is in the clinic after swallowing a metal bead. A radiograph of the GI tract shows a 6 mm cylindrical object in the child's stomach. The child is able to swallow without difficulty and is not experiencing pain. What is the correct course of treatment?

Accepted Answer

Since the child is not in distress and can swallow without difficulty, the best course of action is to monitor and wait for the object to pass naturally through the GI tract. Administering ipecac, using a nasogastric tube, or referring for endoscopic removal are more invasive measures that are not necessary in this scenario.

Quiz 40: Gastrointestinal Disorders