Question . 1. Clinical findings are influenced by a child's developmental stage.

Which of the following features of the physical examination is most strongly

influenced by developmental stage?

Skin turgor

Respiratory rate
Explanation: Respiratory rate is highest in the neonate and
gradually becomes slower approaching adult rates in the
preadolescent-adolescent age period. Respiratory rate may be
influenced by serious pulmonary or airway infection or
inflammation in addition to non-respiratory causes, such as
fever, anxiety, acidosis, pain, heart failure, central nervous
system disease, drugs (stimulants, depressants, aspirin), and
toxins (ammonia). (See Chapter 49 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Lung aeration

Mitral valve closure

Fontanel tension
Question . 2. The vulnerable child syndrome most influences which of the following
components of the well child assessment?

Physical examination

Observation

Developmental assessment

History
Explanation: Parents perceive vulnerability due to many real
or exaggerated risks: premature birth, difficult pregnancy,
previous death of a child, disease in other siblings, or minor
low-risk conditions in this child. The history is usually
exaggerated, embellished, and quite detailed. (See Chapter 49

in Nelson Textbook of Pediatrics, 17
th
edition.)

Growth
Question . 3. During examination of an 8-mo-old child, the difficulty of optimal chest
auscultation is due primarily to:

Recent meal with gastric distention

Rapid respiratory rate

Stranger anxiety
Explanation: Crying makes the chest physical examination
almost impossible, except for detection of the grossest
abnormalities,. If at all possible, the chest auscultation should
be preceded by observation and then performed in the
sleeping, calm, nursing, or feeding infant. (See Chapter 49 in
Nelson Textbook of Pediatrics, 17
th
edition.)
Transmitted nasal sounds

Pliable chest wall
Question . 4. Assessment of the state of well-being by observation relies mostly on
the child's:

Nutritional status

Motor ability

Visual behavior

Interaction with parents
Explanation: The interaction with the parents is most critical,
as this is the child's "normal" environment and is free of
additional factors such as stranger anxiety. As children come
with all varieties of behaviors, it is essential to ask the parents if
the observed behavior is "normal" for the child and, if not, how
it is different. (See Chapter 49 in Nelson Textbook of
Pediatrics, 17
th
edition.)

State variation
Question . 5. Based on an orientation to child development, when would you tell
parents the highest risk of poisoning in children is present?

6 mo

1 yr

2 yr
Explanation: Self-poisoning in toddlers occurs once they
become ambulatory and are able to walk and climb. Consider
no place safe, especially if there are older siblings. Also
consider that child-proof medicine containers will rarely be a
deterrent to a motivated toddler. Remember that plants,
berries, and liquids also present risks for ingestion in this age
group. (See Chapter 49 in Nelson Textbook of Pediatrics, 17
th
edition.)

4 yr

6 yr
Question . 6. Injury control is a more appropriate term than accident prevention
because accidents are:

Not predictable

Not preventable

Random

Not due to chance
Explanation: Injuries have definable risks, are not random,
and are both predictable and preventable. The term "accident"
confuses our meaning and should no longer be used. (See
Chapter 50 in Nelson Textbook of Pediatrics, 17
th
edition.)

Not common
Question . 7. Motor vehicle injuries lead the list of injury deaths for all ages and are
most often associated with:

Alcohol use

Occupant injury

Driver age younger than 17 yr

Presence of more than two occupants in the car

Night driving

All of the above
Explanation: All are risk factors that can be modified by
behaviors and laws, such as a graduated driver's licensing
program. (See Chapter 50 in Nelson Textbook of Pediatrics,
17
th
edition.)
Question . 8. Risk factors for injury include all of the following except:

Toddler age

Female gender
Explanation: After 1-2 yr of age, males have a much higher
injury rate than females. This risk lasts until the 7
th
decade.
Adolescent risk-taking behavior accounts for some of the
difference during the teen years. (See Chapter 50 in Nelson
Textbook of Pediatrics, 17
th
edition.)

Poverty

Front-seating in an automobile

Chaotic family stress
Question . 9. The proper age at which a child may cross a busy street alone after
careful instruction is:

4-5 yr

6-7 yr

8-10 yr

10-12 yr

Developmentally, children below this age are unable to
understand the risk and judge such factors as car speed.
Chronological age does not determine readiness, which
requires instruction, trial runs with a parent, and parental
judgment of the child's ability. (See Chapter 50 in Nelson
Textbook of Pediatrics, 17
th
edition.)

None of the above
Question . 10. The majority of children with medical emergencies present to all of
the following for care except:

Pediatrician's office

Children's hospital emergency department
Explanation: Most children receive all or initial emergency
care at sites other than a specialized pediatric emergency room
in a children's hospital. (See Chapter 51 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Community hospital emergency department

Clinic

Urgent care facility
Question . 11. A general pediatric office should be prepared for emergencies. This
preparedness includes all of the following except:

Training in advanced trauma care
Explanation: Although advanced life support is ideal, it is
unrealistic for a general office to be prepared for advanced
trauma care. The patient should be stabilized as best as
possible, with placement of an airway and intravascular lines,
and transported to a facility capable of caring for pediatric
trauma patients as soon as possible. (See Chapter 51 in
Nelson Textbook of Pediatrics, 17
th
edition.)

Education of staff in CPR

Policies for triage

Procedure for resuscitation

Transport protocols
Question . 12. A 15-mo-old child is in your office with stridor at rest and cyanosis
with the presumptive diagnosis of viral croup. You should do all of the following
except:

Transport immediately in the parent's car to the nearest
emergency department
Explanation: A cyanotic child in respiratory distress is at high
risk for a respiratory arrest. No acutely ill child should be
transported by the parents no matter how short the distance or
how long the delay for EMS to arrive. (See Chapter 51 in
Nelson Textbook of Pediatrics, 17
th
edition.)

Administer oxygen
Administer dexamethasone

Administer racemic epinephrine

Transport after EMS personnel arrive 20 min later
Question . 13. Enhanced 911:

Is one-touch dialing

Identifies patient location
Explanation: The location of the caller is automatically
identified. This is especially important if the caller is unable to
communicate their location (young age, coma, seizure, drug
overdose, disability). (See Chapter 51 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Triages based on severity of illness

Responds within 5 min

Provides MD presence with EMS
Question . 14. Emergency Medical Treatment and Active Labor Act (EMTALA) is a
set of federal regulations that addresses the transfer of patients. Which of the
following statements regarding EMTALA is not true?

The transferring hospital must provide an appropriate medical
screening to assess if the patient has an emergency condition

If an emergency condition exists, the patient's condition must
be stabilized, or if stabilization measures exceed that hospital's
expertise, the patient must be transferred to a hospital capable
of such measures

Transfer of unstable patients is permitted under limited
circumstances

The law does not apply to pediatricians who are on call for
consultation to the emergency department
Explanation: This law is meant to benefit patients and includes
patients of all ages and their doctors. All patients must be
stabilized to the best of the ability of the emergency room staff.
All pertinent data must also be transferred with the patient to
the most appropriate hospital capable of caring for the patient's
condition. (See Chapter 51 in Nelson Textbook of Pediatrics,
17
th
edition.)
Question . 15. There are several requirements in preparing a child for transfer to a
higher level of care (e.g., from the office to the emergency department). In preparing
for transfer of a child, which of the following is not recommended?

Obtaining written consent for transfer from the patient's parent
or guardian
Copying diagnostic tests, radiographs and the child's medical
record

Calling and giving report to the appropriate transport agency

Instructing transport agency to call receiving physician to
secure acceptance for transfer
Explanation: Doctor-to-doctor communication is essential
when transferring a critically ill patient. This is not the
responsibility of an ambulance company. (See Chapter 51 in
Nelson Textbook of Pediatrics, 17
th
edition.)

Documenting name of transport agency and the time that the
transport occurred
Question . 16. Emergencies involving children are stressful for the child, parent, and
EMS-C providers. All of the following are useful in decreasing stress to children and
their families in emergency settings except:

Keeping the parents away during procedures or
resuscitation
Explanation: Indeed, most parents can provide additional
calming and distraction during procedures, and their presence
should be encouraged. The question of parents being present
during resuscitation is controversial, but most physicians find
that it usually does no harm and may be of value later to
grieving parents. (See Chapter 51 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Training staff in calming and distraction techniques

Separating the child from other frightening sights and sounds in
the treatment area

Communicating clearly, with written instructions accompanying
verbal information whenever possible

Screening for mental health needs
Question . 17. The safest and quickest manner to transport a critically ill child from a
community hospital to the regional pediatric center is:

Have the parents drive the child from their local hospital

Request that the local paramedics transport the child

Accompany the child in the ambulance with the local
paramedics

Request that the tertiary pediatric facility assist and
transport the patient
Explanation: The care and transport of a critically ill child
requires staff with specific experience and knowledge of the
pediatric population and the illnesses necessitating
transportation. In addition, the equipment, medications, and
means to monitor children require pediatric-specific expertise.
Coordinated efforts with a pediatric transport program yield the
safest methods of transport. (See Chapter 53 in Nelson
Textbook of Pediatrics, 17
th
edition.)
Question . 18. The transport team from the tertiary hospital is composed of all of the
following except:

A parent who can assist in the care of the child
Explanation: Parents are not expected to provide care during
pediatric transports. Nonetheless, if room is available in the
transport vehicle, a parent may accompany the child. Usually
this is not possible, and the parent follows the transport van in
another vehicle. (See Chapter 53 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Team members skilled in various aspects of pediatric critical
care

A dispatch service that facilitates communication with the
referring hospitals

A medical control physician who is available for telephone
consultation
Question . 19. Appropriately trained and equipped pediatric transport teams should
be able to:

Perform major surgical procedures at the referring hospitals

Provide appropriate medical care during the transport
Explanation: Appropriately trained and prepared (based on
information from the referring hospital) transport staff should be
able to care for the patient en route to the PICU. This does not
mean that a patient's condition cannot deteriorate during
transport as part of the natural history of the disease. Special
transports (ECMO) are not common and are used for only
unusual circumstances. (See Chapter 53 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Place a patient in extremis on ECMO

Transport a patient without incident
Question . 20. The mother of a 5-yr-old near-drowning victim arrives at the pediatric
intensive care unit (PICU). She is highly upset and emotional, and forcefully
demands to see her child. The best response of the PICU staff to the mother would
be:

To sit with her and explain the procedures of the PICU,
including times permitted for visitation, the number of visitors
permitted

To direct her to a social worker who would provide a
description of the rules for visitation in the PICU

To require that she speak with the child's physician before
being permitted to visit the bedside

To direct her to the parents' waiting area, and inform her that
she will be summoned when the time is right

To take her as soon as possible to the bedside, after
having provided a brief description of what the room might
look like, what medical devices will be present, and what
level of response she might expect from her child
Explanation: It is not always possible for a parent to
immediately be brought into a child's PICU room. A health care
provider should be there for the parent to explain the patient's
condition and facilitate ongoing communication. Nonetheless,
this process should be brief, as any delay increases anxiety
and possibly mistrust. (See Chapter 54 in Nelson Textbook of
Pediatrics, 17
th
edition.)
Question . 21. A child has been in the PICU for 10 days and still faces at least a
week of further treatment. Various family members have consulted with a variety of
treating medical staff about prognosis. As a result, the family has heard several
contradictory versions of what the treatment plan will be. You should now:

Advise the family to speak only to you in the future
Explanation: All of these answers have been suggested
(except the letter to the administrator) and depend on the
circumstances in the PICU and the patient. Although "B" has
value, once confusion has taken over it is important for one
person to communicate with the family. Practically, this is not
always possible. (See Chapter 54 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Schedule regular meetings where representatives of the
different services are present and consensus can be reached

Advise the family to write a letter to the hospital administrator

Advise the family not to speak to consulting physicians

Advise the family that this degree of ambiguity is unavoidable in
this setting
Question . 22. A 2-yr-old child arrives in the PICU in respiratory distress and soon
requires intubation and mechanical support. Because of a heart murmur detected 2
days later, a cardiology consultation is requested, and the fellow performing the
consultation speaks with the family, indicating the need for immediate heart surgery.
The family is distressed at this news, and wonders why you have not mentioned the
possibility of surgery. The most appropriate next step in management is to:

Ask the family to discuss the matter further with the cardiology
service

Contact the chief of cardiology and lodge a complaint about the
actions of the fellow

Convene a meeting with representatives from your service
and the cardiology service, develop a plan, and then meet
with the family to present recommendations
Explanation: When such communication catches you off
guard, regroup the team and family and discuss the events that
led to the diagnosis and surgery. Never forget the best interest
of the patient despite less-than-optimal communication. (See
Chapter 54 in Nelson Textbook of Pediatrics, 17
th
edition.)

Advise the family not to give much credence to the fellow's
opinions

Summon the fellow to your office and instruct him/her never to
speak to the family about treatment plans unless you are
present
Question . 23. The mother of one of your PICU patients regularly looks through the
bedside medical chart of her child. Bedside nurses report this to you and express
their discomfort with the practice. Your most appropriate response would be to:

Advise the nurses that it is the mother's right to view the chart
and nothing should be done

Report the matter to the hospital authorities

Suggest to the mother that you or your representative
would like to go through the chart with her on a regular
basis to clarify the jargon and explain the content more
fully
Explanation: Charts should not be read in isolation. Notes or
laboratory data are easily misinterpreted and require a health
care worker to help communicate their meaning and
significance. (See Chapter 54 in Nelson Textbook of Pediatrics,
17
th
edition.)

Instruct the mother that she may not view the chart since it
contains the writings of several different health care providers
who have not consented to her viewing it

Enlist the help of a social worker to persuade her that viewing
the chart is not appropriate
Question . 24. You inform the family of a gravely ill child in the PICU that she is very
likely to die soon. The family, consistent with their faith, wishes to apply oils to her
body and place various amulets on the bed. Your reaction should be to:

Refer the matter to the hospital attorney

Refer the matter to the chaplain

Persuade them that the application of oils and the presence of
amulets cannot possibly influence the child's health status

Inform them that so long as what they wish to do does not
pose immediate threat to their child's health, you support
their wishes
Explanation: This is a most important example of
understanding cultural issues in health, life, and dying. To this
family, not performing the ritual may prevent the child from
dying peacefully. A chaplain familiar with the family's faith is
also useful, whether employed by the hospital or present as the
family's personal spiritual advisor. (See Chapter 54 in Nelson
Textbook of Pediatrics, 17
th
edition.)

Inform them that hospital policies forbid applying the oil
because it is an unauthorized form of medical treatment
Question . 25. Proper use of the PRISM scoring system would include:

Decision-making in end-of-life issues for a chronically ill child

Withdrawal of support decisions for a child with multiple organ
failure

Comparison of level of disease severity between treatment
and control groups
Explanation: The Pediatric Risk of Mortality score is based on
17 physiologic variables (vital and neurologic signs, acid-base,
blood chemistries, hematologic parameters) subdivided into 26
ranges and taking into consideration age (neonate, infant, child,
adolescent). It is best in predicting mortality for populations of
patients and not for an individual PICU patient. Decision-
making at the end of life should never be based on an acute
PRISM score, especially in a chronically ill child. It has no
relevance or reliability in non-PICU patients, such as those
receiving chemotherapy. (See Chapter 56 in Nelson Textbook
of Pediatrics, 17
th
edition.)

Assessment of performance of a chemotherapy regimen
Question . 26. Which of the following scoring systems is useful for triage decisions?

PRISM (Pediatric RISK of Mortality)

Pediatric Trauma Score
Explanation: The pediatric trauma score is made specifically
for triage to a higher-level unit, such as a level I trauma center.
The other scores are most useful in assessing physiologic
instability resource utilization in an acute PICU setting. (See
Chapter 56 in Nelson Textbook of Pediatrics, 17
th
edition.)

APACHE (Acute Physiology and Chronic Health Evaluation)

TISS (Therapeutic Intervention Scoring System)
Question . 27. Regarding resuscitative efforts, the most important goal is:

Restoration of age-appropriate heart rate

Appropriate movement of the chest wall

Auscultation of equal breath sounds in both lung fields

Adequate oxygen delivery and utilization for the body
tissues
Explanation: Although all of these goals are important, they all
reflect the rescuer's ability to restore perfusion and oxygen
delivery to vital tissues. The effectiveness of resuscitation can
be assessed by visualizing good chest rise and palpating good
pulses during rescue breathing and chest compressions,
respectively. (See Chapter 57.1 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Palpation of equal pulses in all four extremities
Question . 28. A 9-mo-old boy is brought to the emergency room in a limp and
unresponsive state. Initial examination shows a pulse rate of 35/min and occasional
irregular breaths. After initiation of CPR (including tracheal intubation), delivery of
oxygen via positive-pressure breaths, and chest compressions, multiple attempts to
insert an IV line fail. The most appropriate next step in management should be to:

Obtain an arterial blood gas sample

Place an intraosseous needle and administer fluids and
inotropic agents
Explanation: Intraosseous (IO) lines should be placed if
venous access is not obtained within 1-2 min of an arrest. The
anterior tibia is the most common site utilized. Chemistries and
other laboratory analyses can be obtained, including a blood
culture, while intravenous fluids and medications can be
delivered through an IO line. The risk of infection is very low.
Once perfusion improves, venous access is usually attainable,
and the IO line can be removed. (See Chapter 57.1 in Nelson
Textbook of Pediatrics, 17
th
edition.)

Obtain a "stat" head CT study to evaluate reasons for
unresponsiveness

Place a transthoracic cardiac pacemaker

Place a thoracostomy tube to evacuate a possible
pneumothorax
Question . 29. A 9-yr-old boy suddenly experiences respiratory distress while dining
in a restaurant, and despite obvious great effort to breathe, he seemingly cannot
move air. He points to his neck and appears progressively cyanotic. The most
appropriate next step should be to:

Ask the headwaiter to call 911 immediately

Give the child a glass of water and urge him to drink it quickly

Carefully review what the child may have eaten last

Deliver a series of up to five abdominal thrusts (Heimlich
maneuver)
Explanation: The child demonstrates the universal sign of
airway obstruction from a foreign body. If he is awake, finger
sweeps should not be done; the Heimlich maneuver is the
treatment of choice. If airway obstruction continues and the
patient becomes unresponsive, EMS should be activated. (See
Chapter 57.1 in Nelson Textbook of Pediatrics, 17
th
edition.)

Hyperextend the neck in an effort to open the airway
Question . 30. Which of the following is true regarding provision of assisted
ventilation in the early moments of an emergency?

Any technique that helps clear the upper airway and safely
produces air movement in both lung fields is acceptable

No one should attempt to deliver positive-pressure ventilation
until tracheal intubation can be accomplished

Mouth-to-mouth ventilation is preferred strongly over bag-mask
ventilation

In both infants and older children, rescue breathing should
involve the rescuer forming a seal over the patient's mouth,
with the patient's nose being occluded by the rescuer's thumb
and forefinger

In proper assisted ventilation, there should be no
movement of the abdominal wall during inspiration
Explanation: With mouth-to-mouth or with endotracheal tube
ventilation, chest rise is paramount. One should avoid air entry
to the esophagus by proper placement of the head and neck.
Techniques to open the airway differ, especially if there is head
and neck trauma. Mouth-to-mouth-and-nose ventilation is
appropriate in infants. (See Chapter 57.1 in Nelson Textbook of
Pediatrics, 17
th
edition.)
Question . 31. A 2-yr-old patient, previously admitted to the hospital for respiratory
distress, is found apneic and pulseless in the early morning hours. She is intubated
and ventilated adequately, and an intra-osseous needle is placed, but she remains
pulseless. The first medications you should employ are:

Lidocaine and epinephrine

Epinephrine and norepinephrine

Norepinephrine and atropine

Lidocaine and atropine

Epinephrine and atropine
Explanation: By this time in an arrest, an ECG should be
available to identify the rhythm. These are the drugs
recommended for asystole, but pulseless electrical activity
(electrical mechanical dissociation) should lead one to search
for a treatable cause of poor pulses in the presence of a
cardiac rhythm capable of effective mechanical cardiac activity
which should be able to support the cardiac output. (See
Chapter 57.1 in Nelson Textbook of Pediatrics, 17
th
edition.)
Question . 32. Causes of pulseless electrical activity include all of the following
except:
Toxins

Pulmonary embolism

Intracranial hemorrhage
Explanation: Agents that work directly on the heart (toxins,
hypoxia) or interfere with cardiac output (tamponade,
pneumothorax) may all produce pulseless electrical activity,
previously known as electrical-mechanical dissociation. If this is
present, the cause must be searched for and treated to achieve
successful resuscitation. (See Chapter 57.1 in Nelson Textbook
of Pediatrics, 17
th
edition.)

Pericardial tamponade

Pneumothorax
Question . 33. The drug of choice for shock refractory ventricular fibrillation is:

Magnesium

Bretylium

Aminophylline

Amiodarone
Explanation: Amiodarone is now the treatment of choice for
shock-resistant ventricular tachycardia or ventricular fibrillation.
Lidocaine is a second but effective choice. (See Chapter 57.1

in Nelson Textbook of Pediatrics, 17
th
edition.)

Digoxin
Question . 34. Supraventricular tachycardia is characterized by all of the following
except:

Rate >220 beats/minute in infants

Response to vagal stimuli

Rate >180 beats/minute in children

Response to adenosine

Gradual onset and gradual termination
Explanation: Supraventricular tachycardia (SVT) classically
has a sudden onset and sudden termination if it occurs
spontaneously. In adults, verapamil was once a choice as
treatment for SVT. In children with SVT and poor cardiac
output, verapamil can cause cardiac arrest. Therefore in all
ages, adenosine is the treatment of choice. (See Chapter 57.1

in Nelson Textbook of Pediatrics, 17
th
edition.)
Question . 35. A 9-yr-old with vomiting and diarrhea has a systolic blood pressure of
75 mm Hg. You should:

Check the fundi for papilledema

Administer 20 mL/kg of normal saline
Explanation: This is an abnormally low systolic blood
pressure. Normal blood pressure between 1 yr to 10 yr should
be 70 + 2 x age (yr), or 88 mm Hg. Normal saline or lactated
Ringer solution without glucose is the initial treatment of choice.
(See Chapter 57.1 in Nelson Textbook of Pediatrics, 17
th
edition.)

Administer 20 mL/kg of lactated Ringer solution in 5% dextrose
in water

Obtain upper and lower limb blood pressure readings

Begin administration of epinephrine or atropine
Question . 36. To check the proper placement of an endotracheal tube, one should
do all of the following except:

Visualize the vocal cords

Monitor end-tidal CO
2

Listen for equal breath sounds

Listen over the stomach

Obtain a lateral chest x-ray
Explanation: Most would obtain an anterior-posterior chest x-
ray. Nonetheless, in a patient with a perfusing rhythm, the most
accurate method is measuring end-tidal CO
2
. This is less
accurate in a patient in asystole. Looking for mist humidity in
the ETT is not 100% accurate and may be misleading
Question . 37. All of the following are anticipated reactions of tissues to the shock
state except:

Increased capillary filling time due to diminished perfusion of
tissues

Stage of "warm shock" reflecting initial vasodilation

Later stage of "cool shock" due to preservation of blood flow to
vital internal organs

Increased production of organic acids due to switch to
anaerobic metabolism

Increased production of bicarbonate due to anaerobic
metabolism
Explanation: Indeed, anaerobic metabolism produces a
severe lactic acidosis. Controversy exists about the use of
bicarbonate therapy to treat this lactic acidosis. Most agree
that, if possible, the underlying etiology (such as hypovolemia
or infection) must be treated first. Bicarbonate therapy may
increase morbidity and possibly mortality (in experimental
animals). Bicarbonate should not be used if the patient has
poor ventilation, because the CO
2
generated from the
bicarbonate may exacerbate hypercarbia and produce
intracellular acidosis. (See Chapter

Question . 38. The condition of a patient in the PICU appears to be worsening, and
the supervising physician asks for the one best test to determine if shock is present.
You suggest:

A mixed venous O
2
saturation measurement
Explanation: The mixed venous saturation and possibly a
serum lactate level measurement are excellent tests. The
mixed venous saturation reflects tissue oxygen extraction,
which reflects oxygen delivery and oxygen consumption. If
tissue oxygen consumption is greater than oxygen delivery, the
mixed venous saturation declines. (See Chapter 57.2 in Nelson
Textbook of Pediatrics, 17
th
edition.)

An arterial blood gas analysis

A venous blood gas

A hematocrit

A metabolic panel including assessment of liver and kidney
function
Question . 39. The factor most clearly predicting mortality in shock is:

Cardiac failure

Renal failure

Hepatic failure

Metabolic acidosis

Multiple organ system failure
Explanation: Multiple organ system failure, also known as
multiple organ dysfunction syndrome (MODS), is a serious
consequence of shock. In many patients, the injury many be
reversible; nonetheless, mortality increases substantially with
each dysfunctioning organ system. (See Chapter 57.2 in
Nelson Textbook of Pediatrics, 17
th
edition.)
Question . 40. The drug pair that meets the dual goals of stimulating the heart and
relaxing peripheral vasculature is:

Isoproterenol and epinephrine

Dopamine and dobutamine
Explanation: Dopamine acts on dopaminergic and -
adrenergic receptors of the heart, while dobutamine acts on -
receptors of the heart and the peripheral arteries. In high
doses, dopamine has -adrenergic effects. (See Chapter 57.2

in Nelson Textbook of Pediatrics, 17
th
edition.)

Dobutamine and amrinone

Epinephrine and norepinephrine

Amrinone and norepinephrine
Question . 41. A 5-yr-old boy presents with petechiae, fresh bruises, low-grade
fever, dizziness, and lethargy. You admit him to the hospital and start an IV infusion.
The most appropriate next step in management would be:

Administration of high-dose Solu-Medrol or Decadron

A CT scan of the head to rule out meningococcal meningitis

Collection of blood for a culture, CBC, and platelet count

Administration of 20 mL/kg of normal saline
Explanation: The dizziness and lethargy suggest poor central
nervous system perfusion and hypotension. Intravenous fluid
(crystalloid) resuscitation is urgently needed and should be
given as soon as possible. It may need to be repeated often. In
addition, intravenous antibiotics must be given rapidly, because
early therapy of meningococcal sepsis with antibiotics has
proven to reduce mortality. Steroids may be needed later if
adrenal insufficiency is demonstrated in a patient unresponsive
to fluid boluses and inotropic agents. (See Chapter 57.2 in
Nelson Textbook of Pediatrics, 17
th
edition.)

Administration of 1-2 mg/kg of furosemide (Lasix)
Question . 42. The normal alveolar-arterial (A-a) oxygen gradient is:

>300 mm Hg

<10 mm Hg
Explanation: The alveolar-arterial oxygen gradient in normal
children from about 1 month of age onward is usually <10 mm
Hg. Any deviation suggests a ventilation/perfusion defect,
intrapulmonary shunt, cardiac right-to-left shunt, or rarely an
alveolar diffusion defect. (See Chapter 57.3 in Nelson Textbook
of Pediatrics, 17
th
edition.)

50 mm Hg

>100 mm Hg
Question . 43. A patient in respiratory distress presents to your office. The most
appropriate immediate response is to:

Attempt a blood gas determination

Immediately intubate the airway and begin positive-pressure
ventilation

Call 911

Place the child in a comfortable position, reassess the
airway, and provide oxygen and other supportive
measures as necessary
Explanation: In almost all patients, oxygen will not harm a
patient in respiratory distress, and it may help. A mask may
frighten some infants, but nasal cannulas are usually well
tolerated. Oxygen should be used-albeit cautiously-in children
with chronic hypercarbia to avoid respiratory depression if the
oxygen chemoreceptors become inhibited. (See Chapter 57.3

in Nelson Textbook of Pediatrics, 17
th
edition.)
Question . 44. Respiratory failure accounts for PICU admissions in what percentage
of patients?

100%

80%

50%
Explanation: The percentage of children admitted with
respiratory failure varies. Nonetheless, acute airway
compromise and respiratory distress are the most common and
potentially predictable causes of "cardiac" arrest in children,
who actually have respiratory arrest. (See Chapter 57.3 in
Nelson Textbook of Pediatrics, 17
th
edition.)

<25%
Question . 45. Complications of mechanical ventilation include all of the following
except:

Air leak

Obstructed endotracheal tubes

Alterations of cardiac output

Reduction in nosocomial infections
Explanation: Indeed, with any indwelling device, endotracheal
tube placement increases the risk of infection. Nosocomial
acquisition of the highly resistant bacterial flora of the PICU,
poor mucociliary transport, atelectasis, suppressive broad-
spectrum antibiotics (which select for superinfection), and
mucosal barrier breakdown all increase in the risk of infection.
(See Chapter 57.4 in
Question . 46. The initial ventilator settings are determined by:

The patient's underlying disease
Explanation: The initial ventilator settings are determined by
the patient's condition. These include a patient with normal
lungs requiring ventilation for surgery or neurologic problems; a
patient with decreased compliance; or a patient with increased
airway resistance. Hypoxia and hypercarbia will require
different strategies, such as adjusting PEEP, FiO
2
, rate, or tidal
volume for CO
2
elimination. (See Chapter 57.4 in Nelson
Textbook of Pediatrics, 17
th
edition.)

The patient's preferences

Standard order sets

Attempts to normalize the blood gases
Question . 47. Patients with severe forms of reactive airways disease (e.g., asthma)
who require mechanical ventilation may benefit from which of the following initial
ventilator parameters?

Rapid rates, short inspiratory times, and tidal volumes <6
mL/kg

Low rates, prolonged inspiratory/expiratory times, and low tidal
volumes (<6 mL/kg)

Low rates, prolonged inspiratory/expiratory times, and
moderate tidal volumes (8-10 mL/kg)
Explanation: Because of high airway resistance, particularly
during expiration, one must avoid air trapping, which will further
exacerbate the ongoing pulmonary pathology. (See Chapter
57.4 in Nelson Textbook of Pediatrics, 17
th
edition.)

Low rates, prolonged inspiratory/expiratory times, and high tidal
volumes (>15 mL/kg)
Question . 48. The most important maneuver in preserving renal function in septic
shock is:

Intravenous infusion of furosemide

Infusion of dopamine at a rate of 1-3 g/kg/min

Rapid restoration of the circulating volume
Explanation: Renal dysfunction in shock of any type may be
due to prerenal or renal etiologies. Prerenal renal dysfunction is
due to poor perfusion of the kidney secondary to hypotension.
If no intrinsic renal injury occurs, renal function will improve with
restoration of renal blood flow. If hypotension is severe and
prolonged, acute tubular or (if even more severe) cortical
necrosis may produce intrinsic renal failure. Acute tubular
necrosis is often reversible, but cortical necrosis results in
chronic renal insufficiency. (See Chapter 57.5 in Nelson
Textbook of Pediatrics, 17
th
edition.)

Proper antibiosis against the offending organism
Question . 49. Which of the following statements regarding continuous venovenous
hemofiltration (CVVH) is true?
Circuit patency is dependent on systemic blood pressure

Water and molecules less than 17,000 daltons in size are
removed from the bloodstream
Explanation: Removal of the molecules helps treat azotemia
but is of value in removing inflammatory cytokines in patients
with the systemic inflammatory response syndrome. (See
Chapter 57.5 in Nelson Textbook of Pediatrics, 17
th
edition.)

CVVH membranes are poorly biocompatible

Hemofiltration can induce hypoalbuminemia
Question . 50. Appropriate nutritional support for the child receiving mechanical
ventilation for bacterial pneumonia should include:

Amino acids, 2 g/kg/day, given intravenously

Full maintenance solution containing 35% dextrose

An age-appropriate enteral formula via nasogastric tube
Explanation: If gastrointestinal motility is normal, it is best to
provide nutrition by the enteral route, using the stomach, and
giving age-appropriate formulas. This improves nitrogen
balance but also reduces the risk of sepsis by lowering the
incidence of transmucosal migration (bacterial translocation) of
enteric bacteria. (See Chapter 57.6 in Nelson Textbook of
Pediatrics, 17
th
edition.)

An elemental formula via nasojejunal tube
Question . 51. In the severely ill child, a catabolic state ensues. Which of the
following statements is true?

Administration of growth hormone diminishes insulin resistance

Hyperglycemia is a beneficial state in the catabolic child

Branch-chain amino acids are beneficial to the previously
normal child

Intensive insulin therapy has reduced mortality in adult
ICU patients
Explanation: Insulin may reverse the catabolic state and
prevent hyperglycemia. This later metabolic problem is often a
risk factor for increased morbidity and mortality in an ICU. (See
Chapter 57

Question . 52. The differential diagnosis for the afebrile child with nausea and
vomiting should include:

Intracranial tumor
Explanation: Nausea and vomiting are common complaints in
a pediatric practice. Although most are due to non-specific
(presumed viral) infections or other identifiable infections
(gastroenteritis, otitis media, pharyngitis), the practitioner must
always be cautious of an intracranial cause. The nature of the
nausea, associated headache or vision problems, head tilt, or
cranial nerve abnormalities should suggest an intracranial
cause of vomiting. Always be cautious and, when possible,
check the fundi for papilledema. (See Chapter 57.7 in Nelson
Textbook of Pediatrics, 17
th
edition.)

Viral gastroenteritis

Salmonella infection

Type A influenza
Question . 53. In the child who has suffered a severe hypoxic ischemic injury, which
of the following is true?

Liver and kidney damage are irreversible

Isolated brainstem function might be preserved
Explanation: The brainstem may be preserved in the presence
of cortical cell death. This is a controversial point in the
discussion of brain death. Today we agree on the legal
definition of whole brain death, which includes the brainstem
and obviously precludes effective spontaneous ventilation.
Cortical brain death proponents want to recognize cortical
death alone as the criterion for legal death. The controversy
has not been resolved. (See Chapter 57.7 in Nelson Textbook
of Pediatrics, 17
th
edition.)

CT scans do not reveal abnormalities until after 1 mo following
injury

Intracranial pressure monitoring improves outcome
Question . 54. Fulminant hepatic failure will lead to encephalopathy, cerebral
edema, and brain death within several days. Which mode of support might best
prevent the progression from grade II to grade III+ hepatic encephalopathy?

Fluid restriction and furosemide infusion

Porcine hepatocyte column filtration

Continuous hemofiltration plus plasma exchange
Explanation: Various modalities have been proposed to treat
hepatic encephalopathy. In addition to controlling intracranial
pressure, preventing bleeding, and lowering ammonia levels,
many have proposed emergency liver transplant. (See Chapter
57.7 in Nelson Textbook of Pediatrics, 17
th
edition.)

Hemodialysis
Question . 55. A 15-yr-old boy is struck by a car while walking. On arrival in the ED,
he is alert and has no signs of upper airway obstruction. Pulse is 140/min,
respiratory rate 40 breaths/min, and blood pressure 70/50 mm Hg. Heart sounds are
distinct, but breath sounds are decreased in the left hemithorax. What is the most
appropriate next step in patient management?
Needle thoracentesis of the left hemithorax
Explanation: Although an x-ray may be helpful for diagnosis
and fluids may improve venous return, prompt evacuation of a
symptomatic hemothorax or pneumothorax is the most
appropriate step. (See Chapter 57.8 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Upright radiograph of the chest

Pericardiocentesis

Rapid intravenous bolus of Ringer's lactate

Arterial blood gas analysis
Question . 56. A 4-yr-old girl sustains a head injury after pulling a television set onto
her. The paramedics intubate her at the scene because of inadequate respiratory
effort. On arrival in the ED, she is being ventilated at a rate of 20 breaths/min, and
her chest wall rises adequately. Pulse is 100/min, blood pressure is 100/70 mm Hg,
and peripheral perfusion is good. What is the most appropriate next step in patient
management?

Immediate head CT

Hyperventilation to attain a PCO
2
of 25 mm Hg

Gentle hyperventilation and an intravenous bolus of mannitol

Evaluation of level of alertness and pupil size and
reactivity
Explanation: At this point, the patient has no signs of
increased intracranial pressure and thus doesn't need mannitol
or hyperventilation. Further clinical assessment in a stable
patient before a head CT is quite appropriate. (See Chapter
57.8 in Nelson Textbook of Pediatrics, 17
th
edition.)

Intravenous bolus of 3% saline
Question . 57. A 3-yr-old boy is brought to the ED after falling two stories from an
open window. He arrives appropriately immobilized and is alert. Pulse is 190/min;
respiratory rate, 28 breaths/min; and blood pressure, 70/30 mm Hg. It is clear that he
has a femur fracture. His abdomen is diffusely tender. After a 20 mL/kg bolus of
Ringer's lactate, his pulse is 180/min and blood pressure is 72/35 mm Hg. The most
appropriate next step in patient management would be:

Insertion of a central venous catheter

Emergent abdominal laparotomy

20 mL/kg bolus of Ringer's lactate
Explanation: Repeated boluses of Ringer lactate or normal
saline solution have been life-saving if administered early and
aggressively in pediatric patients with shock. With time and
signs of blood loss, red cell transfusions become indicated.
(See Chapter 57.8 in Nelson Textbook of Pediatrics, 17
th
edition.)

10 mL/kg infusion of cross-matched, packed red blood cells

10 mL/kg infusion of O-negative, packed red blood cells
Question . 58. A 10-yr-old boy is brought to the ED after being kicked in the
abdomen by a horse. Pulse is 80/min; respiratory rate, 18 breaths/min; and blood
pressure, 110/70 mm Hg. His abdomen is diffusely tender. The most appropriate
diagnostic study for this patient would be:

Abdominal ultrasound study

MRI of the abdomen

Diagnostic peritoneal lavage

Abdominal CT study with intravenous contrast
Explanation: Abdominal CT is now the standard for blunt
pediatric abdominal trauma. It is most useful for solid organs
(liver, spleen, kidneys) but will also demonstrate pancreatic
injury, hemorrhage (free fluid), and intestinal injury. When
available, it has replaced peritoneal lavage. (See Chapter 57.8

in Nelson Textbook of Pediatrics, 17
th
edition.)

Plain abdominal radiographs
Question . 59. In the support of the child with severe ARDS, appropriate goals for
pH, oxygenation, and PCO
2
include:

pH 7.40; PaO
2
90 mm Hg; PCO
2
40 mm Hg

pH 7.50; PaO
2
125 mm Hg; PCO
2
25 mm Hg

pH 7.35; PaO
2
100 mm Hg; PCO
2
45 mm Hg

pH 7.25; PaO
2
60 mm Hg; PCO
2
60 mm Hg
Explanation: This reflects the lung protection strategy with
permissive hypercarbia. There is no need for hyperoxia, and
PaO
2
>90 mm Hg is a sign to reduce the FiO
2
and thus
potentially decrease the risk of oxygen toxicity. (See Chapter
58 in Nelson Textbook of Pediatrics, 17
th
edition
Question . 60. For the child with ARDS receiving mechanical ventilation the prone
position is alternated with the supine position. This measure is used to:

Redistribute total body edema

Equalize pulmonary blood flow to dependent and independent
lung segments

Prevent atelectasis and increased consolidation in
dependent lung segments
Explanation: Body position changes help to improve
respiratory function in the previously dependent lung segments.
Although PaO
2
may improve with position changes, no study
has demonstrated a survival advantage to this procedure. (See
Chapter 58 in Nelson Textbook of Pediatrics, 17
th
edition.)

Decrease the risk of pressure sores
Question . 61. In the management of a child with ARDS and respiratory failure, all of
the following measures are important except:

Normalize blood gases
Explanation: To avoid oxygen toxicity, excessive PEEP and
PIP, and volutrauma or barotrauma, blood gases should not be
normalized. This principle of respiratory management has been
the most significant improvement in the care of ARDS in the
last 10 years. (See Chapter 58 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Use permissive hypercapnia

Accept PaO
2
measurements of 60-80 mm Hg

Reduce airway pressures to prevent barotrauma and
volutrauma
Question . 62. Transplantation of part of an organ from a donor who will survive the
donation process is possible with transplantation of:

Heart or lung

Heart or liver

Cornea or heart

Kidney or liver
Explanation: Kidney transplantation is quite successful from a
related living donor. Split or partial liver transplantation from a
living related donor is also successful. Both procedures, but
particularly liver transplantation, carry risks for the donor,
including death. (See Chapter 60 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Heart or kidney
Question . 63. Complications of transplantation particularly likely to be seen with
bone marrow transplantationinclude:

Graft-versus-host disease (GVHD) and veno-occlusive
disease (VOD)
Explanation: GVHD and VOD may occur after bone marrow
transplantation. Early in the posttransplantation period,
complications due to pancytopenia occur. Anemia,
thrombocytopenia, and neutropenia and their complications
remain the predominant risks until engraftment occurs. (See
Chapter 60 in Nelson Textbook of Pediatrics, 17
th
edition.)
GVHD and hyperthermia

GVHD and thrombocytosis

VOD and hypothermia

VOD and thrombocytosis
Question . 64. One of the more common pathogens responsible for pulmonary
infections in immunocompromised patients following transplantation is:

Staphylococcus epidermidis

Haemophilus influenzae

Clostridium botulinum

Streptococcus pneumoniae

Pneumocystis carinii
Explanation: Pneumocystis carinii pneumonia (PCP) is seen in
any immunosuppressed patient, particularly when T
lymphocyte function or number is reduced. Prophylaxis against
PCP has greatly reduced this potentially lethal complication.
(See Chapter 60 in Nelson Textbook of Pediatrics, 17
th
edition.)

Question . 65. Factors promoting successful acceptance of a transplanted kidney by
the recipient include:

Maintenance of high urine output and maintenance of lower-
than-normal blood pressure

Maintenance of high urine output and use of angiotensin-
converting enzyme (ACE) inhibitors

Maintenance of high urine output and maintenance of
higher-than-normal blood pressure
Explanation: It is essential to maintain renal perfusion and
renal blood flow. Forced diuresis is critical to achievement of
this goal. In addition, it may reduce the risk of anastomotic
vascular thrombosis. (See Chapter 60 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Maintenance of low urine output and maintenance of lower-
than-normal blood pressure

Maintenance of low urine output and maintenance of higher-
than-normal blood pressure
Question . 66. A 2-yr-old boy is pulseless and apneic after extrication from a
swimming pool. Paramedics start CPR, intubate him, and administer 100% oxygen
while providing bag-endotracheal tube breaths. An intraosseous line is placed, and
two doses of epinephrine are administered. A pulse is found after 10 min of
resuscitative measures. The child is transferred to your ED. On arrival, he is deeply
comatose with a temperature of 34C. He is not breathing spontaneously, his heart
rate is 120 beats/min, blood pressure is 60/25 mm Hg, and he has cold extremities.
Oxygen saturation is 85%. Finger stick glucose is 200 mg/dL. Which of the following
interventions is most likely to improve the patient's neurologic outcome?

Administration of high-dose dextrose to improve cerebral
metabolism

Fluid restriction to minimize potential cerebral edema

The addition of positive end-expiratory pressure,
administration of an isotonic fluid bolus, and an
epinephrine infusion to improve oxygenation and
circulation
Explanation: Despite many hopeful new interventions for
hypoxic-ischemic neurologic injury, none has been proven
beneficial. The best approach is to support normal oxygenation
and normal blood pressure to avoid continued cerebral hypoxia
and ischemia, respectively. Monitor blood pressure to improve
cerebral perfusion pressure and possibly to avoid secondary
ischemic injury from raised intracranial pressure. (See Chapter
61 in Nelson Textbook of Pediatrics, 17
th
edition.)

Keeping the patient hypothermic for the first 12-24 hr of his
PICU hospitalization

Hyperventilation to a PaCO
2
of 25 mm Hg
Question . 67. Mr. and Mrs. Smith install a new swimming pool in their backyard.
Three months later, their 2-yr-old son is found pulseless and asystolic in the pool.
Which of the following safety measures would have been most likely to prevent this
tragedy?

A lightweight plastic swimming pool cover

A pool alarm that sounds when water movement is detected

A 5-ft-tall chain link (2.5-inch mesh) isolation fence

D A 5-ft-tall ornamental iron isolation fence (vertical bars 3
inches apart; horizontal crossbars 45 inches apart)
Explanation: Fencing is the best preventive measure. The
other interventions are dangerous (A), not proven, or provide a
false sense of security (E). Children under the age of 3-4 yr
cannot "swim" safely. (See Chapter 61 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Swimming lessons
Question . 68. A 4-yr-old boy is admitted to the PICU after resuscitation from a
swimming pool submersion. He was pulseless and apneic at the scene. On
presentation to the PICU, he is intubated and mechanically ventilated. His vital signs
are normal and he is comatose, with a Glasgow Coma Score of 4. His initial arterial
blood gas is pH 7.12, PaCO
2
35 mm Hg, and PaO
2
145 mm Hg. In counseling the
family regarding the child's prognosis, which of the following results is most likely to
represent a favorable outcome?
A normal head CT scan

Normal intracranial pressure after placement of a Camino
monitor

A serum glucose of 180 mg/dL on admission to the PICU

Resolution of metabolic acidosis on arterial blood gas
measurement

Spontaneous purposeful movement 12 hr after admission
Explanation: Although his initial clinical appearance sounds
ominous, the presence of clinical improvement during 6-12 or
12-24 hr is the best predictor of intact outcome. Unfortunately,
no laboratory or radiologic test has had any valuable predictive
power. Serial examination is the best method to follow the
course and predict the outcome. Indeed, abnormalities (such
as those seen on CT scans) are usually self-evident from
severity of the abnormalities on clinical examination. (See Cha

Question . 69. A 16-yr-old boy with 50% body surface area burns from a house fire
had been on controlled positive-pressure ventilation. His condition continues to
deteriorate, necessitating high FiO
2
and PEEP of at least 12.5 cm H
2
O. Of the
following, the most therapeutic approach is:

Continued positive-pressure ventilation

ECMO

Nitric oxide therapy
Explanation: Inhaled nitric oxide (NO) has shown promise in
managing respiratory (hypoxic) failure after burns. Therapy is
usually started at 5 ppm and titrated to 30 ppm. Hyperbaric
oxygenation is of value in severe carbon monoxide poisoning,
while ECMO is of value if the patient doesn't respond to inhaled
NO. High-frequency ventilation should also be used before
ECMO. (See Chapter 62 in Nelson Textbook of Pediatrics, 17
th
edition.)

Hyperbaric oxygen
Question . 70. A 5-yr-old girl who accidentally spilled hot water on her face and
trunk and is brought to the emergency room. Which of the following is the best
method for estimating body surface area burn?

Rule of 9s

Rule of palm

The Lund and Browder chart
Explanation: Body surface area (BSA) of various anatomic
sites changes with growth and development. The head has a
greater body surface area in the youngest children. (See
Chapter 62 in Nelson Textbook of Pediatrics, 17
th
edition.)

A growth chart
Question . 71. A 10-yr-old boy spilled gasoline on his legs. His pants became
ignited and he suffered 20% body surface area burns. Of the following, the most
important treatment is:

7-day course of penicillin

5-day course of penicillin

10-day course of penicillin

None of the above
Explanation: Initial treatment is to remove the clothing and
place warm saline dressings over the wound. Penicillin is not
an immediate therapy, and there is controversy about whether
it should be used at all. (See Chapter 62 in Nelson Textbook of
Pediatrics, 17
th
edition.)
Question . 72. A 4-yr-old girl sustained a 40% second- and third-degree total body
surface area burn from scalding hot water. Of the following, the most therapeutic
approach is:

Aggressive use of topical antibacterial agents with frequent
dressing changes

Use of intravenous appropriate antibiotics

Excision of the burn wounds and grafting
Explanation: To prevent infection and to facilitate healing,
excision of the wound and removal of all devitalized and dead
tissue must be performed rapidly. Grafting follows. (See
Chapter 62 in Nelson Textbook of Pediatrics, 17
th
edition.)

Use of topical analgesics
Question . 73. A 10-yr-old boy sustained 30% body surface area burns and had
been requiring dressing changes for physical therapy. Which of the following
regimens will provide the best pain management? A. B. C.

Morphine bolus

Morphine continuous infusion

Morphine and Versed bolus

Oral morphine and Ativan
Explanation: Preemptive narcotics before the procedure and
an anxiolytic are the best ways to avoid future behavioral
problems and to provide appropriate pain relief. Boluses may
be added to preemptive therapy
Question . 74. All of the following statements about brain death are true except:

Brain death alone can be used as a justification for withdrawing
all life support
Declaration of brain death in children younger than 2 mo of age
requires two assessments, separated by at least 48 hr

Declaration of brain death in a child 5 yr of age can be made on
clinical criteria alone

Brain death can be declared even if certain brainstem
reflexes (e.g., papillary response) are still present
Explanation: Currently, the legal and medically acceptable
definition of brain death is whole brain death, which includes
the brainstem and cortex. Some suggest that neocortical brain
death should be used, as noted in patients in a persistent
vegetative state (PVS). This remains objectionable because of
the rare patients who wake up from PVS. (See Chapter 64 in
Nelson Textbook of Pediatrics, 17
th
edition.)

Acceptance of brain death is sufficient to declare full legal
death and should facilitate more organ donation opportunities
Question . 75. Ancillary tests to confirm brain death include all of the following
except:

Electroencephalogram

Head ultrasound study
Explanation: Head ultrasonography demonstrates structural
problems, such as presence of blood and edema, but does not
help define function, such as electrical activity or blood flow.
With whole brain death, four-vessel angiography remains the
gold standard. With further experience, Doppler sonography
may be of value. (See Chapter 64 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Radionuclide angiogram

Apnea test

Cerebral angiogram
Question . 76. Correct performance of an apnea test requires:

Pre-oxygenation with 100% O
2
for several minutes

B Significant elevation of the CO
2
level in the blood without
resultant respiratory efforts

Maintenance of acceptable O
2
arterial saturation throughout the
test (usually 2-4 min)

DAll of the above
Explanation: The apnea test helps define absent brain stem
reflexes related to respirations. It may take some time, usually
>10 min, for the PCO
2
to rise to the acceptable level of 60 mm
Hg. (See Chapter 64 in Nelson Textbook of Pediatrics, 17
th
edition.)

None of the above
Question . 77. Fentanyl anesthesia in neonates does all of the following except:

Avoid postoperative hypotension after PDA ligation

Provide analgesia

Cause hyperglycemia
Explanation: Fentanyl is an effective and safe analgesic
anesthetic in newborns and has improved the outcome of
complex surgeries in the neonatal period. Use before, during,
and after the procedure has reduced morbidity and probably
mortality. (See Chapter 65 in Nelson Textbook of Pediatrics,
17
th
edition.)

Avoid hypoglycemia

Prevent acidosis
Question . 78. Deep sedation is associated with all of the following except:

Loss of airway protective reflexes

Loss of airway patency

Loss of cardiovascular stability

Apnea

Seizures
Explanation: Most agents producing deep sedation will
actually suppress physical and electrical seizure activity. Deep
sedation is a risk factor for a cardiopulmonary arrest and
should only be performed in a setting equipped for response to
apnea and bradycardia. (See Chapter 65 in
Question . 79. Akinesia is:

Analgesia

Sedation

Absence of movement
Explanation: Indeed, akinesia induced by neuromuscular
blocking agents (muscle relaxants) has no effect on reducing
pain or producing amnesia. It simply means no movement.
Sedation and analgesia must also be used when a patient
receives neuromuscular blocking agents. (See Chapter 65 in
Nelson Textbook of Pediatrics, 17
th
edition.)

Amnesia

Nystagmus
Question . 80. Risks associated with the use of succinylcholine include all of the
following except:
Seizures
Explanation: With much better and safer neuromuscular
blocking muscle relaxants, succinylcholine is rarely used in the
operating room. (See Chapter 65 in Nelson Textbook of
Pediatrics, 17
th
edition.)

Hyperkalemia

Malignant hyperpyrexia

Myoglobinuria

Elevated intracranial pressure
Question . 81. Malignant hyperthermia is associated with all of the following except:

Hypercarbia

Masseter spasm

Metabolic acidosis

Muscular dystrophy

Morphine
Explanation: Narcotic agents are not associated with the
development of this potentially serious and lethal familial
condition. The spectrum may range from masseter spasms or a
mild increase in intraoperative temperature and CO
2
elimination
to severe muscle rigidity, hyperpyrexia, metabolic acidosis, and
cardiovascular collapse. (See Chapter 65 in Nelson Textbook
of Pediatrics, 17
th
edition.)

A positive family history for the disorder
Question . 82. A 10-yr-old girl with metastatic primitive neuroectodermal tumor
(PNET) of the bone is a hospice patient. She is on oral morphine and is experiencing
increased frequency of uncontrollable pain. Her mother is hesitant to change to
intravenous morphine because of fear that her daughter will become addicted to the
medication. The most appropriate response to her stated fear would be:

Remind her that her daughter is terminally ill, so it doesn't
matter if she becomes addicted

Tell her that the oral morphine will be maintained for now, but
make no promises about the future

Educate her about addiction, tolerance and dependence;
describe the potential risks and benefits of intravenous
morphine; and help her make a decision based on the
priorities of her child and the family
Explanation: Many people (lay and medical) believe in myths
and don't understand opiate drugs. There is a great difference
between addiction and tolerance to the effects of an opiate.
(See Chapter 66 in Nelson Textbook of Pediatrics, 17
th
edition.)

Ask her to trust your judgment that this is the best route to take

Question . 83. Other approaches to pain management that might be considered for
the patient described in Question 82 include:

Adjuvant analgesics

Complementary interventions, such as massage or
hypnotherapy

Spiritual care

All of the above
Explanation: Adding other non-opiate analgesic medications
and using other non-drug related therapies are especially
useful in children with poorly controlled chronic pain.
Combination NSAID and opiates may improve control and
reduce opiate dose, while behavioral approaches help with
anticipation, coping, and articulation of pain. (See Chapter 66 in
Nelson Textbook of Pediatrics, 17
th
edition.)
Question . 84. When the patient described in Question 82 learns that the pain
medication might be changed, she tells the hospice nurse that she is no longer
hurting. What is the likely reason she might have misled the nurse?

Because she knows her mother is against the idea.

Because she is afraid of needles

Because she doesn't want to bother the nurse

All of the above
Explanation: The statement by a child who should be in pain
that he or she no longer hurts often indicates a fear of
something else, such as changing from an oral medication to a
parenteral one (fear of needles) or loss of approval by a parent.
Always be cautious about what children with chronic pain say,
because what they say is often mediated by many important
related factors
Question . 85. A bright 14-yr-old boy has had persistent right leg pain for 6 mo after
a minor soccer injury has healed. He describes the pain as sharp, shooting, and
burning. Results of all imaging studies are normal. He is able to walk on the leg and
is attending school. The type of pain the patient is experiencing is most likely to be:

Neuropathic
Explanation: Neuropathic pain may be difficult to diagnose.
This patient has classic symptoms of what used to be called
reflex sympathetic dystrophy but is now called complex
regional pain syndrome, type I. (See Chapter 66 in Nelson
Textbook of Pediatrics, 17
th
edition.)

Somatic
Visceral

Peripheral
Question . 86. Which type of medication should first be considered to treat the pain
in the child described in Question 85?

Opioids

Tricyclic antidepressants and/or anticonvulsants
Explanation: Neuropathic pain is quite resistant to opiates.
Low-dose tricyclic antidepressants, with or without various
anticonvulsant medications, are helpful. (See Chapter 66 in
Nelson Textbook of Pediatrics, 17
th
edition.)

NSAIDs

Corticosteroids
Question . 87. Other types of treatment that may be considered for the child
described in Question 85 include:

Physical therapy
Explanation: Physical therapy is very useful in rehabilitation. It
also teaches the patient to use the extremity without an
increase in disability, a fear many patients have with chronic
neuropathic extremity pain. (See Chapter 66 in Nelson
Textbook of Pediatrics, 17
th
edition.)

Crutches to eliminate weight bearing

Home schooling to reduce stress

All of the above
Question . 88. A 3-yr-old girl is scheduled to have a bone marrow aspiration for the
first time. Which of the following combination of interventions is most likely to be
helpful to her?

Education abut the procedure and hypnotherapy

Oral sucrose and a pacifier

Distraction and a local anesthetic
Explanation: Local anesthesia plus distraction is a helpful
combination for bone marrow aspiration. Some would also
premedicate with a benzodiazepine. Unless the parents will
create a stressful situation, they should be present to help their
child and even create a helpful distraction. (See Chapter 66 in
Nelson Textbook of Pediatrics, 17
th
edition.)

Separation from her parents and a benzodiazepine
Question . 89. Indications for admission to the hospital after a burn injury may
include all of the following except:

Suspected child abuse

Electric burns through an extremity

Perineal burns

Poor follow-up

No tetanus immunization
Explanation: Lack of immunization against tetanus may be
managed with tetanus toxoid and (if a wound is large or dirty)
with tetanus immune globulin. The other choices indicate that
the patient is at high risk and requires hospitalization. (See
Chapter 62 in Nelson Textbook of Pediatrics, 17th edition.)

Inhalation injury
Question . 90. A 3-mo-old, formerly a 29-wk premature infant, has been scheduled
for repair of bilateral inguinal hernias. The infant had received mechanical ventilation
for the first 6 days of life and had apnea of prematurity that resolved 5 wk previously.
The infant is feeding well and gaining weight and has no requirement for
supplemental oxygen. The hematocrit is 28%. The HMO clerk approves the surgery
on an outpatient basis. All of the following statements are true except:

Risk of postoperative apnea is increased by anemia

Accepted standard of care includes overnight inpatient apnea
monitoring for this infant after general anesthesia because of a
significant risk of postoperative apnea

Postponing the surgery incurs a small but real risk of
incarceration, with complications that may include bowel
obstruction and infarction of testes or ovaries

After spinal anesthetic, monitoring for apnea is not
required, and the infant can be sent home from the
postanesthetic care unit on the day of surgery
Explanation: Postoperative severe apnea can occur in former
premature infants up to roughly 50-55 wk postconception, even
after apnea of prematurity has resolved or has never been
present, despite premature birth. The risk of postoperative
apnea decreases with age. Anemia is an independent risk
factor for apnea, but preoperative transfusion is not
recommended for this hematocrit finding. Former premature
infants up to perhaps 50-60 wk postconceptual age should be
monitored for at least 12-18 hr after anesthesia. If apnea does
not occur in the first 12 hr, it is unlikely to occur thereafter.
Retrospective analysis of anesthetic risk supports delaying
elective surgery in the first 1-2 mo of life. These risks must be
balanced against findings of other studies that suggest that
delay in repairing inguinal hernia may result in incarceration
that cannot be reduced and in additional complications
associated with more emergent surgery. Although apnea is
reported to be much less common after spinal anesthesia for
inguinal surgery in formerly premature infants, current practice
is still to monitor in hospital for apnea for at least 12 hr after a
spinal anesthesia. (See Chapter 65 in Nelson Textbook of
Pediatrics, 17th edition.)
Question . 91. A 12-yr-old, 45-kg, previously healthy child is now on the pediatric
ward 2 hr after repair of a forearm fracture under general anesthesia. You are called
because the child has a fever of 40.6C, a respiratory rate of 60 breaths/ min, a
heart rate of 140 beats/min, and skin color described as "a bit off." Over the phone,
the nurse reviews the anesthetic record and reports that general anesthesia was
administered after a "rapid-sequence induction" because the child had eaten a large
meal just before the injury. The nurse notes from the record that anesthetic induction
was performed with thiopental sodium and succinylcholine. Anesthesia was
maintained with halothane in a mixture of nitrous oxide and oxygen, and the child
received morphine, 3 mg IV, before awakening. The anesthesia record notes stable
vital signs during surgery, which lasted 30 minutes. All of the following are true
except:

Prior to your examining the patient, based on this history, your
two primary considerations in the differential diagnosis are
aspiration pneumonitis and malignant hyperthermia

Because a rapid-sequence induction was successful and the
intraoperative vital signs were stable, aspiration pneumonitis
was prevented, and its likelihood among the differential
diagnostic posibilities is very low

Atelectasis is a more common cause of postoperative
fever than either malignant hyperthermia or aspiration
pneumonitis; this child's severity of fever, tachypnea, and
"off" color are typical for the diagnosis of atelectasis
Explanation: Atelectasis is the most common cause of fever
immediately after surgery, but the severity of the fever, the
degree of tachypnea, and the "color isn't too good" description
(whether reflecting cyanosis or impaired circulation) are
atypical for ordinary postoperative atelectasis. Malignant
hyperthermia is an inherited muscle disorder that produces
acute hypermetabolism, increased CO
2
production,
rhabdomyolysis, and fever. Clinically significant aspiration
pneumonitis is comparatively uncommon in children after
anesthesia and surgery but should be suspected if tachypnea,
hypoxemia, and fever are present postoperatively. Although a
rapid-sequence induction may reduce the likelihood of
aspiration, it does not completely prevent aspiration of gastric
contents. Aspiration may occur, as often on emergence as on
induction. Auscultation of the chest would most probably show
rales, rhonchi, or wheezes, and chest radiograph would
(eventually) show infiltrates. (See Chapter 65 in Nelson
Textbook of Pediatrics, 17th edition.)


Untreated pain increases respiratory rates, but rarely to this degree
Question . 92. In response to social overtures (being held, hugged, kissed, talked
to), a febrile infant does not smile, has a dull, expressionless face, and is not alert to
stimuli. The most appropriate approach to management is to:

Administer ceftriaxone IM after a blood culture and have the
parent and child return to the office in the morning

If the child is older than 6 mo, obtain a blood culture and have
the parents return to the office if the patient remains febrile
Administer acetaminophen and reassess after the infant is no
longer febrile

Administer ceftriaxone after obtaining a blood, urine, and
CSF specimens for culture and admit the child to the
hospital
Explanation: Clinical observation of young patients is critical in
helping you to evaluate and distinguish the degree of risk of
infection and physiologic impairment. In addition to observing
color, tone, grunting, or a bulging fontanel, the response to
social stimuli is valuable. This 3-mo-old had pneumococcal
meningitis. (See Chapter 49 in Nelson Textbook of Pediatrics,
17th edition.)

Administer a normal saline bolus of 20 mL/kg and reevaluate in
1 hr
Question . 93. Paradoxical irritability may be present with all of the following except:

Osteomyelitis

Appendicitis

Extremity cellulitis

Meningitis

Pneumonia
Explanation: Paradoxic irritability is present when a child
becomes anxious and cries during attempts to cuddle and hold
the patient. Movement of a painful extremity, abdomen, or neck
may elicit this response
Question . 94. A previously healthy 7-mo-old white baby boy presents one summer
day with a temperature of 41.1C, a pulse of 190/min, a respiratory rate of 70
breaths/min, and a blood pressure of 65/20 mm Hg. He has a 1-day history of
diarrhea (five stools in 24 hr) and is now unresponsive to verbal commands or
painful stimuli. The most appropriate initial therapy is:

Application of cooling blankets

Administration of aspirin (100 mg/kg)

Administration of ceftriaxone (150 mg/kg)

Administration of dantrolene (10 mg/kg)

Administration of normal saline (20-40 mL/kg)
Explanation: Despite an uncertain etiology, the physiologic
condition is that of shock. The circulation needs to be re-
established to perfuse vital organs.
Question . 95. After receiving normal saline pushes, the patient in Question 97
remains unconscious. A lumbar puncture reveals 3 WBCs/cu mm, 10 RBCs/cu mm,
a protein level of 30 mg/dL, and a glucose level of 75 mg/dL. After the lumbar
puncture, he is noted to be bleeding at venipuncture sites. The most likely diagnosis
is:

Herpes simplex encephalitis

Meningococcemia

Salicylate poisoning

Hemorrhagic shock encephalopathy syndrome
Explanation: Hemorrhagic shock encephalopathy syndrome
may look like heat stroke, but it is a distinct disorder
characterized by encephalopathy, shock, fever, disseminated
intravascular coagulopathy, and other organ failure (heart,
liver). It has a high mortality rate and morbidity. (See Chapter
57 in Nelson Textbook of Pediatrics, 17th edition.)

Malignant hyperthermia
Question . 96. A burn wound characterized by the absence of painful sensation,
bleeding, or capillary refilling is best classified as:

First degree

Moderate to severe

Second degree

Midlevel

Full thickness
Explanation: This defines a full-thickness burn (also known as
a third-degree burn). (See Chapter

Question . 97. A 12-yr-old boy with spina bifida experiences respiratory distress
during induction of anesthesia for an orthopedic procedure. He has been otherwise
well prior to this hospital admission. Past medical history reveals surgery for closure
of the spina bifida at age 3 days, placement of a ventricular peritoneal shunt at 1 mo
of life, and release of contractures at 6 yr of life. He is on ampicillin prophylaxis for
recurrent urinary tract infections since birth and has to be catheterized for urination.
The most likely diagnosis is:

Ampicillin hypersensitivity

Urosepsis

Reactive airway disease

Status epilepticus

Latex anaphylaxis
Explanation: Latex allergy is common in children with multiple
surgical procedures and those who have required
catheterization for urinary retention. The presentation includes
urticaria, wheezing, and hypotension. Bananas may cross-
react with latex. (See Chapter 65

in Nelson Textbook