Social Issues

Question . 1. A 6-mo-old boy is brought to the emergency room and is afebrile but responds poorly to tactile and auditory stimuli. He becomes apneic and unresponsive after a generalized seizure. The parents state that he was perfectly well in the car on the way to the hospital and that they only brought him to the emergency room because of constipation. He requires 10 min of cardiopulmonary resuscitation, after which he is noticed to have a bulging fontanel and bilateral retinal hemorrhages. A chest film reveals two posterior rib fractures. The most likely diagnosis is: CPR-induced retinal hemorrhages and rib fractures Hemorrhagic shock and encephalopathy Hemophilia Status epilepticus Child abuse-shaken baby syndrome Explanation: In the classic shaken baby syndrome, a computed tomography scan of the head reveals diffuse cerebral edema and hemorrhage. CPR in young children does not usually produce retinal hemorrhages and rarely, if ever, produces rib fractures. (See Chapter 35 in Nelson Textbook of Pediatrics, 17th ed.) Question . 2. A young child's response to the death of a parent often is characterized by: Depression and weight loss Denial and magical wishing Explanation: Many young children continue in their daily activities and use denial and magical wishful thoughts for reunion and reappearance. (See Chapter 33 in Nelson Textbook of Pediatrics, 17th ed.) Anger and crying Wishes of death for himself or herself None of the above Question . 3. The effect that statements such as "stop it or you'll give me a headache" have on young children is to: Teach a child to behave Give children a pattern of headaches Create guilt and unrealistic fault Explanation: Statements such as "stop it or you'll give me a headache" may cause a child to suffer significant and unrealistic guilt, especially if the parent leaves for some time or is hospitalized. (See Chapter 33 in Nelson Textbook of Pediatrics, 17th ed.) Provide parents with a way to cope Prepare children for separation Question . 4. All of the following statements about adoption are true except: 42% are stepparent or relative adoptions Most adopted children are from foreign countries Explanation: Five percent of adoptions are from overseas. (See Chapter 30 in Nelson Textbook of Pediatrics, 17th ed.) 1 million children are adopted in the United States each year 15% are adopted through foster care 2-4% of American families have adopted children Question . 5. All of the following statements regarding foster care are true except: Chronic medical illness is present in 35% of children 60% of preschool children in foster care experience developmental delay 42% are white children A majority of foster children receive EPSDT services Explanation: Early prevention screening and developmental testing programs are underutilized in the foster care system. (See Chapter 31 in Nelson Textbook of Pediatrics, 17th ed.) Children frequently stay at more than one foster care home Question . 6. High-quality child care can influence all of the following except: Child cognition Future academic achievement Social development Sibling rivalry

Explanation: Sibling rivalry and aggression may not be affected as much as the cognitive issues. (See Chapter 32 in Nelson Textbook of Pediatrics, 17th ed.) Scores on standardized tests Question . 7. A 3-yr-old boy is missing from his mother's house approximately 1 mo after a divorce. The most likely explanation is: Sleepwalking Drug reaction Running away from his mother Searching for his father Explanation: It is not unusual for the young child to keep asking for the missing parent, to wait at the door or window, or to go outside to look for the parent. (See Chapter 33 in Nelson Textbook of Pediatrics, 17th ed.) Anxiety reaction Question . 8. After divorce, children may demonstrate all of the following except: A feeling of being overburdened by residence in two homes Withdrawal Indifference at times of reunions Academic deterioration Expectations that the parents will never get back together Explanation: Indeed, most children fantasize about the possibility that their parents will remarry. (See Chapter 33 in Nelson Textbook of Pediatrics, 17th ed.) Question . 9. All of the following are age-related behavioral responses to experiencing violence except: Infants-poor sleep Adolescents-short-fuse responses Toddlers-excessive appetite Explanation: All the rest are true, as well as poor appetite, decreased exploration of the environment in toddlers, and poor school performance with hyperactivity in older children. (See Chapter 34 in Nelson Textbook of Pediatrics, 17th ed.) Toddlers-clingy behavior School age-post-traumatic stress syndrome Question . 10. Munchausen syndrome by proxy is characterized by all of the following except: 10% mortality Multiple hospitalizations Induced manifestations by caregiver Ready admission of abuse by parents Explanation: Parents often deny their involvement in inducing symptoms in their children and will rapidly change doctors if it is discussed with them. (See Chapter 35 in Nelson Textbook of Pediatrics, 17thed.) Use of medications or toxins Question . 11. Factors that may be associated with an increased risk of child abuse include: Poverty Military base residence Spouse abuse Unplanned pregnancy All of the above Explanation: Each is a risk factor. Of note, abuse has been reported in all communities and from all socioeconomic levels. (See Chapter 35 in Nelson Textbook of Pediatrics, 17th ed.) Question . 12. A 2-mo-old is admitted with a fracture of the right femur. The mother states that the baby fell off a low couch onto a plush carpeted floor and did not cry. Thereafter, the baby appeared fine. Three days later, the grandmother noted that the baby cried when she changed the diaper and that the leg was swollen. In the emergency department, a bruise was noted over the sternum that was also said to have occurred during the fall 3 days ago. The mother states that she bleeds easily, but that the father of the baby is well. An x-ray film reveals a spiral fracture of the child's femur. Features of this case suggestive of abuse include all of the following except: Multiple sites of injury

Implausible explanation for injury Grandmother's deep concern Explanation: Often, relatives do not know the nature or the cause of the injury, nor do they readily know or admit to the identity of the person who committed the trauma. (See Chapter 35 in Nelson Textbook of Pediatrics, 17th ed.) Injury incompatible with the nature of the fall Delay in seeking medical attention Question . 13. Cardiopulmonary resuscitation in a child with head trauma from abuse commonly results in all of the following except: Recovery of a pulse Retinal hemorrhages and broken ribs Explanation: Retinal hemorrhages and broken ribs rarely follow CPR. The nature of rib fractures is also different in abuse. (See Chapter 35 in Nelson Textbook of Pediatrics, 17th ed.) Recovery of respirations Normal sinus rhythm Recovery from cyanosis Question . 14. Sexual abuse includes all of the following except: Exposing sexual anatomy Touching genitals by two preadolescents Explanation: This is sexual play and is usually normal exploratory behavior if there is no force or coercion and the children are not more than 4 years apart in age. (See Chapter 35 in Nelson Textbook of Pediatrics, 17th ed.) Showing pornography to a child Use of a child to create pornography Incest Question . 15. Pedophiles are best described as: Being female Never having repeated experiences Seeking opportunities to be in contact with children Explanation: Pedophiles often seek out positions and opportunities to be around children. Certain children may be particularly vulnerable, such as those with mental and physical handicaps. (See Chapter 35 in Nelson Textbook of Pediatrics, 17th ed.) Preferring females Being highly violent Question . 16. 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 Explanation: By DNA typing, the blood turned out to be the mother's. The mother has diabetes and employs home glucose monitoring and would purposely put blood on her daughter's underwear. (See Chapter 35 in Nelson Textbook of Pediatrics, 17th ed.) Interrogate the father Isolate the parents and child Determine von Willebrand factor levels Measure fibronectin in the vagina Question . 17. The most likely diagnosis for the child described in Question 16 is: Precocious puberty Sexual abuse Vaginitis Coagulopathy Munchausen syndrome by proxy Explanation: Munchausen by proxy brings attention to the child and caregiver. Often, the perpetrator has some medical background. (See Chapter 35 in

Nelson Textbook of Pediatrics, 17th ed.) Question . 18. All of the following statements regarding adoption are true except: Federal law requires that children in foster care who cannot be safely returned to their families within a reasonable period of time be placed with adoptive families Agencies in the United States that arrange international adoptions have no legal obligation to obtain accurate and complete health histories on children whom families are considering adopting Explanation: (See Chapter 30 in Nelson Textbook of Pediatrics, 17th ed.) Families should be encouraged to speak freely and repeatedly about adoption with the adopted child, beginning in toddler years and continuing through adolescence Most adopted children adjust well and lead healthy, productive lives Many children in foster care waiting to be adopted have "special needs" Question . 19. 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 Explanation: (See Chapter 31 in Nelson Textbook of Pediatrics, 17th ed.) A minority of children in foster care have a history of abuse or neglect An increasing proportion of children entering foster care are adolescents Children in foster care have low utilization rates for all types of care A minority of foster care children have behavioral and adjustment problems Question . 20. All of the following statements regarding child care are true except: Nearly one half of employed mothers with 3- and 4-yr-old children use center care as their primary supplemental care High-quality child care does not influence the cognitive and social development of disadvantaged children Explanation: (See Chapter 32 in Nelson Textbook of Pediatrics, 17th ed.) Middle-class children are not protected from the effects of poor-quality child care Licensure of child-care providers signifies that minimal health, safety, and sanitary practices are being followed Accreditation of a child-care provider suggests that a program is of sufficient quality to promote children's development Question . 21. All of the following statements are true except: Recurrent separations tend to accustom children to separations and make them less wary and guarded about reestablishing the relationship with an absent parent Explanation: (See Chapter 33 in Nelson Textbook of Pediatrics, 17th ed.) Most bereaved families remain socially connected and expect that life will return to some new sense of normalcy School-aged children think more concretely than younger children, recognize the permanence of death, and begin to understand biologic processes of the human body No specific grief sign, symptom, or cluster of behaviors identifies the child or family in need of help with bereavement after the death of a family member Medication, as a first line of treatment, rarely proves useful in normal or uncomplicated grief reactions Question . 22. All of the following statements regarding children and violence are true except: The source of first exposure to violence for children is often television Explanation: (See Chapter 34 in Nelson Textbook of Pediatrics, 17th ed.) The violence children experience and witness has a profound impact on health and development High levels of witnessing violence place children at risk for psychological, social, academic, and physical problems Occasional wife battering is estimated to occur in 16% of all families The most ubiquitous source of exposure to violence for children in the United States is television Question . 23. The source of first exposure to violence for children is often:

Community violence War violence School violence Domestic violence Explanation: (See Chapter 34 in Nelson Textbook of Pediatrics, 17th ed.) Question . 24. The violence children witness affects their development in all of the following ways except: It influences how they view the world and their place in it Children become more capable in motor function from the constant threat of violence Explanation: (See Chapter 34 in Nelson Textbook of Pediatrics, 17th ed.) Fear may thwart their exploration of the world, which is essential in learning in childhood Higher exposure to violence correlates with poorer performance in school, symptoms of anxiety and depression, and lower self-esteem Question . 25. A 6-mo-old child is brought to your office with the chief complaint of leg swelling and decreased leg movement of 3 days' duration. The mother, a single parent, said that the child awoke 3 days ago with the swelling and guarding. She was unaware of any trauma to the child but said that her 2-yr-old "plays rough" with the 6-mo-old. She said that she delayed coming to see you because she had no transportation. An x-ray film reveals a new (less than 7 days old) spiral fracture of the femur. Which of the following should be your next action? Refer the child to an orthopedist for casting Perform a skeletal series, refer the child to an orthopedist for casting, examine and do a skeletal survey of the sibling Perform a skeletal series, refer the child to an orthopedist for casting, examine and do a skeletal survey of the sibling, and report the spiral fracture to appropriate authorities as suspected physical abuse after screening the mother for risk factors and informing the mother of your plan Explanation: (See Chapter 35 in Nelson Textbook of Pediatrics, 17th ed.) Tell the mother you suspect physical abuse and interrogate her until you get a history; when the mother tells you that the child fell from the crib to a carpeted floor and sustained the injury, you conclude that the finding is in keeping with the fracture, with no need to report suspected child abuse Because this fracture is probably due to osteogenesis imperfecta, send the child for genetics evaluation and connective tissue biopsy for a definitive diagnosis Question . 26. The parents of a 4-yr-old girl are in the process of a divorce. The child returned from a visit with the father yesterday. The mother, who has primary custody of the child, examined the child's genitalia because the child complained of dysuria. She found the genitalia to be red and open to the "size of a dime." She asked the girl if the father had done anything to her and the child remained silent. The child has been reluctant to visit the father. The mother brings the child to you because she is concerned that the child has been abused. Which of the following constitutes the most appropriate next step in management? With the mother in the room for support, interview the child by asking if the father has ever done anything to her genitalia. If the child answers in the affirmative, make a report to appropriate authorities. Report what the mother has told you to appropriate authorities. Ask the father to come to your office so that you can interview him. It is likely that the mother has prompted the child. Speak to the child with the mother out of the room. Begin with general questions. Determine knowledge of body parts and private parts. Ask if anything has happened to various body parts. If the child answers in the affirmative, ask what happened. Do a complete examination including inspection of the anus and genitalia. If the child gives any history suggestive of abuse or has findings suggestive of trauma to the anus or hymen that are unexplained, make a report to the appropriate authorities. Explanation: (See Chapter 35 in Nelson Textbook of Pediatrics, 17th ed.) Question . 27. A 6-mo-old child has a 2-mo history of daily projectile vomiting. She has been hospitalized on two occasions. Findings on laboratory studies including an upper GI series and on

swallowing studies have been normal. The mother had similar symptoms as a child. A 3-yr-old sister has been treated for gastroesophageal reflux. You are the fourth physician that the mother, a nurse, has contacted to diagnose and treat these persistent symptoms. Inspection of hospital records indicates that no vomiting took place during either hospital admission. The most appropriate next step in management is: Conduct a complete and detailed work-up for cyclic vomiting with referrals for consultation to gastroenterology, neurology, and nephrology. Persist in your evaluation until a diagnosis is made. Have the mother bring you a sample of the vomitus. Test it for the presence of ipecac. Perform toxicology studies. If results are positive, report as suspected Munchausen syndrome by proxy to proper authorities. Explanation: (See Chapter 35 in Nelson Textbook of Pediatrics, 17th ed.) Place the child on treatment for gastroesophageal reflux in light of the high rate of false-negative results on laboratory testing for this condition. If the condition persists despite treatment, hospitalize the child and obtain surgical consultation. Confront the mother with lack of medical findings for the condition. Indicate that you suspect she is lying about the symptoms. Request a psychiatric consultation for the mother. Report your suspicions to proper authorities with a request that the child remain in the home under weekly supervision by a public health nurse. Consult an allergist and request a work-up for food allergy. Put the child on a restrictive diet and observe for symptoms.