Chapter 12: Development Management of Middle Childhood

Garzon Maaks: Burns’ Pediatric Primary Care, 7th Edition

MULTIPLE CHOICE

1. The primary care pediatric nurse practitioner is examining a 6-year-old child who attends first
grade. The child reports “hating” school. The parent states that the child pretends to be sick
frequently in order to stay home from school. To further assess this situation, the nurse
practitioner will first ask the child:
a. about school performance and grades.
b. why school is so distressing.
c. to name one or two friends.
d. whether bullying is taking place.
ANS: C
The earliest school-age psychosocial milestone occurs when children learn to separate easily
from family, allowing them to go to school. Mastery of these skills enables them to develop
and maintain peer friendships. Social interaction skills are necessary in order to develop
mastery over school activities. Asking the child to describe why school is distressing may not
elicit information, since the child may not be able to articulate this. Bullying is not the only
reason for disliking school, but, if it is, will emerge during a discussion about friends and
schoolmates.

2. The parent of a 10-year-old boy tells the primary care pediatric nurse practitioner that the
child doesn’t appear to have any interest in girls and spends most of his time with a couple of
other boys. The parent is worried about the child’s sexual identity. What will the nurse
practitioner tell the parent?
a. Children at this age who prefer interactions with same-gender peers usually have a
homosexual orientation.
b. Children experiment with sexuality at this age as a means of deciding later sexual
orientation.
c. This attachment to other same-gender children is how the child learns to interact
with others.
d. It’s appropriate to encourage mixed-gender interactions in order to promote
development of sexual values.
ANS: C
At age 10, children usually develop an intense same-gender relationship with a peer. This is
how the child learns to expand the self, shares feelings, and learns how others manage
problems. It does not indicate later sexual orientation and is not a characteristic of
experimentation with sexuality. It is not necessary to encourage mixed-gender interactions.

3. The parents of a 12-year-old child are concerned that some of the child’s older classmates may
be a bad influence on their child. What will the primary care pediatric nurse practitioner tell
the parent?
a. Allowing the child to make poor choices and accept consequences is important for
learning values
b. Children at this age have a high regard for authority and social norms, so this is not
likely to happen
 c. Moral values instilled in the early school-age period will persist throughout
childhood
d. The pressures from outside influences may supersede parental teachings and
should be confronted
ANS: D
Although early school-age children learn values from their parents, these may be challenged
as children learn that others have different values. Parents must confront and negotiate these
issues daily with their children. While children may make poor choices and subsequently learn
from the consequences, it is best for parents to actively discuss these issues with their
children. Children do have a high regard for authority and social norms but may easily
transfer this authority to other, less reliable people, such as peers. Moral values may not
persist if other sources of authority become prominent.

4. During a well child exam of a school-age child, the primary care pediatric nurse practitioner
learns that the child has been having angry episodes at school. The nurse practitioner observes
the child to appear withdrawn and sad. Which action is appropriate?
a. Ask the child and the parent about stressors at home
b. Make a referral to a child behavioral specialist
c. Provide information about anger management
d. Suggest consideration of a different classroom
ANS: A
School-age children are learning to manage emotions and need help to manage their feelings
in acceptable ways. A variety of stressors, including parental divorce, substance abuse,
bullying in school, and early responsibilities, can cause anxiety in the child, who may not
manage these feelings well. Until the underlying cause is better understood, management
options cannot be determined, so referrals to specialists, information about anger
management, or moving to a different classroom may not be indicated.

5. The primary care pediatric nurse practitioner is preparing to conduct a well child assessment
of an 8-year-old child. How will the nurse practitioner begin the exam?
a. Ask the child about school, friends, home activities, and sports
b. Discuss the purpose of the visit and explain the procedures that will be performed
c. Offer age-appropriate information about usual developmental tasks
d. Provide information about healthy nutrition and physical activities
ANS: A
To build rapport with the child and parent, the PNP will begin by asking direct questions to
the child, encouraging the child to share information about daily routines. The other answers
list aspects of the well child visit that can be introduced after the initial conversation.

6. A school-age child has begun refusing all cooked vegetables. What will the primary care
pediatric nurse practitioner recommend to the parent?
a. Allow the child to make food choices since this is usually a phase
b. Ensure that the child has three nutritious meals and two nutritious snacks each day
c. Prepare vegetables separately for the child to encourage adequate intake
d. Teach the child how important it is to eat healthy fruits and vegetables
ANS: B
 Children have food jags that are generally self-limited. The parent’s responsibility is to
provide three nutritious meals and two nutritious snacks each day so that all available choices
are acceptable. Allowing food choices may result in an overabundance of non-nutritious foods
selected. It is not necessary to prepare separate dishes for a child who is going through a
temporary phase. Teaching the child about nutrition is important but will not likely have much
impact during this phase.

7. The primary care pediatric nurse practitioner performs a physical examination on a 12-year-
old child and notes poor hygiene and inappropriate clothes for the weather. The child’s mother
appears clean and well dressed. The child reports getting 6 to 7 hours of sleep each night
because of texting with friends late each evening. What action by the nurse practitioner will
help promote healthy practices?
a. Discuss setting clear expectations about self-care with the mother
b. Give the child information about sleep and self-care
c. Reassure the mother that this “non-compliance” is temporary
d. Tell the mother that experimenting with self-care behaviors is normal
ANS: A
Parents of school-age children should be advised to set clear limits for their children for
cleanliness, healthy exercise, hours of sleep, and other health promotion behaviors to
encourage the development of responsibility for these things. Giving the child information can
be done along with setting expectations, but, at this age, the parent should still be supervising.
While “non-compliance” is a part of this process, and is a means of asserting independence,
parents need to discuss this with children to resolve the issue.

8. During a well child exam on a 6-year-old child, the primary care pediatric nurse practitioner
assesses the child for school readiness. Which finding may be a factor in limiting school
readiness for this child?
a. Adherence to daily family routines and regular activities
b. Having two older siblings who attend the same school
c. Parental concerns about bullying in the school
d. The child’s ability to recognize four different colors
ANS: C
Parental expectation is the strongest predictor of school success in children. Parents who are
worried about what may happen in school can transmit this anxiety to the child. Children who
have a secure family life with daily routines will do better in school. Having older siblings
who attend school increases success. Children at this age are expected to know four colors, so
this is an indication of school readiness.

9. The primary care pediatric nurse practitioner is examining a school-age child who reports
frequent stomach pain and headaches. The parent reports that the child misses several days of
school each month. The child has a normal exam. Before proceeding with further diagnostic
tests, what will the nurse practitioner initially ask the parent?
a. About the timing of the symptoms each day and during the week
b. How well the child performs in school and in extracurricular activities
c. If the parent feels a strong need to protect the child from problems
d. Whether there are any unusual stressors or circumstances at home
ANS: A
 Children with school refusal or school phobia often have symptoms that gradually improve as
the day progresses and often disappear on weekends. The PNP should ask about the frequency
and duration of the symptoms to evaluate this pattern. The other options are important
questions when management of school phobia has begun as a way of understanding
underlying causes for the reluctance to go to school.

10. The primary care pediatric nurse practitioner is evaluating recurrent stomach pain in a school-
age child. The child’s exam is normal. The nurse practitioner learns that the child reports pain
most evenings after school and refuses to participate in sports but does not have nausea or
vomiting. The child’s grandmother recently had gallbladder surgery. Which action is correct?
a. Encourage the child to keep a log of pain, stool patterns, and dietary intake
b. Order radiologic studies and laboratory tests to rule out systemic causes
c. Reassure the child and encourage resuming sports when symptoms subside
d. Refer the child to a counselor to discuss anxiety about health problems
ANS: A
The PNP suspects a somatic disorder after a normal exam and should encourage the child to
keep a food or pain diary to help manage symptoms. The PNP should not “medicalize” the
problem with tests. The child should be encouraged to resume sports and participate in normal
activities. If the symptoms persist, referral for counseling is warranted.