The Respiratory System Question

Nelson Self Assessments website 17th Edition

Question . 1. A 3-yr-old boy is undergoing mechanical ventilation 12 hr after repair of an

atrial septal defect. Opioids and benzodiazepines are being used for analgesia and
sedation. The mandatory ventilatory rate has been decreased from 20 to 10 breaths/min in
preparation for removal of the endotracheal tube. The arterial PO2 is 120 mm Hg and the
arterial PCO2 is 75 mm Hg. The arterial pH is 7.13. The child has no spontaneous
respirations. Auscultation of the chest demonstrates that the breath sounds are slightly
reduced on the left side. Occasional crackles can be heard over both bases.
The most likely reason for this child's acidosis is:
A. Pulmonary edema
B. Pneumonia
C. Cardiogenic shock
D. Respiratory depression
Explanation: As a result of sedation and analgesia, he is hypoventilating, which is
manifested by an acute respiratory acidosis and hypercarbia.Oxygenation may not
be affected if he is breathing enriched oxygen.The reduced breath sounds and
crackles could be due to atelectasis. (See Chapter 357 in Nelson, 17th ed.)
E. Pneumothorax

Question . 2. A 3-mo-old infant is brought to the emergency room because of lethargy

and poor feeding. She appears pale. Other findings include subcostal retractions and use
ofthe abdominal muscles during expiration. Her breathing rate is 30/min. Breath sounds
are decreased bilaterally. She has a prolonged expiratory phase. No wheezing or crackles
are audible.An abnormality in which of the following components of the respiratory
system is most likely to be involved in the genesis of these manifestations?
A. Alveolar surfactant
B. Lung interstitium
C. Intrathoracic airways
Explanation: Airway edema or inflammation will produce this constellation of
findings.With smaller airway involvement, this patient may eventually
demonstrate wheezing. (See Chapter 357 in Nelson Text. Pediatrics, 17th ed.)
D. Diaphragm
E. Medullary respiratory neurons

Question . 3. Which of the following functional findings is most likely in a 12-yr-old girl
who has developed acute rheumatic carditis with severe mitral insufficiency?
A. Increased peak expiratory flow
B. Increased vital capacity
C. Increased residual volume
D. Decreased functional residual capacity
Explanation: Cardiac failure produces interstitial and alveolar edema, which will
reduce the FRC. (See Chapter 357 in Nelson Textbook of Pediatrics, 17th ed.)
E. Increased CO diffusion capacity

The Respiratory System Nelson Self Assessments website 17th Edition 1

Question . 4. A 2-wk-old infant begins to experience episodes of acute respiratory
distress after undergoing repair of esophageal atresia. The episodes appear to be triggered
by crying. The infant becomes agitated and demonstrates decreased breath sounds
bilaterally, with the development of cyanosis and bradycardia. Physical examination
conducted when he is calm reveals mild subcostal retractions with a respiratory rate of 45
breaths/min, bilateral rhonchi, and a prolonged expiratory phase. Which of the following
is most likely to be the cause of the respiratory distress episodes?

A. Patent ductus arteriosus

B. Recurrent laryngeal nerve injury
C. Choanal atresia
D. Pulmonary hypertension
E. Tracheomalacia
Explanation: Tracheomalacia is quite common after repair of esophageal
atresia.Weakness of both the extrathoracic and intrathoracic trachea can produce
episodes of cyanosis and respiratory distress often triggered by crying, anxiety, or
pain.(See Chapter 357 in Nelson Textbook of Pediatrics, 17th ed.)

Question . 5. Intercostal retractions are caused by:

A. Direct traction applied by the diaphragm on the ribs

B. Contraction of the internal intercostal muscles
C. Contraction of the external intercostal muscles
D. Decreased pleural pressure
Explanation: When the compliance of the chest is greater than the negative
intrathoracic pressure generated during inspiration, retractions will develop.The
intercostal space is even more compliant than the chest wall. (See Chapter 357 in
Nelson Textbook of Pediatrics, 17th ed.)
E. Recruitment of the scalene and sternocleidomastoid muscles

Question . 6. A 1-mo-old infant is breathing supplemental oxygen from a hood at a

measured concentration of 45% after developing respiratory distress. A PO2 of 60 mm
Hg, a PCO2 of 50 mm Hg, and a pH of 7.30 are measured in a blood sample obtained
from the left radial artery. Which of the following interpretations is most consistent with
these findings?

A. The blood sample is venous

B. The infant has a right-to-left shunt via the ductus arteriosus
C. Oxygen diffusion across the alveolar-capillary membrane is impaired
D. The patient is hypoventilating
E. The blood gas anomalies are caused by ventilation-perfusion inequality
Explanation: The patient has both hypercarbia and hypoxia.Assuming the FIO2 in
the hood is 45%, one would expect a PaO2 much higher than 60 mmHg.The most
common cause of hypoxia in children with acute respiratory disorders is a
ventilation/perfusion mismatch. (See Chapter 357 in Nelson, 17th ed.)

The Respiratory System Nelson Self Assessments website 17th Edition 2

Question . 7. A premature infant is undergoing mechanical ventilation for respiratory
distress syndrome. Peak inspiratory pressure is 32 cm H2O, positive end-expiratory
pressure (PEEP) is 5 cm H2O, and ventilatory rate is 30 breaths/min. The infant has
decreased peripheral perfusion, manifested as a prolonged capillary refill time and weak
arterial pulses. The central venous pressure measured at the right atrium with an
umbilical venous catheter is 2 mm Hg (or approximately 3 cm H2O). Arterial PO2 is 80
mm Hg, and arterial PCO2 is 38 mm Hg.Which of the following measures is most likely
to result in an improvement in this infant's perfusion?

A. Reduce PEEP to 3 cm H2O

B. Reduce peak inspiratory pressure to 28 cm H2O
C. Reduce ventilatory rate to 26 breaths/min
D. Administer 10 mL/kg of normal saline
Explanation: The PaO2 and PCO2 are quite appropriate and in the target range for
appropriate therapy.Poor peripheral perfusion and weak pulses (and presumably
low blood pressure) in this setting should respond to expansion of the
intravascular volume with normal saline.The poor perfusion may have preceded
the initiation of PEEP, but may have also been exacerbated by the PEEP. (See
Chapter 357 in Nelson Textbook of Pediatrics, 17th ed.)
E. Begin an infusion of dopamine at 5 g/kg/min

Question . 8. A 5-mo-old infant develops signs of respiratory distress after coughing and
sneezing for 3 days. He has marked subcostal and intercostal retractions and a respiratory
rate of 80 breaths/min. Breath sounds are markedly diminished on both sides. Diffuse
crackles can be heard bilaterally. There is no stridor. Arterial oxygen saturation in 100%
oxygen by non-rebreather mask is 80%. The skin is pale and peripheral arterial pulses are
weak.Which of the following is the most appropriate immediate course of action?

A. Administration of corticosteroids
B. Intubation of the trachea and mechanical ventilation
Explanation: This child is in respiratory failure.An arterial blood gas
determination may be helpful, but persistent hypoxia (80% saturation on pulse
oximetry) while the patient is on 100% FIO2 is an indication for intubation and
mechanical ventilation.CPAP may be tried under very controlled circumstances
but rarely avoids intubation.(See Chapter 357 in Nelson Textbook of Pediatrics,
17th ed.)
C. Sampling of arterial blood and measurement of arterial pH and blood gases
D. Administration of normal saline
E. Administration of diuretics

The Respiratory System Nelson Self Assessments website 17th Edition 3

Question . 9. A 16-yr-old boy who has been diagnosed with a yet uncharacterized form
of muscular dystrophy develops increased somnolence. He responds only to painful
stimuli. His respiratory rate is 40 breaths/min. His arterial oxygen saturation in room air
is 87%. After administration of supplemental oxygen, the arterial PO2 is 150 mm Hg, the
arterial PCO2 is 70 mm Hg, and the arterial pH is 7.30. Which of the following
statements defines this situation most accurately?

A. Decreased hypoxic drive after correction of the hypoxemia has resulted in acute
hypercapnia
B. Pulmonary hypertension caused by chronic hypoxemia has produced increased
ventilation-perfusion inequality
C. Renal tubular compensation of prolonged hypercapnia has resulted in an elevation
of serum bicarbonate levels
Explanation: Owing to poor ventilatory muscular effort, the patient has been
hypoventilating for a long enough time to allow renal tubular reabsorption of
bicarbonate to compensate for the prolonged hypercarbia (respiratory
acidosis).Compensation cannot totally correct the pH to normal.If the drive for
ventilation was inhibited by the hyperoxia, the PCO2 would be even higher and
the pH lower. (See Chapter 357 in Nelson Textbook of Pediatrics, 17th ed.)
D. The patient has become dehydrated
E. A fixed intrapulmonary right-to-left shunt is responsible for the limited response
to administration of oxygen

Question . 10. A 4-mo-old African-American infant was found unresponsive in his crib
by his mother in the early morning and could not be resuscitated. He had been placed for
sleep on his back but was found on his stomach. At a well-child examination the previous
day, he had been found to be in good health and received his routine immunizations. He
was born at 36 wk of gestation and weighed 2,420 g. His medical history was otherwise
unremarkable. After a thorough scene investigation, autopsy, and review of the medical
history, the cause of death was determined to be sudden infant death syndrome (SIDS).
Which of the following factors has not been found to be associated with greater risk of
SIDS?

A. Prematurity
B. Movement to a prone position after having been placed supine to sleep
C. Immunizations
Explanation: Multiple studies have looked at the potential associations between
immunizations and SIDS.None has ever demonstrated a relationship with SIDS.
(See Chapter 360 in Nelson Textbook of Pediatrics, 17th ed.)
D. African-American heritage
E. Low birth weight

The Respiratory System Nelson Self Assessments website 17th Edition 4

Question . 11. In the clinical scenario described in Question 10, which of the following
physiologic abnormalities is most likely to be related to the child's sudden, unexpected
death due to SIDS?

A. Increased susceptibility to bacterial infection

B. Prolonged Q-T interval
C. Medium-chain fatty acid metabolic abnormality
D. Arousal responsiveness from sleep
Explanation: Arousal responsiveness from sleep is thought to be the most
common mechanism for SIDS.This together with rebreathing in the prone
position may explain many cases. B has been associated with SIDS but is
uncommon. C has also been associated with SIDS but its incidence is
unknown.Both B and C should be suspected when more than one case of SIDS
occurs in a family or if there are non-healthy affected family members.(See
Chapter 360 in Nelson Textbook of Pediatrics, 17th ed.)
E. Brainstem autonomic control of heart rate and blood pressure

Question . 12. Of the following, the strongest risk factor associated with SIDS is:

A. Smoking by the mother in the prenatal period

Explanation: This is the epidemiologically correct answer.Although C is also
important, the prenatal exposure is more dominant. (See Chapter 360 in Nelson
Textbook of Pediatrics, 17th ed.)
B. Smoking by the father in the prenatal period
C. Exposure of the infant to environmental tobacco smoke after he or she is born
D. Smoking by the mother prenatally only in association with alcohol use
E. There is no association between smoking and SIDS

Question . 13. All of the following measures are recommended by the American
Academy of Pediatrics to reduce the risk of SIDS except:

A. Placing babies on their back to sleep

B. Avoiding waterbeds, sofas and other soft surfaces for sleep
C. Avoiding overheating during sleep
D. Using a pacifier if the infant is not breast feeding
Explanation: Pacifier use is interesting, as some believe that it reduces the risk of
SIDS.It is controversial and is not consistently agreed on as a protective factor
and is not recommended by the AAP.(See Chapter 360 in Nelson Textbook of
Pediatrics, 17th ed.)
E. Avoiding pillows in the infant's sleep environment

The Respiratory System Nelson Self Assessments website 17th Edition 5

Question . 14. All of the following statements are true except:

A. Most episodes of acute pharyngotonsillitis are viral

B. Rapid enlargement of one tonsil is typical of pharyngotonsillitis
Explanation: Enlargement of one tonsil, which occurs acutely, is typical of a
peritonsillar abscess and not routine pharyngotonsillitis.Peritonsillar abscesses
may obstruct the airway and are treated with intravenous antibiotics (penicillin is
OK) and incision and drainage or aspiration.(See Chapter 368 in Nelson, 17th ed.)
C. With cryptic tonsillitis, a frequent clinical presentation is halitosis, chronic sore
throat, or a history of expelling foul-tasting and foul-smelling cheesy lumps
D. In many children, the diagnosis of airway obstruction is made by history and
physical examination
E. Tonsillectomy alone is usually performed for recurrent or chronic
pharyngotonsillitis

Question . 15. Which of the following is not an indication for adenoidectomy alone?

A. Chronic nasal infection (chronic adenoiditis)

B. Chronic sinus infections that have failed medical management
C. Recurrent bouts of acute otitis media
D. Recurrent otorrhea in children with tympanostomy tubes
E. Recurrent pharyngotonsillitis
Explanation: In this situation tonsillectomy alone is effective treatment.(See
Chapter 368 in Nelson Textbook of Pediatrics, 17th ed.)

Question . 16. A 7-yr-old African-American boy is brought to your office by his parents,
who describe loud snoring, difficulty breathing, and obstructed breathing at night. His
teacher has complained that he seems inattentive and hyperactive, but his parents think he
is just a "high-energy" child. The father is obese and on CPAP for obstructive sleep
apnea, and his BMI is 20 kg/m2. Findings on physical examination are completely
unremarkable except for 2+ tonsillar hypertrophy and some mouth breathing.What is the
most appropriate next step in diagnosis?

A. Neuropsychological testing
B. Lateral soft tissue radiograph of the neck
C. CT study of the upper airway
D. Diagnostic testing for obstructive sleep apnea
Explanation: Although all of these are useful, at some point it is most wise to
perform dynamic testing for obstructive sleep apnea in a sleep laboratory.(See
Chapter 369 in Nelson Textbook of Pediatrics, 17th ed.)
E. ECG and echocardiogram

The Respiratory System Nelson Self Assessments website 17th Edition 6

Question . 17. A 10-yr-old African-American boy is referred to you by the school
psychologist for medical management of suspected ADHD because of inattention,
behavior problems, and poor school performance. He goes to bed at 10:30 P.M. and falls
asleep immediately. His brother will no longer share a room with him because of loud
snoring. It is difficult for his parents to wake him for school in the morning at 7:00 A.M.
He reports that he struggles to stay awake and pay attention during the day. He usually
naps for 1-2 hr after school, but not in school. On the weekends, he stays up until
midnight and sleeps until 9:00 A.M. He denies sudden losses of muscle tone, dreaming
during the day, or sleep paralysis. Findings on physical examination are remarkable for a
BMI of 30 kg/m2 and 3+ tonsillar hypertrophy. Which of the following is the most likely
diagnosis?

A. Insufficient sleep
B. Delayed sleep phase syndrome
C. Obstructive sleep apnea syndrome
Explanation: His snoring, BMI, and tonsillar hypertrophy strongly suggest
obstructive sleep apnea.It would be interesting if in addition to snoring the family
noted pauses between his noisy sleep-related breathing.(See Chapter 369 in
Nelson Textbook of Pediatrics, 17th ed.)
D. Narcolepsy
E. Idiopathic hypersomnia

Question . 18. You receive a follow-up note from your community cardiology colleague
that a mutual patient, a 7-yr-old boy with trisomy 21, has new findings of pulmonary
hypertension. The child had a VSD that spontaneously closed by age 2 yr. His room air
pulse oximetry value is 98%. The second heart sound is loud and the intensity of the P2
component is increased. ECG shows normal sinus rhythm and right ventricular
hypertrophy. Echocardiogram shows normal intracardiac anatomy with no evidence of a
PDA, but there is mild tricuspid regurgitation with an increased jet velocity across the
tricuspid valve. The heart size was normal on x-ray study. Your colleague is planning a
cardiac catheterization to assess the nature and severity of the pulmonary hypertension.
He also orders thyroid function studies.You see the child in your office for a pre-
catheterization general health assessment. The child, who is usually very cooperative, is
sleepy and irritable. You note prominent mouth breathing, 3+ tonsillar hypertrophy, and a
prominent pectus deformity.What is the most appropriate next step in management?

A. Check pre-catheterization hemoglobin level, hematocrit, electrolytes, and clotting

factors
B. Request diagnostic studies for obstructive sleep apnea
Explanation: Children with trisomy 21 have an increased risk for obstructive sleep
apnea.In this case, the pulmonary hypertension is not due to cardiac problems but
is most likely to be due to prolonged hypoxia and hypercarbia during sleep.(See
Chapter 362 in Nelson Textbook of Pediatrics, 17th ed.)
C. Order a lateral soft tissue radiograph of the neck
D. Order an MRI study of the upper airway
E. Start the child on steroids to shrink the enlarged tonsils

The Respiratory System Nelson Self Assessments website 17th Edition 7

Question . 19. Nosebleeds are commonly associated with all of the following except:

A. Digital trauma
B. Menstruation
Explanation: The five most common causes of epistaxis are on your hand (the
fingers!).Menstruation-related epistaxis is extremely uncommon. With severe
recurrent non-infection-related epistaxis, the child may have a coagulopathy such
as von Willebrand disease.(See Chapter 362 in Nelson Pediatrics, 17th ed.)
C. Family history of epistaxis
D. Sinus infections
E. Dry winter air

Question . 20. Nosebleeds in children most commonly arise from

A. Turbinates
B. Nasopharynx
C. Posterior septum
D. Kiesselbach's plexus (anterior septum)
Explanation: This is an easily reachable area that is easily irritated by picking or
inflammation.(See Chapter 362 in Nelson Textbook of Pediatrics, 17th ed.)
E. Maxillary sinus

Question . 21. When a disk battery is seen as a foreign body in the nose of a child, which
of the following is the most important consideration in management?

A. The patient should be referred electively to a specialist for removal

B. It may leak and cause local tissue damage
Explanation: These are particularly dangerous because of the risk of a chemical
burn or pressure necrosis in a small space and because attempts to remove them
could actually push them from the anterior space to the more distal posterior
space.Immediate removal is indicated.(See Chapter 362 in Nelson, 17th ed.)
C. The parents should remove it immediately
D. Nose drops should be given until it can be removed
E. Removal may be simply done in the office

Question . 22. Nasal polyps in children are:

A. Never found to arise in the ethmoid sinus

B. Common in infancy
C. Seen only in children with cystic fibrosis
D. Associated with allergic rhinitis
Explanation: Although cystic fibrosis is a common cause of nasal polyps,
especially in children younger than 12 yr, it is also seen with other conditions
such as allergies.(See Chapter 363 in Nelson Textbook of Pediatrics, 17th ed.)
E. Hard to distinguish from nasal turbinates

The Respiratory System Nelson Self Assessments website 17th Edition 8

Question . 23. The paranasal sinuses in children:

A. Are all present at birth

B. Develop during the teenage years
C. Grow and develop during the first seven years of life
Explanation: Some sinuses are present at birth, whereas others develop after
birth.Aeration as seen on x-ray may occur after sinus formation.(See Chapter 365
in Nelson Textbook of Pediatrics, 17th ed.)
D. Easily visualized on plain radiographs
E. Are unlikely to be infected before the age of 12 yr

Question . 24. An 18-mo-old girl has a 2-day history of rhinorrhea, pharyngitis, and low-
grade fever. During the night, she wakes with a barky cough, hoarseness, and inspiratory
stridor. Which of the following is the most likely etiologic agent?

A. Influenza virus type A

B. Respiratory syncytial virus
C. Parainfluenza virus
Explanation: This is the classic presentation of croup.Involvement of the vocal
cords (laryngitis in adults) is most often due to parainfluenza virus but may also
be due to any of these pathogens.(See Chapter 371 in Nelson Textbook of
Pediatrics, 17th ed.)
D. Adenovirus
E. Mycoplasma pneumoniae

Question . 25. A 2-yr-old boy is presented to the emergency department at 3 A.M. with a
chief complaint of fever and cough. His respiratory rate is 36/min, his temperature is
39oC, and his pulse oximetry reading is 96%. On physical examination he has a barky
cough and stridor only with crying. He is well hydrated, able to drink, and consolable.
What is the appropriate next step in patient management?

A. Nasal washing for influenza virus and respiratory syncytial virus

B. Lateral radiograph of the neck
C. Nebulized racemic epinephrine
D. Complete blood count and blood culture
E. Dose of dexamethasone
Explanation: In this patient with croup and manifesting stridor only with crying,
dexamethasone is indicated.If there were stridor at rest, racemic epinephrine and
dexamethasone would be indicated. (See Chapter 371 in Nelson Textbook of
Pediatrics, 17th ed.)

The Respiratory System Nelson Self Assessments website 17th Edition 9

Question . 26. You are the pediatric consultant for a community emergency department.
The department's physician calls to ask advice about a 3-yr-old boy with fever and a
cough. He thinks the patient has croup but is also concerned about epiglottitis. Which of
the following physical findings is most helpful in attempting to differentiate croup from
epiglottitis?
A. Fever
B. Barky cough
Explanation: In an unimmunized child, epiglottitis usually manifests with high
fever, toxicity, air hunger, and drooling but without a barking cough.Epiglottitis is
uncommon in children immunized against H. influenzae type b, and if it occurs, it
does so in unimmunized children or those with an unusual bacterial etiology. (See
Chapter 370 in Nelson Textbook of Pediatrics, 17th ed.)
C. Stridor
D. Drooling
E. Respiratory distress

Question . 27. You are a primary pediatrician in an office where a third-year medical
student is doing her clerkship. You have just seen the fifth patient that day with a classic
clinical presentation for croup: barky cough, fever, and stridor when agitated. You once
again prescribe dexamethasone. The third-year medical student asks about the data for
the use of steroids in croup. Which of the following has not been demonstrated in studies
of the use of steroids in croup?

A. Shorter hospitalization
B. Decreased need for subsequent medical interventions
C. Oral dexamethasone is as effective as intramuscular administration
D. Decreased need for oxygen
Explanation: Dexamethasone has been quite effective in the management of
children with mild to moderate croup.Its efficacy in reducing the need for oxygen
in more severely affected children has not been demonstrated.(See Chapter 371)
E. Reduced hospitalization

Question . 28. A 4-yr-old boy presents with sore throat and fever of sudden onset. He has
difficulty swallowing and his breathing is labored. He is drooling and sitting upright and
leaning forward in a tripod position. What is the appropriate next step in patient
management?
A. Complete blood count and blood culture followed by immediate prophylactic
intravenous antibiotics
B. Lateral radiograph of the neck
C. Dose of oral dexamethasone
D. Direct laryngoscopy in the operating room
Explanation: This is the classic presentation for epiglottitis. Although this
disorder is uncommon in the era of immunization against H. influenzae type b,
physicians must be aware of this dangerous disease with its requirement for
immediate airway protection.(See Chapter 371 in NelsonPediatrics, 17th ed.)
E. Complete physical examination including inspection of the oral cavity

The Respiratory System Nelson Self Assessments website 17th Edition 10

Question . 29. A 2-yr-old girl had an upper respiratory tract infection approximately 5-7
days ago. She had a low-grade fever, cough, and rhinorrhea. She did not require any
medical intervention. She appeared to be improving; now, however, she has a high fever
and brassy cough. On physical examination she is toxic-appearing with a fever of 39.8oC.
She can lie flat; she does not drool and has no dysphagia, but does have some evidence of
respiratory distress with increased work of breathing and retractions. On auscultation her
lungs are clear bilaterally. Which of the following is the most appropriate antibiotic for
this condition?

A. Erythromycin
B. Ciprofloxacin
C. Ampicillin
D. Gentamicin
E. Nafcillin
Explanation: This child has bacterial tracheitis as a complication of a previous
viral respiratory tract infection.The most likely bacterial organism is
Staphylococcus aureus, although other organisms may be responsible.Some
physicians might use ceftriaxone to cover these pathogens.(See Chapter 371 in
Nelson Textbook of Pediatrics, 17th ed.)

Question . 30. A 2-yr-old girl has had symptoms of an upper respiratory infection for 1
week. Over the past 24 hours, fever and tachypnea developed, with worsening cough and
increased work of breathing. She has a temperature of 39.1o C, a respiratory rate of
40/min, and mild to moderate intercostal retractions. Oxygen saturation is 94-95%. Her
examination reveals diffuse wheezing, inspiratory rhonchi, and crackles in the right
anterolateral chest. Chest film shows a shaggy right heart border, generalized
hyperinflation, and peribronchial cuffing. White blood cell count is 18,000/mm3with
70% granulocytes.Of the following, which is the most appropriate next step in diagnosis?

A. Sputum culture
B. Lung puncture
C. Blood culture
Explanation: The child has bacterial pneumonia.A child this young usually does
not produce sputum or require a lung puncture.A blood culture is quite
appropriate.Viral PCR assay may be better than a viral culture. (See Chapter 379
in Nelson Textbook of Pediatrics, 17th ed.)
D. Viral culture
E. Cold agglutinins titer

The Respiratory System Nelson Self Assessments website 17th Edition 11

Question . 31. Outpatient management of the patient described in Question 30 is
considered in view of the patient's clinical status. Clinical features suggest a bacterial
pneumonia. Which of the following is the most appropriate treatment option?

A. Penicillin PO
B. Cefixime PO
C. Erythromycin PO
D. Cephalexin PO
E. Amoxicillin PO
Explanation: High-dose oral amoxicillin will be effective against most
pneumococci.With highly resistant pneumococci, treatment with intravenous
vancomycin is necessary.(See Chapter 379 in Nelson Pediatrics, 17th ed.)

Question . 32. A previously healthy 12-yr-old boy presents with upper respiratory
symptoms of 8 days' duration, with worsening cough and fever. The season is autumn.
Examination reveals a temperature of 39C, a respiratory rate of 24/min, and inspiratory
crackles in both lung fields. Oxygen saturation is 93-94%. Chest film shows scattered
infiltrates in multiple lung fields, more focal consolidation in the right lower lobe, and
blunting of the right costophrenic angle. White blood cell count is 11,000/mm3 with a
normal differential.Which of the following is the most appropriate next step in diagnosis?

A. Sputum culture
B. Tuberculin skin testing
C. Throat culture
D. Cold agglutinins titer
Explanation: It is likely that this patient has Mycoplasma pneumonia.More
effective diagnostic tests include Mycoplasma PCR and IgM assays.(See Chapter
379 in Nelson Textbook of Pediatrics, 17th ed.)
E. Erythrocyte sedimentation rate

Question . 33. Which of the following is the most appropriate next step in the
management of the patient described in Question 32?

A. Erythromycin PO
Explanation: Erythromycin or azithromycin is quite effective in improving the
clinical course of Mycoplasma pneumonia. (See Chapter 379 in Nelson Textbook
of Pediatrics, 17th ed.)
B. Amoxicillin PO
C. No antibiotic therapy
D. Ceftriaxone IM
E. Cefuroxime IV

The Respiratory System Nelson Self Assessments website 17th Edition 12

Question . 34. A 4-yr-old boy has had rhinorrhea and cough for 4 days, with fever,
worsening cough, and chest discomfort over the past 2 days. His temperature is 40.1oC,
respiratory rate is 28/min, and oxygen saturation is 88%. Examination reveals splinting,
decreased breath sounds, and dullness to percussion over the right posterior chest, with
crackles heard over the right upper posterior chest. His white blood cell count is 30,000/mm3
with a predominance of granulocytes. Chest film shows opacification of the right hemithorax.
A right lateral decubitus film of the chest reveals significant pleural fluid.Which of the
following is the most appropriate next step in diagnosis and management?

A. Tube thoracostomy drainage

Explanation: Thoracentesis is of value both as a diagnostic aid and as a
therapeutic procedure.This patient obviously had a symptomatic effusion and
improved dramatically after withdrawal of 700 mL of cloudy fluid.(See Chapter
379 in Nelson Textbook of Pediatrics, 17th ed.)
B. Bronchoscopy
C. Sputum culture
D. Nasopharyngeal swabs for viral antigens
E. Cold agglutinins titer

Question . 35. Gram stain of the pleural fluid from the patient described in Question 34
reveals gram-positive cocci in clusters.Which of the following is the most appropriate
treatment?

A. Ampicillin IV
B. Cefuroxime IV
C. Erythromycin IV
D. Erythromycin and ampicillin IV
E. Cefotaxime and vancomycin IV
Explanation: The child probably has pneumococcal pneumonia.It could be
pneumonia due to S. aureus, but there are no pneumatoceles.The pneumococcus is
becoming resistant to penicillins and even to cephalosporins.If it is a life-
threatening illness, vancomycin should be added. (See Chapter 379 in Nelson)

Question . 36. A 7-yr-old child with a 3-yr history of cough, intermittent wheezing, and
poor growth has two sweat chloride values of 36 and 41 mEq/liter. Additional diagnostic
testing to rule out cystic fibrosis should include:

A. CT imaging of the chest

B. Nasal potential difference measurement
Explanation: This is a useful test that has abnormal results in CF. Today's DNA
testing for the many (in the hundreds) of mutations in the CFTR gene is available
and is of great value in equivocal test results.(See Chapter 402 in)
C. Fat balance measurement (72-hr stool collection)
D. DNA analysis for the F508 mutation
E. Sweat chloride analysis in siblings

The Respiratory System Nelson Self Assessments website 17th Edition 13

 Question . 37. A 12-yr-old child with confirmed cystic fibrosis has experienced
cramping abdominal pain intermittently for the past 8 days. The pain is diffuse and
unrelated to eating and is not attended by guarding or rebound. The patient denies emesis
or diarrhea. The most likely cause of the abdominal pain is:

A. Intussusception
B. Peritonitis
C. Pancreatitis
D. Distal intestinal obstruction syndrome (DIOS)
Explanation: DIOS, also called meconium ileus equivalent, is an obstruction due
to impacted stool.If the patient has been receiving high-dose pancreatic enzymes,
a fibrosing colonopathy must also be considered. (See Chapter 402 in Nelson)
E. Cholecystitis

Question . 38. A newborn infant fails to pass meconium for the first 48 hr. Abdominal
distention and emesis have occurred overnight. The next diagnostic steps would include:

A. Sweat chloride assay

B. Genotyping the child for CF
C. Contrast imaging of the lower gastrointestinal tract
Explanation: The examination will look for a meconium plug or a small left colon
(which suggests proximal intestinal obstruction as in atresias).In both examples,
CF must be considered.If Hirschsprung disease is considered, a suction biopsy
should also be performed.(See Chapter 402 in Nelson Pediatrics, 17th ed.)
D. Manometry
E. Serum immunoreactive trypsin assay

Question . 39. A 3.5-kg male infant born at term after an uncomplicated pregnancy and
delivery develops respiratory distress shortly after birth and requires mechanical
ventilation. The chest radiograph reveals a normal cardiothymic silhouette but a diffuse
ground-glass appearance to the lung fields. Surfactant replacement fails to improve gas
exchange. Over the first week of life, the hypoxemia worsens. Results of routine cultures
and echocardiographic findings are negative. A term female sibling died at 1 mo of age
with "respiratory distress."Which of the following is the most likely diagnosis?

A. Total anomalous pulmonary venous return

B. Meconium aspiration
C. Neonatal pulmonary alveolar proteinosis
Explanation: RDS in a term infant not responding to surfactant replacement
therapy is most likely to represent neonatal pulmonary alveolar proteinosis.(See
Chapter 389 in Nelson Textbook of Pediatrics, 17th ed.)
D. Disseminated herpes simplex infection
E. Medium-chain acyl-dehydrogenase deficiency

The Respiratory System Nelson Self Assessments website 17th Edition 14

Question . 40. Which of the following laboratory evaluations should be obtained in the
case in Question 39?

A. Blood and tracheal cultures for virus and yeast

B. Repeat echocardiogram
C. RFLP analysis of the SP-B gene
Explanation: Neonatal alveolar proteinosis is due to a genetic mutation causing a
deficiency of surfactant protein B.(See Chapter 389 in Nelson Pediatrics, 17th ed.)
D. RFLP analysis of the MCAD gene
E. Urine organic acid screen

Question . 41. If the laboratory analysis confirms SP-B deficiency, what is the most
appropriate next step in management of the patient described in Question 39?

A. Obtain a lung biopsy

B. Begin inhaled nitric oxide
C. Discuss lung transplantation with the family
Explanation: ECMO is a temporizing bridge to lung transplantation, which
potentially can cure this disorder. (See Chapter 389 in Nelson Pediatrics, 17th ed.)
D. Administer surfactant
E. Begin corticosteroids

Question . 42. A 3.2-kg full-term female infant is delivered by vaginal delivery. She is
initially cyanotic and is in significant respiratory distress. Auscultation of the chest
reveals diminished breath sounds in the left hemithorax and a scaphoid abdomen. After
bag and mask ventilation, an endotracheal tube is placed. The point of maximal impulse
(PMI) is shifted to the right side of the chest.The most important initial intervention is:

A. Immediate bronchoscopy
B. Placement of a nasogastric tube
Explanation: This patient potentially has a diaphragmatic hernia and needs gas to
be removed or prevented from entering the bowel, which acts as a space-
occupying lesion in the chest.(See Chapter 370 in Nelson Textbook of Pediatrics,
17th ed.)
C. A chest radiograph to assess placement of endotracheal tube
D. Immediate surgery
E. Administration of epinephrine

The Respiratory System Nelson Self Assessments website 17th Edition 15

Question . 43. A 14-yr-old boy with a pectus excavatum deformity presents for
evaluation. He denies any exercise intolerance or cough but does experience intermittent
wheezing on exertion. He states he is not concerned about how his chest appears.
Physical examination reveals a mild pectus deformity. Which of the following
abnormalities on diagnostic work-up suggests the need for surgical correction?

A. FEV1/FVC ratio of 0.60 on spirometry

B. A Wolff-Parkinson-White pattern on ECG
C. Low ventilatory reserves during a maximal exercise test
D. A total lung capacity of 80% of predicted
E. A peak work capacity of 60% of predicted
Explanation: Many children with a pectus excavatum do not need surgery
according to results of work capacity studies.(See Chapter 410 in Nelson 17th ed.)

Question . 44. A 15-yr-old boy with thoracic scoliosis undergoes evaluation for surgery.
History is unremarkable, and findings on physical examination are normal except for a
mild thoracic scoliosis. A Cobb angle of 25 degrees is noted on the chest radiograph. His
vital capacity is 80% of predicted, and his exercise tolerance is minimally reduced.What
is the most appropriate next step in treatment of this patient?

A. Repeat assessment in 6 mo
Explanation: Depending on where he is in his puberty growth spurt, the curve
may not change, or if he continues to grow, the curve may worsen.(See Chapter
410 in Nelson Textbook of Pediatrics, 17th ed.)
B. Reassurance that surgery will not be required
C. Spinal fusion surgery
D. Bone density assessment (DEA scan)
E. Physical therapy to correct scoliosis

Question . 45. A 7-yr-old girl presents with a history of low-grade fever, nonproductive
cough, and mild dyspnea. After treatment with an oral antibiotic, the child began to show
some signs of improvement. However, the child subsequently experienced increasing
dyspnea, a productive cough, and wheezing. A chest radiograph demonstrates
hyperlucency. Spirometry shows a severe obstructive pattern. The most likely diagnosis is:

A. Pulmonary alveolar microlithiasis

B. Wilson-Mikity syndrome
C. Follicular bronchitis
D. Bronchiolitis obliterans
Explanation: Bronchiolitis obliterans may follow a viral bronchitis or
pneumonia.Measles virus and adenovirus may be potential agents.(See Chapter
378 in Nelson Textbook of Pediatrics, 17th ed.)
E. Postviral syndrome

The Respiratory System Nelson Self Assessments website 17th Edition 16

 Question . 46. A 3-yr-old boy has been coughing daily for 2 mo. The cough is
nonproductive and occurs during sleep in the early morning hours as well as during the
day, particularly when the child is active. On physical examination both height and
weight are in the 50-75th percentile, and chest examination is unremarkable. There is no
evidence of digital clubbing. A chest roentgenogram is interpreted as normal. The
diagnostic procedure most likely to ascertain the cause is:

A. Sputum cytology and culture

B. Sweat chloride testing
C. Bronchoscopy
D. Complete blood count
E. Trial of bronchodilator therapy
Explanation: This is a common pattern seen in some children with
asthma.Bronchitis in children is often an incorrect diagnosis, as many children are
later found to have asthma.(See Chapter 376 in Nelson Pediatrics, 17th ed.)

Question . 47. A previously healthy 2-yr-old girl is given oral antibiotic therapy for a
cough, fever, and patchy consolidation of the right lower lobe. No crackles are heard on
chest auscultation. The fever abates, the cough improves, but a follow-up chest film at 8
wk demonstrates even more dense consolidation involving the right lower lobe. Next
steps in the evaluation should include:

A. Bronchoscopy
Explanation: This child could have many problems such as a foreign body, but the
clinical picture is highly suggestive of a sequestration.If a pulmonary
sequestration is found, Doppler flow studies of the artery supplying the
sequestration will show the artery coming from the aorta.(See Chapter 370 in
Nelson Textbook of Pediatrics, 17th ed.)
B. Bacterial culture of the nasopharynx
C. Barium esophagram
D. Allergy skin testing
E. Lung biopsy

Question . 48. For the mechanically ventilated child, which medical condition is most
often associated with successful wean off all ventilatory support?

A. Central hypoventilation
B. Bronchopulmonary dysplasia
Explanation: Children with BPD usually are successfully weaned.The others in
choices A and C often become dependent on their ventilator.(See Chapter 411 in
Nelson Textbook of Pediatrics, 17th ed.)
C. Spinal muscular atrophy
D. None of the above

The Respiratory System Nelson Self Assessments website 17th Edition 17

Question . 49. All of the following may present a barrier to home discharge on a
ventilator except:

A. Lack of appropriate housing

B. Lack of committed caregivers
C. Lack of private insurance
Explanation: Communication and being able to provide constant care are keys to
home ventilator management.Insurance status could be private or public.(See
Chapter 411 in Nelson Textbook of Pediatrics, 17th ed.)
D. Lack of telephone

Question . 50. A 2-yr-old boy undergoing outpatient surgery for tonsillectomy vomits
while recovering from general anesthesia in the postoperative recovery area. Within 1-2
min he develops tachypnea, chest retractions, and hypoxemia. Which of the following is
the most likely explanation for these findings?

A. Acute blood loss from postoperative bleeding

B. Anesthetic reaction
C. Bacterial infection and toxin release
D. Acute airway obstruction from aspirated material
Explanation: Acutely after an aspiration there is a mechanical obstruction with
irritation, which can cause bronchospasm.Later a chemical pneumonia and
possibly bacterial infection may supervene.(See Chapter 380 in Nelson Textbook
of Pediatrics, 17th ed.)
E. Atelectasis

Question . 51. Of the following diagnostic tests, the most sensitive for detecting recurrent
airway aspiration is:

A. Upper gastrointestinal series

B. Modified barium swallow with video fluoroscopy
Explanation: This dynamic study will often demonstrate aspiration during
swallowing but may not show aspiration from emesis or reflux.(See Chapter 380
in Nelson Textbook of Pediatrics, 17th ed.)
C. A gastroesophageal radionuclide scintiscan
D. Chest CT scan
E. Bronchoscopy

The Respiratory System Nelson Self Assessments website 17th Edition 18

Question . 52. A 4-wk-old healthy-appearing term infant is evaluated in the office for
stridor, which has persisted since birth. The noisy breathing is accompanied by moderate
signs of inspiratory obstruction including suprasternal and subcostal retractions. He feeds
adequately and is gaining weight but frequently spits up. The most likely cause of his
symptoms is:

A. Tracheomalacia
B. Vascular ring
C. Laryngomalacia
Explanation: Laryngomalacia is common and often produces noisy breathing that
worsens with viral upper respiratory tract infections or in the supine position.(See
Chapter 370 in Nelson Textbook of Pediatrics, 17th ed.)
D. Tonsil and adenoid hypertrophy
E. Subglottic hemangioma

Question . 53. A 3-mo-old infant has had progressively worsening biphasic stridor. Her
parents report two brief episodes of croup. A 1-cm-diameter hemangioma is present on
her right thigh. Airway radiographs are most likely to show:

A. Asymmetric subglottic narrowing

Explanation: Airway hemangiomas may produce stridor and crouplike symptoms
with viral upper respiratory tract infections.Facial hemangiomas distributed in a
"beard pattern" carry the highest risk for an associated airway
hemangioma.Airway lesions may also occur in the absence of any cutaneous
lesions.(See Chapter 375 in Nelson Textbook of Pediatrics, 17th ed.)
B. Gastroesophageal reflux
C. Enlarged adenoids
D. Tracheomalacia
E. Laryngeal cyst

Question . 54. The most common bronchial foreign body is:

A. Raw carrot fragments

B. Popcorn
C. Nut fragments, particularly peanuts
Explanation: Anything small enough can get into the bronchus."Small" is relative
to the size of the bronchus and is thus age dependent.Nuts, sunflower seeds, and
the like should not be given to small children.(See Chapter 372 in Nelson
Textbook of Pediatrics, 17th ed.)
D. Nails
E. Coins

The Respiratory System Nelson Self Assessments website 17th Edition 19

Question . 55. A 6-mo-old boy presents with biphasic stridor and a recent episode of
croup. He has had minimal response to bronchodilator therapy. His past history reveals
that he was a premature infant who was intubated and ventilated for 6 wk. The most
likely cause of his respiratory distress is:

A. Acquired subglottic stenosis

Explanation: Subglottic stenosis may be congenital or acquired. Direct
laryngoscopy will confirm the diagnosis.(See Chapter 373 in Nelson Textbook of
Pediatrics, 17th ed.)
B. Vascular ring
C. Viral laryngotracheobronchitis
D. Reactive airways disease/chronic lung disease
E. Reflux laryngitis

Question . 56. A 4-yr-old boy with a history of tracheoesophageal fistula (TEF) repair at
birth is evaluated for a chronic cough. The cough has persisted since he was discharged
from the hospital after his TEF repair. The cough is dry and barking and occasionally
associated with expiratory wheezing. The most likely cause of the chronic cough is:

A. Cough-variant asthma
B. Sinusitis
C. Tracheomalacia
Explanation: Tracheomalacia is very common after a TEF repair.Some patients
also develop reactive airways and reflux.(See Chapter 370 in Nelson Textbook of
Pediatrics, 17th ed.)
D. Gastroesophageal reflux
E. Subglottic stenosis

Question . 57. A 4-yr-old boy with two older sisters is evaluated for symptoms of
chronic hoarseness and strained voice, which has been present for several months. The
hoarseness is worse in the evening and lessens in the morning. He has no symptoms of
airway obstruction. The most likely cause of his symptoms is:

A. Laryngopharyngeal reflux with reflux laryngitis

B. Recurrent respiratory papillomatosis
C. A malignant laryngeal neoplasm
D. A congenital laryngeal cyst
E. Vocal nodules (screamer's nodes)
Explanation: Chronic hoarseness or deepness of the voice that is exacerbated with
talking, singing, or crying is common.Treatment is symptomatic; no surgery is
needed.(See Chapter 375 in Nelson Textbook of Pediatrics, 17th ed.)

The Respiratory System Nelson Self Assessments website 17th Edition 20

Question . 58. A 23-mo-old male infant with mild eczema is presented for evaluation of
recurrent wheezing episodes. His mother reports that he developed recurrent wheezing
with colds following acute RSV infection at age 6 mo for which he was hospitalized and
received oxygen by nasal cannula and nebulizer treatments. This was his only
hospitalization, but he has been seen on several occasions in the emergency department
of their local hospital. She adds that there are no pets in the home and that his father does
smoke, but always outside. She herself has moderate asthma and mild seasonal allergies
and would like to know if this means her son will have asthma also. You inform the
child's mother that her son may be at risk for persistent wheezing.Which of the following
is not a risk factor for the persistent wheezing phenotype in this infant?

A. Passive smoke exposure

B. Maternal history of asthma
C. Maternal history of allergies
Explanation: Drug or food allergies in themselves are not a risk factor for
asthma.(See Chapter 376 in Nelson Textbook of Pediatrics, 17th ed.)
D. Mild eczema
E. Recurrent episodes of wheezing

Question . 59. An 11-mo-old infant is admitted to the hospital in December because of

failure to thrive and recurrent pneumonia. Within 24 hr of his hospitalization, he develops
progressive clear nasal drainage, mild respiratory distress with a respiratory rate of
48/min, intercostal retractions, and diffuse wheezing throughout the lung fields. His
oxygen saturation is 88% on room air. His parents state that his 4-yr-old sibling has had
cold symptoms for about 4 days.What is the most appropriate next step in the acute
treatment of this patient?

A. Trial of nebulized albuterol

B. Oxygen supplementation via nasal cannula
Explanation: Any previously well patient who becomes hypoxic and is in
respiratory distress must be given warmed, humidified oxygen regardless of the
diagnosis.(See Chapter 359 in Nelson Textbook of Pediatrics, 17th ed.)
C. Nasopharyngeal wash for RSV antigen and viral culture
D. A sweat chloride test
E. A 2-mg/kg load of oral corticosteroids, then 1 mg/kg twice daily for 5 days

Question . 60. An 8-yr-old boy presents with a 24-hr history of fever, chills, cough,
dyspnea, and malaise. Examination reveals an ill-appearing child who is mildly
tachypneic with bibasilar crackles. There are no ill contacts; however, he did help his
grandmother clean her pigeon coop the day before presentation.The diagnosis of
hypersensitivity pneumonitis would be based primarily on:

A. Chest radiograph and complete blood count

B. Pulmonary function tests
C. A high index of suspicion based on the clinical presentation in association with a
suspected exposure

The Respiratory System Nelson Self Assessments website 17th Edition 21

 Explanation: The history and clinical course are the key, especially if the patient
gets better every time he or she is removed from the antigen (e.g., on weekends
for factory workers).(See Chapter 383 in Nelson Textbook of Pediatrics, 17th ed.)
D. Flexible fiberoptic bronchoscopy with bronchoalveolar lavage
E. Skin testing and serum precipitins to the suspected antigen

Question . 61. A 17-yr-old boy previously well presents with a history of cough and
dyspnea 24 hr after working in a corn silo. Examination reveals a normal-appearing
young man who is mildly tachypneic with normal findings on lung auscultation. There
are no ill contacts. Silo filler's disease is typically a result of:

A. Carbon monoxide poisoning

B. Hydrocarbon toxicity
C. Ammonia toxicity
D. Nitrogen dioxide toxicity
Explanation: Inhaled chemical or gaseous agents produce airway
inflammation.Silo filler's disease results from fermentation and gas production in
a closed space.(See Chapter 383 in Nelson Textbook of Pediatrics, 17th ed.)
E. Cyanide toxicity

Question . 62. A 16-yr-old boy attempted suicide by ingesting the herbicide

paraquat.Which of the following is the most ominous prognostic indicator?

A. Ingestion of dilute solution

B. Ingestion of 40 mg of paraquat per kg of body weight
Explanation: The dose is the most important.Smoking this agent when it is used as
a herbicide is also toxic.(See Chapter 384 in Nelson Text Pediatrics, 17th ed.)
C. Complaint of vomiting and diarrhea
D. Oxygen saturation of 91% on room air
E. Restrictive pattern on pulmonary function tests

Question . 63. A 6-yr-old girl presents with a 1-mo history of mild cough, intermittent
low-grade fever, intermittent wheezing, and an episode of hemoptysis. Pulse rate is
100/min; respiratory rate is 25/min; lung ausculation reveals diffuse end-expiratory
wheeze. Chest film shows nonspecific bilateral diffuse infiltrates. There is marked
peripheral eosinophilia on complete blood count.The most likely diagnosis is:

A. Pulmonary infiltrates with eosinophilia (L?ffler syndrome)

Explanation: This disorder has many potential causes, or it may be a primary
disease.Eosinophilia is a major clue!(See Chapter 384 in Nelson Textbook of
Pediatrics, 17th ed.)
B. Asthma
C. Cystic fibrosis
D. Mycoplasma pneumonia
E. Pulmonary lymphoma

The Respiratory System Nelson Self Assessments website 17th Edition 22

 Question . 64. A 4-yr-old previously well girl presents with fever (temperature of
103F), nonproductive cough, dyspnea, and left-sided chest pain. Initial examination
reveals an ill-appearing child; pulse rate is 125/min, respiratory rate is 40/min, and room
air oxygen saturation is 89%. Auscultation demonstrates decreased air movement on the
left side, with crackles. Chest radiograph shows a left lower lobe consolidation.CBC
reveals marked leukocytosis.The child was hospitalized and provided with supplemental
oxygen and started on high-dose IV cefuroxime.Two days later the child is still febrile
with a temperature of 102oF; respiratory rate is 35/min and room air oxygen saturation is
90%. Findings on lung examination and chest film are unchanged from admission.Which
of the following is the most appropriate next step?

A. Change antibiotics to IV ampicillin/sulbactam

B. Obtain chest CT scan
C. Add oral macrolide antibiotic
D. Send blood for an immune work-up
E. Begin IV vancomycin
Explanation: This child probably has a pneumococcal infection with resistant
organisms that has not responded to cefuroxime.(See Chapter 379 in )

Question . 65. A 15-yr-old boy presents with a history of chronic cough productive of
yellow-green sputum, dyspnea on exercise, digital clubbing, and poor weight gain. He
has a history of recurrent sinopulmonary infections. The patient is a thin-appearing young
man; his pulse rate is 95/min and respiratory rate is 24/min; auscultation of the lungs
demonstrates diffuse fine crackles and end-expiratory wheezing.The gold standard
technique for demonstrating bronchiectasis is:

A. Bronchoscopy with bronchoalveolar lavage

B. Ventilation-perfusion scan
C. Thin-section high-resolution CT scan of the chest
Explanation: CT scanning of the chest is the diagnostic test of choice to
demonstrate bronchiectasis.(See Chapter 396 in Nelson Pediatrics, 17th ed.)
D. Bronchography
E. Chest MRI study

Question . 66. A 6-yr-old girl presents 72 hr after undergoing a

tonsillectomy/adenoidectomy with fever, cough, dyspnea, and right-sided chest pain.
Examination reveals an ill-appearing child; her temperature is 104F, pulse rate 110/min,
and respiratory rate 40/min; her lungs have decreased air movement on the right, with
dullness to percussion. Complete blood count demonstrates marked leukocytosis with left
shift, and appearance on chest radiograph is consistent with a pulmonary abscess.Which
of the following is the most appropriate initial management?

A. Admit for IV antibiotics providing aerobic and anaerobic coverage

Explanation: Most lung abscesses are the result of aspiration and contain
anaerobic bacteria.They can usually be managed with high-dose antibiotics, with
no need for drainage.(See Chapter 397 in Nelson Textbook of Pediatrics, 17th ed.)

The Respiratory System Nelson Self Assessments website 17th Edition 23

 B. Arrange for percutaneous drainage in interventional radiology department
C. Prescribe oral macrolide antibiotic and follow-up evaluation within 24 hr
D. Arrange for thoracotomy and decortication
E. Arrange for bronchoscopic drainage of the abscess

Question . 67. A 3-yr-old child does well for the first 6 hr following surgery. Then
dyspnea and tachycardia develop, with rapid shallow respirations. On physical
examination the patient has decreased breath sounds and coarse rales on the right.Which
of the following is the most appropriate first step in treatment?

A. Chest tube placement

B. Intravenous antibiotics
C. Positive pressure ventilation
D. Fiberoptic bronchoscopy
E. Cough, deep breathing, and percussion
Explanation: This patient has atelectases and needs assistance to achieve good
inspiratory efforts, etc.Careful use of pain medications to control chest or
abdominal pain and to avoid oversedation is also valuable.(See Chapter 392 in
Nelson Textbook of Pediatrics, 17th ed.)

Question . 68. An 18-yr-old female patient presents with chest pain, tachypnea, and
cyanosis of sudden onset 1 wk after the birth of her first child. Her chest radiograph is
nondiagnostic, but her PaO2 is 60 mm Hg on 40% oxygen. The most likely diagnosis is:

A. Preeclampsia
B. Legionella pneumonia
C. A fractured rib
D. A pulmonary embolism
Explanation: Pulmonary embolism must be considered with the sudden onset of
chest pain, dyspnea, and cyanosis. A normal-appearing chest radiograph with
significant hypoxia is classic for pulmonary embolism. A spiral CT study is a
useful test to determine the presence of a pulmonary embolism. (See Chapter 395)
E. Hysterical hyperventilation

Question . 69. All of the following are gastrointestinal manifestations of cystic fibrosis
except:
A. Intussusception
B. Appendicitis
C. Colonic mucosal thickening
D. Gastric outlet obstruction
Explanation: Other causes of intestinal obstruction are possible and include
neonatal meconium ileus, congenital ileal atresia, neonatal mucus plus syndrome,
meconium ileus equivalent (from insufficient use of pancreatic enzyme
replacement), intussusception, inguinal hernia, and appendiceal obstruction. (See
Chapter 402 in Nelson Textbook of Pediatrics, 17th ed.)
E. Inguinal hernias

The Respiratory System Nelson Self Assessments website 17th Edition 24

Question . 70. All of the following statements regarding cystic fibrosis are true except:

A. Incidence of 1 case per 3,500 black and 1 case per 17,000 white infants
Explanation: The incidence of cystic fibrosis is highest in northern European
whites (1 in 3500) and lowest in Asian infants in Hawaii (1 in 90,000). (See
Chapter 402 in Nelson Textbook of Pediatrics, 17th ed.)
B. Autosomal recessive inheritance
C. More than 700 gene mutations
D. F508 as the dominant mutation
E. WI282X mutation in 60% of Ashkenazi Jews
F. Severity of lung disease is not predictable by the gene mutation

Question . 71. The most common manifestation of preliminary involvement in children

with cystic fibrosis is:

A. Cyanosis
B. Clubbing
C. Cough
Explanation: The cough begins as dry and nonproductive but progresses to loose
with production of purulent sputum. (See Chapter 402 in Nelson Textbook of
Pediatrics, 17th ed.)
D. Wheezing
E. Nasal polyps

The Respiratory System Nelson Self Assessments website 17th Edition 25