Facts read from pncb.org and 1 more · last checked Nov 7, 2026
60 questions across newborn, child and adolescent visits, split the way PNCB splits its scored items. Every option is explained, the three wrong ones included.
Figure 1.Test content outline: 150 scored questions, one mark each
IV. Leadership, Ethics, and Practice Management8 Q · 5%
How this set is weighted
The set follows the outline's shares: 21 assessment and diagnosis, 18 health maintenance, 18 management and 3 on leadership, ethics and practice management, matching 35%, 30%, 30% and 5%. No question here also appears on a section page. Like PNCB's items, every question has four lettered choices and one best answer.
60 questions, all four areas
0 / 60 answered60 questions
Tap an option: why each one is right or wrong appears under it.
Assessment and Diagnosis · 35%
A 4-year-old's parents report that the child's feet turn in when running and that the child often sits in a 'W' position. The kneecaps point inward when standing, hip internal rotation is 80°, and external rotation is 20°. The MOST LIKELY cause is:
Metatarsus adductus is a curved forefoot seen in infancy; it does not change hip rotation or kneecap direction.
Tibial torsion is the usual cause of in-toeing in toddlers; the kneecaps face forward and the thigh-foot angle turns inward, with normal hip rotation.
Hip dysplasia limits abduction and causes a limp or leg-length difference, not increased internal rotation with W-sitting.
In-toeing after age 3 with inward-pointing kneecaps, W-sitting, and hip internal rotation far greater than external rotation is increased femoral anteversion, which usually corrects with growth.
A 24-month-old says about 15 single words and uses no two-word phrases. The toddler follows simple commands, points to show interest, and has good eye contact. Which is the MOST appropriate next step?
About 15 words and no two-word phrases at 24 months is an expressive language delay, so hearing is tested and a speech-language evaluation (with early intervention referral) is arranged now.
Waiting six months to recheck delays both the hearing test and therapy for a delay that is already present.
Many late talkers do catch up, but it cannot be predicted for an individual child, and reassurance gives up the most responsive period for therapy.
Pointing to share interest, good eye contact, and following commands make autism less likely; an isolated expressive delay is evaluated for hearing and speech first.
A 7-year-old girl's height has fallen from the 25th to the 3rd percentile over 3 years. She has a broad chest with widely spaced nipples, a low posterior hairline, and had puffy hands and feet as a newborn. Which test should be obtained to establish the diagnosis?
Falling height percentiles with a broad shield chest, low posterior hairline, and puffy hands and feet as a newborn suggest Turner syndrome, which a karyotype confirms.
GH stimulation testing looks for growth hormone deficiency and would not identify the chromosomal cause suggested by these features.
A bone age helps judge remaining growth potential but does not establish any diagnosis.
IGF-1 screens for GH deficiency; girls with Turner syndrome often have normal levels, so it would mislead.
A 3-year-old boy who walked at 18 months falls often, climbs stairs one step at a time holding the rail, and uses his hands on his thighs to rise from the floor. His calves appear enlarged. Which test should be obtained FIRST?
Late walking, frequent falls, climbing stairs one step at a time, a Gowers sign, and calf pseudohypertrophy in a boy suggest Duchenne dystrophy; a markedly raised creatine kinase is the first test, then genetic testing.
Brain imaging is for central causes with upper motor neuron signs, not for proximal weakness with a Gowers sign.
Hypothyroidism can raise CK and cause weakness, but it does not produce calf pseudohypertrophy in a boy with this pattern.
Nerve conduction studies evaluate neuropathy; in a myopathy they are normal and do not come first.
A 6-year-old has headaches 2 to 3 times a week for a month, lasting about an hour and relieved by rest, with no vomiting or nighttime waking. Which part of the physical examination is MOST important in deciding whether brain imaging is needed?
Blood pressure belongs in every headache exam, but hypertension leads to a hypertension workup rather than brain imaging.
Neck stiffness raises concern for meningitis in an acutely ill child; it does not decide imaging for recurring headaches in a well child.
Imaging for headache is driven by red flags such as an abnormal neurologic exam or papilledema, so a careful neurologic and funduscopic exam is what decides it.
Sinus tenderness is an unreliable sign and does not bear on the need for neuroimaging.
A 3-month-old's parents note that the right pupil looks white in flash photographs. On exam the red reflex is absent on the right and normal on the left. Which is the MOST appropriate next step?
Rechecking later delays diagnosis of a possibly life-threatening tumor or a cataract that causes permanent amblyopia.
Photoscreening detects refractive and alignment risk factors in older children; it does not evaluate leukocoria in an infant.
Flash artifacts do occur, but an absent red reflex on exam confirms the concern rather than explaining it away.
A white pupil in photos with an absent red reflex on exam can be retinoblastoma or congenital cataract, so the infant needs an urgent ophthalmology evaluation.
An 18-month-old girl developed normally until 12 months but has since lost her few words and purposeful hand use and now makes repetitive hand-wringing movements. Head circumference growth has slowed from the 50th to the 10th percentile. The MOST LIKELY diagnosis is:
Cerebral palsy is nonprogressive, so lost skills point away from it.
Autism can include early language regression, but it does not cause loss of purposeful hand use or decelerating head growth.
Angelman syndrome shows delay from infancy, frequent laughter, seizures, and ataxia, rather than regression after normal development.
Normal early development in a girl, followed by loss of words and purposeful hand use, hand-wringing stereotypies, and slowing head growth, is classic Rett syndrome.
A 14-month-old with dark skin was exclusively breastfed without supplements. Exam shows bowed legs, widened wrists, and a rachitic rosary. Labs: calcium low-normal, phosphorus low, alkaline phosphatase elevated, PTH elevated. The MOST LIKELY diagnosis is:
Physiologic bowing is symmetric, improves by about age 2, and comes with normal labs and no wrist widening.
An exclusively breastfed, unsupplemented toddler with dark skin, wide wrists, a rachitic rosary, low phosphorus, high alkaline phosphatase, and high PTH has vitamin D-deficiency rickets.
Blount disease is a growth disturbance of the proximal tibia in early walkers; it does not cause a rosary or abnormal labs.
X-linked hypophosphatemia also lowers phosphorus, but PTH is usually normal and there is often a family history; the diet history fits vitamin D deficiency.
A 12-year-old fainted suddenly, without any warning symptoms, after being startled by a loud alarm clock. A cousin died unexpectedly while swimming. Examination is normal, and an ECG has been ordered. The MOST LIKELY diagnosis is:
WPW causes episodes of rapid palpitations from an accessory pathway; startle-triggered syncope with a family history of sudden death while swimming points to a channelopathy instead.
Hypertrophic cardiomyopathy causes syncope during exertion and usually a murmur that rises with Valsalva, not fainting at rest after a startle.
Sudden syncope triggered by a startling noise, with a relative who died unexpectedly while swimming, fits congenital long QT syndrome, in which adrenergic surges set off torsades; the ECG and cardiology referral confirm it.
Vasovagal syncope follows standing, pain, or heat with a prodrome of warmth, nausea, or tunnel vision; fainting without warning after a startle does not fit it.
A 7-month-old's corneal light reflex is asymmetric. On cover testing, when the left eye is covered, the right eye moves outward to fixate on the light. This finding indicates:
An outward-turned right eye would move inward to take up fixation; the outward refixation shows the opposite deviation.
When the fixing left eye is covered, the deviated right eye has to move to pick up the light; moving outward means it had been turned inward, which is right esotropia and needs ophthalmology referral at this age.
Pseudostrabismus gives symmetric corneal reflexes and no refixation on cover testing; here both are abnormal.
The left eye was fixing, which is why covering it forced the right eye to move; the deviated eye is the one that moves.
A 4-month-old spits up after most feeds, occasionally forcefully. The infant feeds eagerly, is not irritable, and weight has tracked the 50th percentile. Examination is normal. Which is the MOST appropriate plan?
An upper GI series looks for anatomic problems such as malrotation; it neither diagnoses reflux nor is needed in a healthy infant.
Frequent spitting up in a content, thriving infant is physiologic reflux, which needs no tests or drugs and usually resolves by 12 to 18 months.
Pyloric ultrasound is for progressive projectile vomiting with poor weight gain, usually at 2 to 8 weeks.
Acid suppression does not reduce regurgitation and adds infection risk; it is not used in a happy spitter.
At a 12-month visit, a parent worries that the child is 'slower' than a cousin of the same age. The child passed a standardized developmental screen at 9 months, and surveillance today finds no clear delay. Which is the MOST appropriate action?
Deferring to the next scheduled screen dismisses the one risk signal surveillance found, the parent's own concern.
The M-CHAT-R/F is an autism screen validated for 16 to 30 months and does not address a general concern at 12 months.
A full diagnostic evaluation follows a positive screen or clear delay; ordering it before screening skips a step.
Parental concern raised during surveillance is itself a reason to give a standardized screen at that visit, outside the 9-, 18-, and 30-month schedule.
A 7-year-old with 1 week of sinusitis develops eyelid swelling, pain with eye movement, proptosis, and double vision. The MOST LIKELY diagnosis is:
Dacryocystitis causes a tender swelling over the inner corner of the eye at the tear sac, without proptosis.
Allergic swelling is itchy and painless, without fever, proptosis, or restricted movement.
Pain with eye movement, proptosis, and double vision after sinusitis mean infection behind the orbital septum; the child needs emergency referral for contrast CT and IV antibiotics.
Preseptal cellulitis swells the eyelid but spares eye movement and does not push the eye forward; mistaking orbital for preseptal disease is the dangerous error.
A 4-year-old girl was diagnosed with oligoarticular juvenile idiopathic arthritis 3 months ago. Her ANA is positive, and her eyes are not red or painful. Which eye assessment is MOST appropriate?
Fundoscopy looks at the retina and cannot detect inflammation in the anterior chamber.
A young child with oligoarticular JIA and a positive ANA has the highest risk of silent anterior uveitis, so slit-lamp screening every 3 months is recommended.
JIA uveitis is usually white and painless, so waiting for symptoms lets cataract and vision loss develop.
Yearly exams are for lower-risk groups, such as older age at onset or longer disease duration.
A 5-year-old has had a swollen, warm right knee with morning stiffness for 3 weeks, starting after a viral illness. ANA is positive, RF is negative, and ESR is normal. Which interpretation is MOST appropriate?
JIA requires arthritis lasting at least 6 weeks, so a knee swollen for 3 weeks after a viral illness cannot yet be labeled JIA, and postviral arthritis remains likely.
ANA is positive in many healthy children; in JIA it marks uveitis risk rather than confirming the diagnosis.
Most children with JIA are RF-negative, so a negative RF excludes nothing.
The ESR is often normal in oligoarticular JIA, so it cannot rule it out.
A 2-year-old refuses to bear weight on the right leg after twisting while running yesterday. The child is afebrile, has full painless hip motion, and has point tenderness over the distal tibia. Tibial radiographs are normal. The MOST LIKELY diagnosis is:
Refusing to bear weight after a twist, with point tenderness over the distal tibia and painless hip motion, is a toddler's spiral fracture, which is often invisible on the first radiographs.
Perthes disease affects children of about 4 to 8 years and limits hip rotation, not a 2-year-old with tibial tenderness.
Septic arthritis causes fever and a hot, painful joint that the child will not move.
Transient synovitis involves the hip and limits its motion, which is full and painless here.
At a 4-year well visit, the left testis is not seen in the scrotum while the boy stands. With the child seated cross-legged, it can be brought fully into the scrotum and remains there after release. The scrotum is well developed. The MOST LIKELY diagnosis is:
A hernia is a groin bulge that enlarges with straining, while the testis itself sits normally in the scrotum.
An undescended testis cannot be brought into the scrotum or springs back as soon as it is released, and the scrotum on that side is often underdeveloped.
An ascending testis was once in the scrotum but can no longer be brought down; this one still reaches and stays in the scrotum.
A testis that an active cremasteric reflex pulls up, but that can be brought fully into a well-developed scrotum and stays there after release, is retractile; it is rechecked yearly because some later ascend.
For 4 months, a 14-year-old has had lower abdominal cramping several days a week that is relieved by defecation, with alternating hard and loose stools. Growth, examination, and screening labs are normal, and there are no night-time symptoms. The MOST LIKELY diagnosis is:
Functional constipation causes infrequent, hard stools, not alternating hard and loose stools.
Recurrent pain relieved by defecation, with a change in stool form, for months and without alarm features meets Rome IV criteria for irritable bowel syndrome.
Crohn disease brings alarm features such as weight loss, slowed growth, night symptoms, or abnormal labs, none of which is present.
Functional abdominal pain-NOS is diagnosed only when pain is not related to stooling; here it is.
The parents of a 4-month-old who room-shares ask when the infant can move to a separate bedroom. Which advice is MOST consistent with AAP 2022 safe sleep guidance?
Sleeping through the night is a feeding and sleep milestone, not a safe sleep criterion.
AAP safe sleep guidance advises room-sharing without bed-sharing, ideally for at least the first 6 months, because it lowers the risk of SIDS.
SIDS risk peaks at 1 to 4 months but has not passed at 4 months, so moving now gives up the protective effect early.
Rolling changes the advice about swaddling and sleep position, not the advice to share a room.
A healthy 13-year-old boy at Tanner stage 3 is embarrassed by a tender, 2-cm, rubbery disk of tissue under each areola. Which is the MOST appropriate plan?
Hormone testing is for very large or prepubertal gynecomastia or signs of an endocrine disorder.
A tender, rubbery disk under each areola in a mid-pubertal boy is physiologic gynecomastia, which affects many boys and usually resolves within 1 to 2 years.
Surgery is considered only when gynecomastia persists after puberty or causes severe distress.
Imaging is for a hard, fixed, eccentric, or rapidly growing mass, not symmetric subareolar tissue.
The parents of a 3-year-old use legal cannabis edibles. Which advice MOST reduces the risk of accidental ingestion by the child?
Toddlers climb, so height alone does not keep a curious child away from candy-like products.
An unmarked candy tin hides the warning label and invites the child to treat the edibles as sweets.
Cannabis edibles look like candy and can cause lethargy, ataxia, and breathing problems in a toddler, so they are kept locked, in their original child-resistant packaging, and out of sight.
Even a low-dose product can poison a small child, who receives a large dose per kilogram.
A 15-year-old who vapes nicotine daily says he 'might quit someday.' Which response is MOST appropriate?
Medication is for a teen who is ready to quit and dependent; it is not the response to someone who only might quit someday, and evidence in adolescents is limited.
Scare messages provoke resistance in adolescents, and overstated claims cost credibility.
Breaking confidentiality without a safety reason damages trust and makes him less likely to return.
An ambivalent teen responds best to motivational interviewing, and exploring what he likes and dislikes about vaping helps him voice his own reasons to quit.
The family of a 2-year-old plans to renovate their 1930s house. Which advice is MOST appropriate?
Most children with elevated lead levels have no symptoms, so waiting for them misses the exposure.
Dry sanding produces the most lead dust, and open windows spread it rather than remove it.
Renovating a home built before 1978 releases lead dust, so young children and pregnant family members stay away until the work and a professional cleanup are complete.
An ordinary vacuum blows fine lead dust back into the air; cleanup needs HEPA equipment and wet methods.
The father of a 4-month-old smokes only outside on the porch. Which advice is MOST appropriate?
Outdoor smoking still brings residue indoors on the smoker's body and clothes.
Smoking outdoors lowers but does not remove exposure, because thirdhand smoke residue on hair, skin, and clothing reaches the baby, so quitting with quitline support is the goal.
Timing cigarettes to naps does not stop the residue the infant contacts afterward.
E-cigarette aerosol also contains nicotine and fine particles that the baby breathes.
A 10-year-old tells a parent that a 'friend' from an online game asked for photos and told him to keep it secret. Which advice is MOST appropriate?
A request for photos with pressure for secrecy is a sign of online grooming, so the conversation is kept as evidence and reported to law enforcement or the NCMEC CyberTipline.
Confronting the offender can escalate contact and alert him to delete evidence.
Blocking helps, but deleting the chat destroys the evidence investigators need.
Banning games punishes the child for telling and discourages future disclosure.
The family of a 3-year-old wants to buy a pet turtle. Which advice is MOST appropriate?
A reptile tank in the kitchen spreads Salmonella to food-preparation surfaces.
Small turtles carry the same Salmonella risk, which is why their sale is banned in the United States.
The shell itself carries the bacteria, so limiting what a toddler touches does not protect her.
Reptiles commonly carry Salmonella, and the CDC advises against keeping them in homes with children younger than 5, so a different pet is the safer choice.
A parent worries that the five injections due at the 2-month visit on the AAP 2026 immunization schedule will overwhelm the baby's immune system and asks to space them out. Which response is MOST accurate?
Delaying leaves a young infant exposed during the months when pertussis, Hib, and pneumococcus are most dangerous.
Infants meet thousands of antigens daily, and today's vaccines contain fewer antigens than older ones, so giving them together does not overwhelm the immune system.
Combination vaccines and the simultaneous schedule have been studied extensively for safety and immune response.
Spacing adds visits and needle sticks and leaves the infant unprotected longer, with no reduction in any real burden.
Parents of a 9-month-old ask about using a mobile baby walker to help her learn to walk. Which advice is MOST appropriate?
Gates are often left open, and walkers also bring children within reach of hot drinks and stoves.
A time limit does not remove the hazard, which happens in seconds.
Mobile walkers cause stair falls, burns, and poisonings and do not help walking, so the AAP advises against them; a stationary activity center offers the same play without mobility.
A 2-year-old with visible plaque on the upper incisors has never seen a dentist. Which is MOST appropriate at this primary care visit?
Varnish should not wait for a dentist, especially in a child with visible plaque who has no dental home yet.
A smear of fluoride toothpaste is recommended from the first tooth; fluoride-free paste removes protection.
The USPSTF recommends that primary care apply fluoride varnish to primary teeth from eruption through age 5, and every child is referred to a dental home.
Ingestible fluoride is reserved for selected high-risk children whose water lacks fluoride and does not replace varnish applied in the office.
A 4-year-old had complete surgical repair of a ventricular septal defect with a prosthetic patch 3 months ago and is scheduled for a dental cleaning. Which is MOST appropriate?
Repair removes the need for prophylaxis only after 6 months without a residual defect, once the patch has endothelialized; at 3 months it is still indicated.
Bacteremia happens with any manipulation of the gums, so waiting to see bleeding gives the dose too late.
A course after the procedure misses the bacteremia that occurs during it and adds needless antibiotic exposure.
AHA guidance recommends endocarditis prophylaxis for dental procedures during the first 6 months after a congenital heart defect is completely repaired with prosthetic material, as a single amoxicillin dose of 50 mg/kg given 30 to 60 minutes before.
A 10-year-old with ADHD has improved attention on methylphenidate by teacher Vanderbilt ratings, but reading skills remain 2 grade levels below peers. Which is the MOST appropriate next step?
Adding an alpha-agonist targets residual ADHD symptoms, not a persistent academic skill gap.
Raising the dose treats inattention, which is already controlled; it cannot fix a specific reading disorder.
Changing ADHD medication does not address a learning disability when the current one is working.
When attention has improved on medication but reading stays well behind, a coexisting learning disability is likely, and a school psychoeducational evaluation is the step toward specific supports.
A 3-year-old with spastic quadriplegic cerebral palsy who cannot walk (GMFCS level IV) is seen for follow-up and has no hip pain. Which surveillance is MOST important to arrange?
Hip displacement is common and often painless in nonambulatory children with cerebral palsy, so surveillance uses AP pelvis radiographs every 6 to 12 months to track migration and refer early.
EEG is for suspected seizures; there is no role for yearly routine EEGs in cerebral palsy.
Spine imaging is for new neurologic signs or progressive scoliosis on exam, not routine yearly surveillance.
Knee contractures are followed clinically; knee films are not a surveillance tool, and they miss the silent hip migration.
A 2-year-old has atopic dermatitis flares in the antecubital and popliteal areas despite daily emollients. There is no history of food reactions. Which is the MOST appropriate treatment?
Non-sedating antihistamines do not treat eczema inflammation and do little for its itch.
Topical calcineurin inhibitors are steroid-sparing second-line agents, used mainly for the face and folds or for maintenance, not as the first flare treatment.
Elimination diets without a confirmed food allergy restrict nutrition and do not improve the skin.
A topical corticosteroid is first-line for an eczema flare, and a short course of a medium-potency agent suits the flexures of a 2-year-old's body, with emollients continued.
A 5-year-old has daily soiling with small amounts of stool, passes large hard stools every 5 days, and has a palpable fecal mass in the left lower quadrant. Which is the MOST appropriate initial treatment?
Daily soiling with a palpable fecal mass is overflow from an impaction, so the first step is disimpaction, here with high-dose oral polyethylene glycol for several days, before maintenance therapy and toilet sitting.
Fiber and fluids support long-term bowel health but cannot clear an established impaction.
A glycerin suppository acts only on the rectum and cannot clear a large mass, and weeks of daily rectal treatment distress a child.
Starting maintenance with the impaction still in place increases leakage and cramping and delays control.
A 12-year-old has had periumbilical pain for 6 months without weight loss, bleeding, night waking, or dysphagia. Growth and examination are normal. The parent asks for Helicobacter pylori testing. Which is MOST appropriate?
In functional abdominal pain without alarm features, H. pylori testing is not recommended, because infection does not explain the symptoms and eradication does not relieve them.
Treating without a confirmed infection or indication promotes resistance and exposes the child to adverse effects.
A stool antigen test is a valid method when testing is indicated, but a positive result here would lead to treatment that does not help the pain.
Antibody tests cannot separate past from current infection and are not recommended for children.
A 2-year-old refuses to use the left arm after being lifted by the hand. The arm is held slightly flexed and pronated, with no swelling or point tenderness. Which is the MOST appropriate management?
Films are for a fall, swelling, point tenderness, or a failed reduction, not for the classic pull history.
Pulling on an extended arm is the mechanism of the injury, not a reduction maneuver.
Refusal to use the arm after being lifted by the hand, held flexed and pronated without swelling or tenderness, is radial head subluxation; hyperpronation reduces it without imaging and succeeds more often than supination-flexion.
Splinting treats a fracture; after a successful reduction the child uses the arm normally within minutes.
A 9-month-old wakes 3 times a night and is fed back to sleep each time. Growth is normal. Which is the MOST appropriate advice?
Repeated night wakings in an infant who is fed to sleep reflect a sleep-onset association; laying the baby down drowsy but awake teaches self-settling, and most 9-month-olds no longer need night feeds.
Cereal in a bottle does not improve sleep and adds choking risk and excess calories.
Melatonin is not recommended for infants and does not address a learned sleep association.
Bed-sharing raises the risk of sleep-related infant death and deepens the dependence on a parent to fall back asleep.
A 4-year-old has pink eye with watery discharge, no fever, and normal behavior. The parents ask about preschool. According to AAP guidance, which is correct?
A fixed week of exclusion has no public health basis for routine conjunctivitis.
Requiring drops for readmission drives needless antibiotic use, since most pink eye in preschoolers is viral.
AAP child care guidance does not exclude children for conjunctivitis unless they have fever, a change in behavior, or are part of an outbreak; handwashing limits spread.
Waiting for the discharge to clear keeps the child out for days with no benefit to others.
A 17-year-old with PCOS has a BMI of 33. Which screening is recommended?
Ultrasound is not used to diagnose PCOS within 8 years of menarche or to monitor it, and transvaginal scanning is rarely appropriate for a teen.
AMH is not validated for diagnosing or monitoring PCOS in adolescents.
A karyotype evaluates primary amenorrhea with short stature or ambiguous development; it has no role in PCOS.
Adolescents with PCOS and obesity have a high risk of prediabetes and type 2 diabetes, so glycemic screening with HbA1c or an oral glucose tolerance test is recommended, along with lipids, blood pressure, and mood.
A 10-year-old with hemoglobin SS disease has had 4 pain crises requiring hospitalization this year and takes no disease-modifying therapy. Which is MOST appropriate?
Folic acid supports red cell production but does not reduce crises.
Hydroxyurea reduces pain crises, acute chest syndrome, transfusions, and admissions, and it is offered to all children with HbSS from 9 months of age; four admissions a year without it is a clear indication.
Chronic transfusion is for stroke prevention after an abnormal transcranial Doppler or a stroke, not the first step for frequent pain.
Long-acting opioids do not prevent vaso-occlusive crises and add dependence risk.
A 13-year-old with class 2 obesity has not improved after 6 months of intensive health behavior and lifestyle treatment and asks about medication. The parent worries about side effects. The MOST appropriate response is to:
Several anti-obesity medications are FDA-approved from age 12, so this statement is outdated.
Surgery is not the next step for this teen, who is asking about medication.
Waiting for further weight gain is the watchful waiting the guideline explicitly discourages.
The AAP 2023 guideline advises offering anti-obesity medication to adolescents 12 and older with obesity as an add-on to lifestyle treatment, discussing benefits and adverse effects with the family.
A 10-year-old with moderate atopic dermatitis has frequent flares at the same flexural sites despite daily emollients and a topical corticosteroid applied during each flare. Which change is MOST likely to reduce flare frequency?
Daily high-potency steroid on clear skin risks atrophy and adrenal suppression in a child.
IgE panels have many false positives, and the diets they prompt restrict nutrition without reducing flares.
Oral antihistamines do not control eczema inflammation and do not prevent flares.
Proactive therapy, a topical steroid or calcineurin inhibitor applied twice weekly to previously affected skin after it clears, lowers flare frequency in recurrent atopic dermatitis.
A 16-year-old with type 1 diabetes comes to a visit with a parent who manages most insulin decisions. Which action BEST prepares the adolescent for transfer to adult care?
A structured transition process uses readiness assessments from about 14 years to find self-care gaps, such as dosing decisions, and builds skills with time alone with the teen before transfer at 18 to 21.
Starting at 18 leaves no time to build skills before transfer; preparation begins in early adolescence.
Tying transfer to HbA1c links it to glycemic control rather than to the teen's readiness and skills.
Transferring before the teen can manage insulin decisions leads to lost follow-up and worse control.
A 3-year-old has had 2 pneumonias, 1 episode of pneumococcal bacteremia, and 6 ear infections in the past year despite complete immunizations. Which is the MOST appropriate initial evaluation?
Chest CT looks for structural lung disease such as bronchiectasis; it does not screen for immunodeficiency.
Recurrent sinopulmonary infections with invasive pneumococcal disease suggest an antibody defect, so the first screen is a CBC with differential and IgG, IgA, and IgM levels, often with vaccine titers, before immunology referral.
The DHR test screens for chronic granulomatous disease, which brings catalase-positive bacterial and fungal abscesses rather than recurrent pneumococcal infection.
Complement screening is for recurrent Neisseria or invasive encapsulated infections after antibody defects are excluded.
An 8-year-old has missed 12 days of school this term. Each morning the child cries, complains of stomachaches, and clings to the parent at drop-off, and symptoms resolve when allowed to stay home. Exam is normal. Which is the MOST appropriate plan?
Home instruction rewards avoidance and makes the return harder.
School avoidance driven by separation anxiety is treated with CBT using exposure and a prompt, graded return to school.
A parent in the classroom is an accommodation that maintains the separation fear instead of treating it.
Benzodiazepines are not recommended for childhood anxiety; an SSRI is added when moderate to severe symptoms do not respond to CBT.
A 7-year-old girl has 1 day of dysuria and frequency without fever or flank pain. A clean-catch urinalysis is positive for leukocyte esterase and nitrite. Which is MOST appropriate?
In a child, a urine culture is sent before antibiotics to confirm infection and guide therapy, and empiric treatment is chosen by local resistance.
A urinary analgesic eases dysuria but leaves the infection untreated, and it is not a substitute for culture-guided antibiotics.
Imaging is not needed for a first afebrile lower UTI in a school-age child and should not delay treatment.
Nitrofurantoin is a reasonable agent for cystitis, but 14 days is longer than needed, and starting it without a culture skips the step children require.
A PNP learns that a local middle school removed its drinking-water fountains and sells only sugar-sweetened drinks. Which action is community-level advocacy?
A water prescription still works one child at a time and is not a community-level action.
Community-level advocacy targets a policy or environment that affects a whole population, such as asking the school board to restore free drinking water.
Changing intake forms improves clinic screening but does not change the school's policy.
Counseling patients one by one is individual-level advocacy and leaves the school environment unchanged.
Several children with asthma from one apartment complex have frequent exacerbations. Home visits find cockroach infestation and mold. Which action BEST addresses this pattern?
Air purifiers do not remove cockroach allergen, which settles in dust, or fix the moisture that feeds mold.
Stepping up medication treats the children's symptoms but leaves the shared housing trigger in place.
A cluster of exacerbations tied to shared housing conditions calls for a population-level response: working with the health department or code enforcement to remediate the pests and mold for every family in the complex.
Immunotherapy referrals address one child at a time and do not remove the environmental cause.
A 9-year-old with type 1 diabetes reads and does math at grade level but needs glucose checks, snacks, and insulin doses during the school day. The parents ask which school plan will secure these supports. Which is MOST appropriate?
An IFSP is the early intervention plan for children from birth to age 3, not a school-age plan.
A child whose diabetes needs health accommodations at school but who does not need special education is covered by a Section 504 plan, which writes the glucose checks, snacks, and insulin dosing into the school's obligations.
An informal arrangement depends on one teacher and lapses with substitutes, field trips, and new school years; it gives the family no enforceable protection.
An IEP is for a disability that requires special education services; a child learning at grade level does not qualify just because of diabetes care needs.
A running total sits here; it fills in after your last pick.
Using the misses after the set
Your score here does not translate into PNCB's scaled score, and no fixed percentage passes the real exam. Use the misses instead: sort them by area chip, then open the matching section page for its traps and 15 to 18 more questions. The leadership and ethics questions live only here.
For a calibration closer to the board itself, PNCB sells its own module, $52 for 75 questions with rationales. On pass rates, PNCB reports 80.7% (2024) of first-time takers passing (by year).
Answer every question
An unanswered item earns nothing and a wrong one costs nothing extra, so the handbook advises guessing (p. 3). With about a minute per item, flag and move on rather than stall.