Of the following, the skin manifestation that is MOST suggestive of SLE in children is

Correct Answer: A

Rationale: In pediatric patients, Systemic Lupus Erythematosus (SLE) can present with various skin manifestations. The MOST suggestive skin manifestation of SLE in children is a malar rash, which is a characteristic butterfly-shaped rash across the cheeks and bridge of the nose. This rash is highly specific to SLE and is a key diagnostic feature. Discoid rash (option B) is more commonly seen in Discoid Lupus Erythematosus rather than systemic SLE. Photosensitive rash (option C) can occur in SLE but is not as specific or characteristic as the malar rash. Cutaneous vasculitis (option D) is associated with SLE but is less specific and less common than the malar rash in pediatric patients. Educationally, understanding the specific skin manifestations of SLE in children is crucial for accurate diagnosis and timely intervention. Teaching healthcare providers to recognize the malar rash as a hallmark sign of SLE can lead to prompt referral to a pediatric rheumatologist for further evaluation and management. This knowledge enhances the quality of care provided to pediatric patients with SLE and improves outcomes.

Correct Answer: D

Rationale: Kawasaki disease (KD) is a vasculitis that primarily affects children. The correct answer is D) vesicular rash because it is not a common clinical feature of KD. The classic clinical features of KD include bilateral non-exudative bulbar conjunctivitis (A), cracked lips (B), and edema and erythema of the hands and feet (C). Vesicular rash is not typically seen in KD but may be seen in conditions like chickenpox or hand-foot-and-mouth disease. Understanding these distinct clinical features is crucial for pediatric clinical nurse specialists to accurately diagnose and manage KD in children. Recognizing the specific symptoms of KD can lead to prompt treatment and prevent potential complications such as coronary artery aneurysms. Nurses play a vital role in early identification and intervention in KD cases, making this knowledge essential for their practice.

Correct Answer: C

Rationale: In this scenario, the most likely diagnosis is bullying (Option C). Children who are teased by their peers as 'weak' are often victims of bullying, which can have significant negative effects on their mental health and well-being. Bullying involves repeated aggressive behavior towards an individual, with the intention of causing harm. It can manifest in various forms, including physical, verbal, and social/emotional bullying. In this case, the child being teased by schoolmates fits the profile of a victim of bullying. School phobia (Option A) refers to an irrational fear of going to school, typically due to anxiety or stress related to school settings. Anxiety disorder (Option B) is a broad category that includes various conditions characterized by excessive worry, fear, or nervousness. Hypothyroidism (Option D) is a medical condition caused by an underactive thyroid gland and would not be the primary diagnosis in this context. Educationally, understanding the differences between these options is crucial for healthcare professionals working with children. Recognizing signs of bullying, such as changes in behavior, social withdrawal, or unexplained injuries, is essential for early intervention and support. By identifying and addressing bullying behavior, healthcare providers can help create a safe and supportive environment for children to thrive both academically and emotionally.

Correct Answer: A

Rationale: In this scenario, the most helpful investigation is a factor VII assay. Factor VII deficiency is a rare bleeding disorder that can present with symptoms such as spontaneous ecchymosis, bleeding from the nose and urine, and prolonged PT and/or PTT. Given the family history of a deceased daughter with a similar illness, and the normalization of coagulation parameters with vitamin K administration, it is likely that the child has a vitamin K-dependent coagulation factor deficiency, which includes factor VII. Option B, factor II assay, is incorrect because factor II deficiency is not associated with the symptoms described and would not explain the normalization of coagulation parameters with vitamin K administration. Option C, drug level, is irrelevant in this case as there is no mention of any specific medications or toxins involved. Option D, von Willebrand factor assay, is incorrect as von Willebrand disease typically presents with different symptoms like mucosal bleeding and a prolonged bleeding time, which are not consistent with the case presented. Educationally, understanding the importance of selecting the appropriate diagnostic tests based on clinical presentation and history is crucial for healthcare professionals, especially pediatric clinical nurse specialists. This case highlights the significance of considering rare bleeding disorders in pediatric patients with recurrent bleeding episodes and abnormal coagulation profiles. Conducting targeted investigations like a factor VII assay can lead to a timely and accurate diagnosis, enabling appropriate management and genetic counseling for the family.

Correct Answer: D

Rationale: In the case presented, the correct diagnostic test to exclude would be a lumbar puncture (Option D). This is because the infant is presenting with retinal hemorrhages and severe pallor along with a history of being on amoxicillin for otitis media, which suggests a possible diagnosis of shaken baby syndrome due to non-accidental trauma rather than an infectious etiology. Coagulation studies (Option A) would help assess for any bleeding disorders that could explain the retinal hemorrhages. A skeletal survey (Option B) would be important to assess for signs of non-accidental trauma. A CT scan (Option C) would be useful to evaluate for any intracranial hemorrhage or other traumatic injuries. From an educational perspective, it is important for pediatric clinical nurse specialists to understand the diagnostic workup for pediatric patients presenting with concerning symptoms. In this case, recognizing the signs suggestive of non-accidental trauma and knowing which diagnostic tests are appropriate based on the clinical presentation is crucial for providing timely and appropriate care for the infant. It also highlights the importance of considering child abuse in the differential diagnosis when presented with certain clinical findings in pediatric patients.