Cystic fibrosis (CF) is the most common fatal autosomal recessive disease among the Caucasian population. An individual must inherit a defective copy of the CF gene (one from each parent) to have CF. Cystic fibrosis is usually diagnosed in infancy or early childhood, but patients may be diagnosed later in life. For individuals diagnosed later in life, respiratory symptoms are frequently the major manifestation of the disease.

Pathophysiology
This disease is caused by mutations in the CF transmembrane conductance regulator protein, which is a chloride channel found in all exocrine tissues. Chloride transport problems lead to thick, viscous secretions in the lungs, pancreas, liver, intestine, and reproductive tract as well as increased salt content in sweat gland secretions. In 1989, major breakthroughs were made in this disease with the identification of the CF gene. The ability to detect the common mutations of this gene allows for routine screening for this disease as well as the detection of carriers. Genetic counseling is an important part of health care for couples at risk.
Airflow obstruction is a key feature in the presentation of CF. This obstruction is due to bronchial plugging by purulent secretions, bronchial wall thickening due to inflammation, and, over time, airway destruction. These chronic retained secretions in the airways set up an excellent reservoir for continued bronchial infections.

Clinical Manifestations

The pulmonary manifestations of this disease include;

• a productive cough, wheezing, hyperinflation of the lung fields on chest x-ray, and pulmonary function test results consistent with obstructive airways disease.
• Colonization of the airways with pathogenic bacteria usually occurs early in life.
• Staphylococcus aureus and Haemophilus influenzae are common organisms during early childhood. As the disease progresses, Pseudomonas aeruginosa is ultimately isolated from the sputum of most patients.
• Upper respiratory manifestations of the disease include sinusitis and nasal polyps.

Nonpulmonary clinical manifestations include;

• gastrointestinal problems (eg, pancreatic insufficiency, recurrent abdominal pain, biliary cirrhosis, vitamin deficiencies, recurrent pancreatitis, weight loss),
• genitourinary problems (male and female infertility), and
• Clubbing of the extremities.

Assessment and Diagnostic Findings

Most of the time, the diagnosis of CF is made based on an elevated result of a sweat chloride concentration test, along with clinical signs and symptoms consistent with the disease. Repeated sweat chloride values of greater than 60 mEq/L distinguish most individuals with CF from those with other obstructive diseases. A molecular diagnosis may also be used in evaluating common genetic mutations of the CF gene.

Medical Management
Pulmonary problems remain the leading cause of morbidity and mortality in CF. Because chronic bacterial infection of the airways occurs in individuals with CF, control of infections is key in the treatment.

• Antibiotic medications are routinely prescribed for acute pulmonary exacerbations of the disease. Depending upon the severity of the exacerbation, aerosolized, oral, or intravenous antibiotic therapy may be used. Antibiotic agents are selected based upon the results of a sputum culture and sensitivity. Patients with CF have problems with bacteria that are resistant to multiple drugs and require multiple courses of antibiotic agents over long periods of time.
• Bronchodilators are frequently administered to decrease airway obstruction. Differing pulmonary techniques are used to enhance secretion clearance. Examples include manual postural drainage and chest physical therapy, high-frequency chest wall oscillation, and other devices that assist in airway clearance (PEP masks [masks that generate positive expiratory pressure], “flutter devices” [devices that provide an oscillatory expiratory pressure pattern with positive expiratory pressure and assist with expectoration of secretions]).
• Inhaled mucolytic agents such as dornase alfa (Pulmozyme) or N-acetylcysteine (Mucomyst) may also be used. These agents help to decrease the viscosity of the sputum and promote expectoration of secretions.
• Anti-inflammatory: To decrease the inflammation and ongoing destruction of the airways, anti-inflammatory agents may also be used. These may include inhaled corticosteroids or systemic therapy. Other anti-inflammatory medications have also been studied in CF. Ibuprofen was studied in children with CF and some benefit was demonstrated, but there is little information on its use in young or older adults with CF.
• Supplemental oxygen is used to treat the progressive hypoxemia that occurs with CF. It helps to correct the hypoxemia and may minimize the complications seen with chronic hypoxemia (pulmonary hypertension).
• Lung transplantation is an option for a small, select population of CF patients. A double lung transplant technique is used due to the chronically infected state of the lungs seen in end-stage CF. Because there is a long waiting list for lung transplant recipients, many patients die while awaiting a transplant.
• Gene therapy is a promising approach to management, with many clinical trials underway. It is hoped that various methods of administering gene therapy will carry healthy genes to the damaged cells and correct defective CF cells. Efforts are underway to develop innovative methods of delivering therapy to the CF cells of the airways.

Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses are:

• Ineffective airway clearance related to thick, tenacious mucus production.
• Ineffective breathing pattern related to tracheobronchial obstruction.
• Risk for infection related to bacterial growth medium provided by pulmonary mucus and impaired body defenses.
• Imbalanced nutrition: less than body requirements related to impaired absorption of nutrients.
• Anxiety related to hospitalization.
• Compromised family coping related to child’s chronic illness and its demands on caregivers.
• Deficient knowledge of the caregiver related to illness, treatment, and home care.

Nursing Management
Nursing care of the adult with CF includes assisting the patient to manage pulmonary symptoms and to prevent complications of CF.

• Specific nursing measures include strategies that promote removal of pulmonary secretions; chest physiotherapy, including postural drainage, chest percussion, and vibration, and breathing exercises are implemented and are taught to the patient and to the family when the patient is very young.
• The patient is taught the early signs and symptoms of respiratory infection and disease progression that indicate the need to notify the primary health care provider.
• The nurse emphasizes the importance of an adequate fluid and dietary intake to promote removal of secretions and to ensure an adequate nutritional status. Because CF is a life-long disorder, patients often have learned to modify their daily activities to accommodate their symptoms and treatment modalities.
• Although gene therapy and double lung transplantation are promising therapies for CF, they are limited in availability and largely experimental. As a result, the life expectancy of adults with CF is shortened.
• For the patient whose disease is progressing and who is developing increasing hypoxemia, preferences for end-of-life care should be discussed, documented, and honored.
• Patients and family members need support as they face a shortened life span and an uncertain future.

Asthma is a chronic inflammatory disorder of the airways associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing. These episodes are usually associated with airflow obstruction within the lung, often reversible, either spontaneously or with treatment.

Factors that precipitate/aggravate asthma include: allergens, infection, exercise, drugs (aspirin), tobacco, etc.

Pathophysiology:-

Airway inflammation is the primary problem in asthma. An initial event in asthma appears to be the release of inflammatory mediators triggered. The mediators are released from bronchial mast cells, alveolar macrophages, and epithelial cells. Some mediators directly cause acute bronchoconstriction.” The inflammatory mediators also direct the activation of eosinophils and neutrophils, and their migration to the airways, where they cause injury Called “late-phase asthmatic response” results in epithelial damage, airway edema, mucus hypersecretion and hyper responsiveness of bronchial smooth muscle varying airflow obstruction leads to recurrent episodes of wheezing, breathlessness, chest tightness and cough.

Causes/Triggers of Asthma:

The exact causes of asthma are still unknown but we do know that children are more likely to have asthma if other members of the family also have it. Related conditions like hay fever, eczema or food allergies can also increase the risk of asthma.

Smoking during pregnancy or exposing a child to tobacco smoke will increase their risk of developing asthma. Being overweight also increases the risk of developing asthma.

Though some children lose their symptoms as they grow older, asthma is a chronic disease so symptoms may come back later in life.

• Asthma is a breathing disease which is triggered by various allergies and substance, like:
  • polluted matters, smoking, animal products and many more.
• Asthma problems can be caused by different foods which can react on the immune system of the body. Some people have allergy with particular food and various symptoms are appeared in your body like swelling, vomiting, diarrhea, rash, wheezing and breathing problems. The use of foods like peanuts, shellfish, eggs, various dairy products can be harmful for the patients so they should avoid all these foods. All such foods and wine containing histamine can cause development in asthma.
• The fizzy drinks, prepared salads and meats, home brewed beer and wine can contain the allergic reaction. If you have some problems of allergy, then you should contact with specialist for the allergic problems. The women can face the asthma problems during their periods, pregnancy, puberty and menopause.

The following things can trigger an asthma attack:

• Colds and Viral Infections
• House Dust Mites
• Fur and dander from pets
• Changes in weather, and cold air
• Pollen
• Tobacco smoke and pollution
• Mould
• Chemicals
• Allergies
• Exercise

Clinical Manifestations

The three most common symptoms of asthma are cough, dyspnea, and wheezing. In some instances, cough may be the only symptom. Asthma attacks often occur at night or early in the morning, possibly due to circadian variations that influence airway receptor thresholds.

• Cough. There are instances that cough is the only symptom.
• Dyspnea. General tightness may occur which leads to dyspnea.
• Wheezing. There may be wheezing, first on expiration, and then possibly during inspiration as well.
• Asthma attacks frequently occur at night or in the early morning.
• An asthma exacerbation is frequently preceded by increasing symptoms over days, but it may begin abruptly.
• Expiration requires effort and becomes prolonged.
• As exacerbation progresses, central cyanosis secondary to severe hypoxia may occur.
• Additional symptoms, such as diaphoresis, tachycardia, and a widened pulse pressure, may occur.
• Exercise-induced asthma: maximal symptoms during exercise, absence of nocturnal symptoms, and sometimes only a description of a “choking” sensation during exercise.
• A severe, continuous reaction, status asthmaticus, may occur. It is life-threatening.
• Eczema, rashes, and temporary edema are allergic reactions that may be noted with asthma.

Assessment of the severity of asthma attack

• The severity of the asthma attack must be rapidly evaluated by the following clinical criteria. Not all signs are necessarily present.

Assessment of severity in children over 2 years and adults

Assessment and Diagnostic Findings

A complete family, environmental, and occupational history is essential.

• Positive family history. Asthma is a hereditary disease, and can be possibly acquired by any member of the family who has asthma within their clan.

• Environmental factors. Seasonal changes, high pollen counts, mold, pet dander, climate changes, and air pollution are primarily associated with asthma.
• Comorbid conditions. Comorbid conditions that may accompany asthma may include gastroeasophageal reflux, drug-induced asthma, and allergic broncopulmonary aspergillosis.

Complications

Complications of asthma may include status asthmaticus, respiratoryfailure, pneumonia, and atelectasis. Airway obstruction, particularly during acute asthmatic episodes, often results in hypoxemia, requiring the administration of oxygen and the monitoring of pulse oximetry and arterial blood gases. Fluids are administered because people with asthma are frequently dehydrated from diaphoresis and insensible fluid loss with hyperventilation.

Medical Management

Immediate intervention is necessary because the continuing and progressive dyspnea leads to increased anxiety, aggravating the situation.

Goals of Asthma Therapy

• Prevent recurrent exacerbations and minimize the need for emergency department visits or hospitalizations
• Maintain (near‐) “normal” pulmonary function
• Maintain normal activity levels (including exercise and other physical activity)
• Provide optimal pharmacotherapy with minimal or no adverse effects

Pharmacologic Therapy

There are two classes of medications—long-acting control and quick-relief medications—as well as combination products.

• Short-acting beta2-adrenergic agonists
• Anticholinergics
• •Corticosteroids: metered-dose inhaler (MDI)
• Leukotriene modifiers inhibitors/antileukotrienes
• Methylxanthines

Mild to moderate attack

– Reassure the patient; place him in a 1/2 sitting position.
– Administer:

• salbutamol (aerosol): 2 to 4 puffs every 20 to 30 minutes, up to 10 puffs if necessary during the first hour. In children, use a spacer 1to ease administration (use face mask in children under 3 years).
Single puffs should be given one at a time, let the child breathe 4 to 5 times from the spacer before repeating the procedure.

• prednisolone PO: one dose of 1 to 2 mg/kg
– If the attack is completely resolved: observe the patient for 1 hour (4 hours if he lives far from the health centre) then give outpatient treatment: salbutamol for 24 to 48 hours (2 to 4 puffs every 4 to 6 hours depending on clinical evolution) and prednisolone PO (1 to 2 mg/kg once daily) to complete 3 days of treatment.
– If the attack is only partially resolved, continue with salbutamol 2 to 4 puffs every 3 to 4 hours if the attack is mild; 6 puffs every 1 to 2 hours if the attack is moderate, until symptoms subside, then when the attack is completely resolved, proceed as above.
– If symptoms worsen or do not improve, treat as sever attack.

Severe attack
– Hospitalise the patient; place him in a 1/2 sitting position.
– Administer:
• oxygen continuously, at least 5 litres/minute or maintain the SpO2 between 94 and 98%.
• salbutamol (aerosol): 2 to 4 puffs every 20 to 30 minutes, up to 10 puffs if necessary in children under 5 years, up to 20 puffs in children over 5 years and adults. Use a spacer to increase effectiveness, irrespective of age.

or salbutamol (solution for nebulisation), see Life-threatening attack
• prednisolone PO: one dose of 1 to 2 mg/kg
In the case of vomiting, until the patient can tolerate oral prednisolone, use hydrocortisone IV:
Children 1 month to < 5 years: 4 mg/kg every 6 hours (max. 100 mg per dose)
Children 5 years and over and adults: 100 mg every 6 hours
– If the attack is completely resolved, observe the patient for at least 4 hours. Continue the treatment with salbutamol for 24 to 48 hours (2 to 4 puffs every 4 hours) and prednisolone PO (1 to 2 mg/kg once daily) to complete 3 days of treatment.

Reassess after 10 days: consider long-term treatment if the asthma attacks have been occurring for several months. If the patient is already receiving long-term treatment, reassess the severity of the asthma (see table) and review compliance and correct use of medication and adjust treatment if necessary.
– If symptoms worsen or do not improve, see Life-threatening attack.

Life-threatening attack (intensive care)
– Insert an IV line.
– Administer:
• oxygen continuously, at least 5 litres/minute or maintain the SpO2 between 94 and 98%.
• salbutamol + ipratropium nebuliser solutions using a nebuliser:

The two solutions can be mixed in the nebuliser reservoir.

• corticosteriods (prednisolone PO or hydrocortisone IV) as for severe attack
– If the attack is resolved after one hour: switch to salbutamol aerosol and continue prednisolone PO as for severe attack
– If symptoms do not improve after one hour:

• administer a single dose of magnesium sulfate by IV infusion in 0.9% sodium chloride over 20 minutes, monitoring blood pressure:

Children over 2 years: 40 mg/kg

Adults: 1 to 2 g

• continue salbutamol by nebulisation and corticosteriods, as above.

Notes:

– In pregnant women, treatment is the same as for adults. In mild or moderate asthma attacks, administering oxygen reduces the risk of foetal hypoxia.

– For all patients, irrespective of the severity of the asthma attack, look for underlying lung infection and treat accordingly.

If a conventional spacer is not available, use a 500 ml plastic bottle: insert the mouthpiece of the inhaler into a hole made in the bottom of the bottle (the seal should be as tight as possible). The child breathes from the mouth of the bottle in the same way as he would with a spacer. The use of a plastic cup instead of a spacer is not recommended (ineffective).

Nursing Management

The immediate nursing care of patients with asthma depends on the severity of symptoms. The patient and family are often frightened and anxious because of the patient’s dyspnea.
Therefore, a calm approach is an important aspect of care.

• Assess the patient’s respiratory status by monitoring the severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs.
• Obtain a history of allergic reactions to medications before administering medications.
• Identify medications the patient is currently taking.
• Administer medications as prescribed and monitor the patient’s responses to those medications; medications may include an antibiotic if the patient has an underlying respiratory infection.
• Administer fluids if the patient is dehydrated.
• Assist with intubation procedure, if required.

Promoting Home- and Community-Based Care

Teaching Patients Self-Care

• Teach patient and family about asthma (chronic inflammatory), purpose and action of medications, triggers to avoid and how to do so, and proper inhalation technique.
• Instruct patient and family about peak-flow monitoring.
• Teach patient how to implement an action plan and how and when to seek assistance.
• Obtain current educational materials for the patient based on the patient’s diagnosis, causative factors, educational level, and cultural background.

Continuing Care

• Emphasize adherence to prescribed therapy, preventive measures, and need for follow-up appointments.
• Refer for home health nurse as indicated.
• Home visit to assess for allergens may be indicated (with recurrent exacerbations).
• Refer patient to community support groups.
• Remind patients and families about the importance of health promotion strategies and recommended health screening.

Basis of Pediatrics Nursing

Student Name: ___________S/O_____________ Roll No: ________

Maximum Marks: 100   Passing Marks: 50  Time: 3 Hours Date:

A. OBJECTIVE SECTION

MCQs

Note: Circle the one best answer.

1. Which cell type is responsible for the early asthmatic response?
   1. Basophil
   2. Eosinophil
   3. Mast cell
   4. Neutrophil
2. Congenital cyanotic heart disease includes:
   1. VSD.
   2. Patent Ductus Arteriosus.
   3. Fallot tetralogy.
   4. ASD
3. Fallot tetralogy include:
   1. Pulmonary stenosis
   2. Ventricular septal defect
   3. Over riding aorta
   4. All of the above
4. Serious complications of Fallot tetralogy includes
   1. Eisenminger syndrome
   2. Recurrent pneumonia
   3. Brain abscess
   4. Pulmonary hypertension

1. Major manifestations of Rheumatic fever include all the following, Except:
   1. Carditis
   2. Arthralgia
   3. Chorea
   4. Erthema nodosa
2. All the following are true about acute bronchiolitis, Except:

• Most cases are under two years old.
• Most cases are caused by respiratory syncytial virus.
• Antibiotics are recommended in infants below three months age.
• Steroids maybe helpful in some cases.

1. Bronchial asthma is characterized by all the following, Except:

• Hyper active air way
• Clubbing
• Spasmodic cough
• Bilateral chest wheezes

1. All of the following cause acute wheezing, Except:

• Bronchitis
• Bronchiolitis
• Bronchiaectasis
• Bronchial asthma

1. All of the following are common causes of bacterial pneumonia, Except:

• Staphylococci.
• Hemophillus influenza.
• Pseudomonas.
• Klepsiella.

1. All of the following are common causes of empyema, Except:

• Staphylococcal pneumonia
• Lung abscess
• Measles
• Chest injury

1. The organ of gas exchange in the fetus is the
   1. Amniotic fluid
   2. Umbilical cord
   3. Placenta
   4. Lungs
2. Commonest cause of bacterial pneumonia in infancy:
   1. H.. influenza
   2. Streptococcus
   3. Staphylococcus
   4. Pneumococcus
3. Serious complications of staphylococcal pneumonia include all the following Except :
   1. Lung abscess
   2. Bronchitis
   3. Empyema
   4. Lung collapse
4. Asthma triggers include all the following Except :
   1. Viral respiratory infections
   2. Tobacco smoke
   3. House dust mite
   4. Steroids
5. Which of the following statement is not true about Breast milk

• It contains carbohydrates  7.0 gm %.
• It contains proteins  4.0 gm %.
• It contains water 87.5 %.
• It contains less calcium than cow milk.

1. Non nutritional marasmus may be caused by.

• Acute gastroenteritis.
• Staphylococcal pneumonia.
• V.S.D.
• Urinary tract infections

1. All the following are causes vitamin D deficiency rickets, Except:

• Low calcium in diet.
• Prolonged breast feeding
• Lack of sun exposure.
• Non response of bone receptors to vitamin D

1. Colostrum is privileged by having.

• High iron.
• High antibodies.
• High vitamin D.
• High calcium

1. The important reflex necessary for breast feeding:

• Moro reflex
• Grasp reflex
• Rooting reflex
• Cough reflex

1. The clinical signs of kwashiorkor include the following, Except:
   1. Edema
   2. Skin changes
   3. Hair changes
   4. Bone changes
2. The complications of rickets include all of the following, Except:
   1. Tetany
   2. Tetanus
   3. Respiratory infection
   4. Fractures
3. Breast milk contains all of the following nutritional constituents, Except:
   1. 7.2 gm fats
   2. l.2 gm proteins
   3. 7.0 gm carbohydrates
   4. 87.5% water
4. A fourth degree marasmus infant is characterized by .
   1. Loss of buccal pad of fats.
   2. Skin changes
   3. Edema.
   4. Bowed legs
5. Breast milk contains all of the following nutritional constituents, Except:
   1. 3.5 gm fats
   2. 1.2 gm proteins
   3. 3.5gm carbohydrates
   4. 87.5% water
6. Recommended basic requirement of vitamin D for infants is:
   1. 400 u Ikg
   2. 800 ulkg
   3. 200 ulkg
   4. 100 u/kg
7. Breast milk in the first three days after delivery shows all the following, Except:
   1. Called colostrum
   2. Rich in proteins
   3. High vitamin K content
   4. High caloric value
8. The clinical signs of kwashiorkor include the following except
   1. Edema
   2. Skin changes
   3. Hair changes
   4. Bone changes
9. Colostrum is Breast milk secreted in the first post-natal :
   1. 2-3 days
   2. One week.
   3. 3-5 days
   4. One month
10. Which of the following is not a compulsory vaccine given in the first year of life:
    1. Measles Vaccine.
    2. BCG Vaccine.
    3. Meningitis vaccine.
    4. Polio vaccine.
11. All the following infectious diseases are essentially associated with rash, Except:
    1. German measles.
    2. Chickenpox.
    3. Mumps.
    4. Roseola infantum
12. The incubation period of chickenpox is:
    1. One week
    2. 2 to 3 weeks
    3. 2 to 3 months
    4. 3 days
13. Oral polio vaccine is.
    1. Live attenuated vaccine.
    2. Killed vaccine.
    3. Given at birth.
    4. Given at 4,8,12 months of age
14. Paroxysmal stage of pertussis persists for:
    1. 2 weeks
    2. 4 weeks
    3. 3 weeks
    4. 8 weeks

1. The incubation period of measles is :
   1. 2 weeks
   2. 4 weeks
   3. 3 weeks
   4. 8 weeks
2. The incubation period of Chickenpox is :
   1. 3 weeks
   2. 4 weeks
   3. 8 weeks
   4. 1 week
3. Rash of measles is characterized by all the following Except:
   1. Starts behind the ears.
   2. Spread from above downwards
   3. May be hemorrhagic in immunocompromised children
   4. May be vesicular
4. The manifestations of rubella syndrome include the following except
   1. Mental retardation
   2. Microcephaly
   3. Cardiac defects
   4. Macrocephaly
5. The virus causing chicken pox
   1. Rubella
   2. Varicella
   3. Herpes simplex
   4. None
6. Paroxysmal stage of pertussis persists for :
   1. 2 weeks
   2. 3 weeks
   3. 4 weeks
   4. 6 weeks
7. Measles rash begins :
   1. On chest and back
   2. Behind ear
   3. Behind neck
   4. On the face
8. Complications of diphtheria include all the following Except :
   1. Squint
   2. Flaccid paraplegia
   3. Heart failure
   4. Ataxia
9. The most common cause of hypovolemic shock is .
   1. Acute renal failure.
   2. Heart failure.
   3. Gastro enteritis.
   4. Toxic. coma
10. The most common cause for recurrent abdominal pains in children is.
    1. Renal stones.
    2. Familial Mediterranean fever
    3. Intestinal parasites.
    4. Inflammatory bowel disease.
11. Serious complications of gastroenteritis include:
    1. Dehydration
    2. Acidosis
    3. Shock
    4. All of the above
12. Hypertonic dehydration is characterized by:
    1. Moist tongue
    2. Lost skin elasticity
    3. High serum sodium
    4. Drowsiness
13. All of the following are correct about physiological jaundice, Except:
    1. It is a conjugated hyperbilirubinemia
    2. The baby looks healthy and feeds well
    3. Doesn’t exceed 12 mg/dl
    4. It doesn’t persist more than 7 days
14. All of the following are true about phototherapy, Except:
    1. Reduce serum unconjugated bilirubin level.
    2. Can cause watery stools.
    3. Increase fluid requirement.
    4. Can be a substitute for Exchange transfusion in small preterm with hyperbilirubinemia.
15. Neonatal period extends up to:
    1. 21 days.
    2. 28 days.
    3. 30 days.
    4. 35 days.
16. Moro reflex in normal neonates disappear at
    1. 1 week
    2. 3 weeks
    3. 6 weeks
    4. 3 months
17. The umbilical cord contains
    1. One artery and one vein
    2. One artery and two capillaries
    3. Two arteries and one vein
    4. Two veins and one artery
18. Persistence of Moro reflex at 12 weeks indicate :
    1. Brain damage
    2. Normal child
    3. Hungry child
    4. Irritable child
19. Atelectasis due to intra-bronchial obstruction may be due to:
    1. Foreign body
    2. Mucus plug
    3. Both
    4. None
20. Common presentations of chronic renal failure in children include :
    1. Anemia
    2. Bone deformity
    3. Hypertension
    4. All of the above
21. The cause of death in spinal polio is:
    1. Paralysis of respiratory muscles
    2. Cardiac arrest
    3. Cranial nerve paralysis
    4. Urinary complications
22. All of the following might be causes of cerebral palsy ,Except:
    1. Kernicterus.
    2. Toxoplasmosis.
    3. Congenital hypothyroidism.
    4. Tuberous sclerosis
23. Cerebral palsy is characterized by
    1. Mental retardation
    2. Motor disability
    3. Curable
    4. Sensory loss
24. The fatal poliomyelitis is :
    1. Bulbar polio
    2. Spinal polio
    3. Encephalitis
    4. Cerebral polio
25. Delayed puberty may be due to:
    1. Growth hormone deficiency
    2. Malnutrition
    3. Hypothyroidism
    4. All of the above
26. The site of lesions in myasthenia gravis:
    1. Spinal cord
    2. Neuromuscular junction
    3. Cranial nerves
    4. All of the above
27. An infant sits without support by….. Month.
    1. 5 month.
    2. 7 month.
    3. 8 month.
    4. 9 month.
28. The head circumference ,by the end of the second year equals:
    1. 35 cm.
    2. 45 cm.
    3. 50 cm.
    4. 60 cm .
29. Infants body weight is tripled by the age of:
    1. 5 months
    2. 24 months
    3. 12 months
    4. 18 months
30. Short stature may be due to:
    1. Growth hormone deficiency
    2. Malnutrition
    3. Hypothyroidism
    4. All the above
31. An infant supports his head by … … months
    1. 2 months
    2. 4 months
    3. 8 months
    4. 10 months
32. Weight gain in the first four months of age increase by
    1. 250 gm/month.
    2. 500 gm/ month
    3. 800 gm/ month
    4. 1500 gm/ month
33. Grasp reflex in normal neonates is present since.
    1. 1 week
    2. 3 weeks
    3. Birth
    4. 3 months
34. The first deciduous tooth appears by
    1. 3-4 months
    2. 4-5 months
    3. 8-9 months
    4. 5-7 months
35. The faster weight gain is seen at
    1. First year and puberty
    2. Second year and puberty
    3. Puberty
    4. Infancy
36. A child starts crawling
    1. 5 months
    2. 7 months
    3. 8 months
    4. 9 months
37. The average monthly weight gain in the first 4 months :
    1. 250 gm.
    2. 500 gm.
    3. 750 gm.
    4. 1000 gm

B.  Read each statement carefully and circle the correct answer as true or false. (10 Marks)

1. Humans serve as a reservoir for meningococcal meningitis.
   1. True
   2. False
2. Currently there is no vaccine for meningococcus.
   1. True
   2. False
3. Tetanus is nearly always fatal.
   1. True
   2. False
4. Viral meningitis (“aseptic meningitis”) is usually far more severe and deadly than bacterial or fungal meningitis.
   1. True
   2. False
5. The common cold is caused by one virus.
   1. True
   2. False
6. Mycobacterium tuberculosis can survive up to 10 years suspended in fine aerosols.
   1. True
   2. False
7. Meningitis refers to inflammation of the brain.
   1. True
   2. False
8. Is meningitis contagious?
   1. True
   2. False
9. Spina bifida is the deformity of the brain.
   1. True
   2. False
10. Cleft lip and palate occurs always unilaterally.
    1. True
    2. False

SUBJECTIVE SECTION (20 Marks)

Attempt any five of the following questions. All questions carry equal marks.

Q.No. 01 List the causes of birth defects and explain any one of them: (04 Marks)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Q.No. 02 Define the Mylomeningocele along with sign and symptoms. (04 Marks)

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Q.No. 03 Write 10 most common accidents of children age with their preventive measures. (04 Marks)

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Q.No. 04 Define tetanus. Explain nursing management of tetanus case. (04 Marks)

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Q.No. 05 Enlist the responsibilities of a pediatric nurse. (04 Marks)

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Q.No. 06 Write down the difference between diarrhea and dysentery. (04 Marks)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Q.No. 07 Define Down Syndrome and elaborate its nursing management. (04 Marks)

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………..THE END………….