2nd Pedia course

1. PEM MCQS 2022 PART2
Dr. Abdullah Akkam
Consultant-Pediatrics/Pediatric Emergency
Children Hospital/KSMC

2. MCQ1
1) A 12-year-old male is brought by the EMS after his parents found him in his bedroom agitated and confused. He
has no other medical problems and is not taking any medication. His temperature is 37.9°C, heart rate is 170
beats/min, RR is 22 breaths/min, and blood pressure is 140/85 mm Hg. His pupils are 5 mm and reactive, his
mucous membranes are dry, he has red facial flushing, and no obvious bowel sounds on examination. He is
delirious, agitated, and writhing in bed, continuously mumbling and picking at the air. Of the following, the BEST
next management step for this boy is to administer intravenous
 a) diazepam
 b) naloxone
 c) phenobarbital
 d) pyridostigmine
15/01/1444

3. 2) A 2-year-old boy is brought to the emergency department after being found with an empty bottle of chewable
junior acetaminophen (160-mg tablets) in his hand and pill fragments in his mouth. His mother reports that the 24-
count bottle had been full and that she found 5 tablets scattered on the ground. She found him 30 minutes ago. The
13-kg boy is playful and alert. His temperature is 36.8°C, heart rate is 120 beats/min, respiratory rate is 20
breaths/min, blood pressure is 107/62 mm Hg, and oxygenation is 100% on pulse oximetry. The remainder of his
physical examination is unremarkable. Of the following, the MOST appropriate next intervention is to
 a) administer activated charcoal
 b) administer N-acetylcysteine
 c) administer syrup of ipecac
 d) obtain a 4-hour acetaminophen level before further therapy is initiated
 e) perform gastric lavage
MCQ2
3

4. 3) A 2-year old girl is brought to the emergency department 4 hours after ingesting an unknown number of prenatal
vitamins containing ferrous sulfate. She has vomited several times and has had 1 loose stool. The alert child is
holding her stomach and crying. On physical examination, her temperature is 37.3°C, respiratory rate is 30
breaths/min, heart rate is 136 beats/min, and blood pressure is 82/50 mm Hg. Of the following, the laboratory test
that is MOST reliable in predicting her risk of developing severe toxicity is
 a. blood glucose
 b. serum bicarbonate
 c. serum iron
 d. total iron-binding capacity
MCQ3
4

5. 4) A 5-year-old boy is brought to the emergency department for wheezing and abdominal pain. In the waiting area,
he experiences profuse emesis and diarrhea. On physical examination, the afebrile child is in moderate respiratory
distress and has a heart rate of 72 beats/min, respiratory rate of 20 breaths/min, and blood pressure of 120/82 mm
Hg. He is somnolent and has copious secretions and bibasilar rales. His pupils are 1 mm bilaterally but react
minimally to light. The boy is diffusely weak, with occasional fasciculations. Deep tendon reflexes are difficult to
elicit. Of the following, the MOST likely diagnosis is
 a. acute intermittent porphyria
 b. acute lead poisoning
 c. Guillain-Barre syndrome
 d. organophosphate poisoning
MCQ4
5

6. 5) A 26-month-old boy is brought to the ED after his mother found him with an open bottle of drain cleaner that
contains sodium hydroxide. At presentation, he is drooling and has swelling of the lips and scattered burns of the
oral mucosa. He is not in respiratory distress and his vital signs are within normal limits for his age. Of the following,
after addressing his airway, breathing, and circulation, the MOST appropriate next step in his treatment is
 a. administration of a weak acid (e.g. orange juice) to neutralize the alkali
 b. administration of intravenous corticosteroids
 c. administration of water to try to dilute the alkali
 d. arranging for urgent esophagoscopy
MCQ5
6

7. MCQ6
6) A 14-year-old female adolescent comes to the ED after ingesting oven cleaner in a suicide attempt, but is now
remorseful. The event occurred 30 minutes ago. She is complaining of chest pain and dysphagia, but is not having
any difficulty breathing and has not vomited. She is tearful but in no acute distress. There is some pooling of
secretions in her mouth and erythema of her posterior oropharynx. Her lungs are clear to auscultation and her
abdomen is soft and nontender. Vital signs are within normal limits for age. The patient is placed on a monitor and
toxicology screens are sent. Of the following, the BEST next management step for the patient is to
 a) administer activated charcoal
 b) make her status nil per os
 c) perform barium swallow
 d) offer water
15/01/1444

8. MCQ7
7) A 13-year-old male adolescent who reportedly ate a detergent pod 3 hours earlier is being evaluated. According
to the patient and his family, after watching internet videos he decided to bite a liquid laundry detergent pod. The
patient reported that it tasted bad so he immediately spit out the contents. He then looked further on the internet
and got nervous, so he told his parents, who drove him to the ED. The patient describes some irritation to his tongue
and mild pain with swallowing. He denies any cough or trouble breathing and his family reports that he is acting
normally without any fatigue or confusion. On examination, his vital signs are normal and he is alert and oriented.
He has mild erythema to his tongue but none to his posterior pharynx. He has a supple neck without tenderness or
crepitus, clear breath sounds bilaterally, and his abdomen is soft and nontender. Of the following, the next BEST
management step for this patient would be to
 a) consult gastroenterology for esophagoscopy
 b) consult otolaryngology for bronchoscopy
 c) discharge from the hospital with follow-up
 d) perform chest radiography
15/01/1444

9. 8) A 13-year-old boy and his friend are dropped off at the ambulance bay of the ED because he became
confused and agitated at a party. Although his friend is not able to provide an extensive medical history, he
is able to state that the patient was seen taking some unknown substance . His symptoms of initial agitation
and then somnolence started soon after the ingestion. On presentation to the ED, the boy has a
temperature of 36.9°C, a heart rate of 160 beats/min, a respiratory rate of 18 breaths/min, and a blood
pressure of 116/75 mm Hg. During the physical examination, the patient is moaning and will open his eyes
only to deep sternal rub. He also has bidirectional nystagmus in both eyes and has tachycardia but no
discernible murmur. His skin is warm, dry, and well perfused. His pupils are midpoint and briskly reactive. He
has normal bowel sounds. No clonus is noted on neurological examination, and he has +2 deep tendon
reflexes in his lower extremities. Of the following, the MOST likely substance he ingested was
 a) cocaine
 b) γ-hydroxybutyrate
 c) heroin
 d) ketamine
MCQ8
9

10. 9) An 8-year-old boy seated in the back seat of his father’s old truck has a sudden collapse, and is unresponsive and
limp. His father pulls over to the side of the road and removes him from the truck. The boy regains consciousness
after 2 minutes and is brought to the closest ED by ambulance. On arrival, he complains of headache and nausea,
with amnesia of the syncopal episode. The child has no significant medical history, with no intercurrent illness. The
father witnessed no seizure activity. There is a strong odor of car exhaust on the clothing of the father and child. The
boy is alert, with a pulse oximetry reading of 98% (room air) and normal vital signs. His physical examination findings
are normal. Of the following, the toxic exposure MOST likely to explain this child’s symptoms is
 a) benzene
 b) carbon monoxide
 c) cyanide
 d) sulfur dioxide
MCQ9
10

11. MCQ10
10) A 5-year-old child is brought to the ED by EMS after being pulled out of a house fire. On arrival, he is awake and
alert, and has a cough productive of clear sputum but is otherwise in no distress. He has no burns to the skin. The
paramedic states that he was unconscious in a smoke-filled bedroom, but awoke on the scene and has been awake
and alert since then. His temperature is 37.4°C, pulse rate is 126 beats/min, RR is 32 beats/min, blood pressure is
96/64 mm Hg, and SpO2: is 100%. He is placed on a partial rebreather mask and intravenous access established. Of
the following, the test MOST likely to aid in the immediate evaluation and treatment of this patient is
 a) blood gas with co-oximetry
 b) chest radiography
 c) cyanide level
 d) cervical spine radiography
15/01/1444

12. MCQ11
11) A 4-month-old boy is brought to the ED after accidentally being given ant killer that was being kept in a formula
can. The family immediately called EMS personnel, who are bringing him to the ED for evaluation. Members of the
EMS team state that they have started administering albuterol via nebulizer, as the infant appears to be wheezing.
On his arrival in the ED, the child is intermittently agitated and then sleepy, with copious drooling. He vomited just
before coming into the ED. His vital signs are a temperature of 37.1°C, a heart rate of 170 beats/min, a RR of 28
breaths/min, and a blood pressure of 93/60 mm Hg. His breath sounds are significant for rales and rhonchi
bilaterally, and he is experiencing tachypnea and respiratory distress with retractions. He also has loose watery stools
in his diaper. Of the following, the MOST appropriate antidote to manage this patient’s acute symptoms is
 a) atropine
 b) deferoxamine
 c) physostigmine
 d) pralidoxime
15/01/1444

13. MCQ12
12) A 14-year-old arrives by ambulance in respiratory failure after being found unresponsive in a park. He is being
ventilated via bag and mask, and frothy secretions are noted. He is obtunded and unable to provide any further
history. On examination, his temperature is 36.4°C, his heart rate is 48 beats/min, and his blood pressure is 88/46
mm Hg. The monitor shows a narrow complex rhythm. There is little spontaneous respiratory effort, and he is
receiving artificial ventilation with a respirator bag at 16 breaths/min with SpO2:s of 95%. There are no external
signs of trauma. His pupils are between 1 and 2 mm bilaterally and reactive to light. He has been placed in a cervical
collar by the prehospital care providers. His lungs have crackles bilaterally. His heart sounds are normal, without
murmurs or gallops. He is well perfused with 2+ pulses. Of the following, the BEST next step in the treatment is to
administer
 a) activated charcoal
 b) atropine
 c) epinephrine
 d) naloxone
15/01/1444

14. MCQ13
13) You are evaluating a 14-year-old boy with altered mental status. He was brought to the ED by ambulance from a
huge “rave” party when bystanders saw him lying on the ground in a confused state. His parents report that he has a
history of depression and that his only medication is fluoxetine. He has not been sick recently. On physical
examination, he is disoriented and moderately agitated and seems to be hallucinating. His temperature is 38.1°C, his
pulse is 142 beats/min, his RR is 35 breaths/min, his blood pressure is 172/92 mm Hg, and his SpO2: is 100% on
room air. He is alert but not oriented to time, place, or person. He is diaphoretic and tremulous. His pupils are
dilated and mildly reactive. Other than tachycardia and tachypnea, his heart and lung examination findings are
normal. His bowel sounds are hyperactive. A neurological examination reveals increased tone in the lower
extremities, increased patellar reflexes, and inducible clonus with plantar flexion. There is no rigidity of the lower
extremities. An intravenous line has been established, and a 12-lead EKG, laboratory tests, and urine drug screening
have been ordered and are pending. Of the following, the BEST initial treatment for this patient would be
administration of
 a) cyproheptadine
 b) dantrolene
 c) diazepam
 d) physostigmine
15/01/1444

15. MCQ14
14) A 4-year-old girl is brought to the ED after being involved in a low-speed vehicle crash. According to the
paramedics, the car sustained very little damage because the crash happened in an alleyway, but the child got
splashed with industrial strength sulfuric acid from an open container and sustained extensive burns to the face and
torso. The paramedics intubated the patient for airway protection and pain control. On arrival, the child is noted to
be completely undressed and covered in a blanket. Her temperature is 37°C, heart rate is 150 beats/min, assisted RR
is 25 breaths/min, and SpO2: is 100% on 100% oxygen. She has obvious partial thickness chemical burns on the
exposed areas of her body—face, neck, hands. Her breath sounds are clear. Remainder of the examination findings
are normal. Of the following, the MOST appropriate method of decontamination for this patient is
 a) application of mineral oil
 b) irrigation with polyethylene glycol solution
 c) irrigation with water
 d) mechanical removal
15/01/1444

16. MCQ15
15) A 12-year-old girl comes to the ED with the chief complaint of right leg pain. Two days prior, she sustained an
injury after a log rolled onto her right lower leg. Her parents report that she had been seen in an ED, where a “distal
tibia fracture” was diagnosed and a short leg cast was applied. Orthopedic follow-up had been scheduled for several
days later, but the pain had worsened despite the scheduled use of ibuprofen. On evaluation, the patient is in
obvious discomfort. Her vital signs are a temperature of 37.2°C, a heart rate of 110 beats/min, a RR of 14
breaths/min, and a blood pressure of 122/68 mm Hg. She has a short leg cast on the right lower extremity. She
reports pain with active and passive movement of her toes. Her toes are not swollen, but they are cool to touch and
have decreased sensation to light touch. Capillary refill time is 3 sec. The remainder of her physical examination
findings are normal. Of the following, the BEST next step in the treatment of this patient is to
 a) administer IV morphine and elevate the extremity
 b) administer IV morphine and obtain radiographs
 c) administer IV morphine and remove the cast
 d) provide oral analgesics and refer to orthopedic clinic
15/01/1444

17. 16) 18 An 8-week-old former 28-week premature male infant is brought to the ED with increased fussiness
and a mass that has been evident in the right inguinal region for the past few hours. The patient has a
history of having a reducible right inguinal hernia and is scheduled to be evaluated by a surgeon. There has
been no vomiting or blood in the stool. When examined, the infant is alert but fussy. His vital signs are a
temperature of 37.1°C, a heart rate of 170 beats/min, a respiratory rate of 52 breaths/min, and a blood
pressure of 80/50 mm Hg. The abdomen is soft and nontender. Bowel sounds are normal. There is a
nonreducible, mildly tender mass in the right inguinal region. There is no overlying erythema or ecchymosis.
The testicles are nontender and normal. You plan to attempt manual reduction of the inguinal hernia. Of the
following, the BEST initial option to decrease pain and distress would be to use
 a) active distraction
 b) intramuscular ketamine
 c) intravenous propofol
 d) oral sucrose
MCQ16
17

18. 17) A 14-year-old boy arrives by ambulance after sustaining an injury during a football game. He tripped and
was then tackled; he has an obvious deformity to his left femur. Paramedics placed a peripheral intravenous
catheter and provided two doses of fentanyl en route for his severe pain, with only minimal relief.
Intravenous ketorolac and a dose of morphine are administered to facilitate radiographic imaging. After the
radiographs are obtained, the orthopedist is requesting procedural sedation to facilitate placement of a
traction splint. You are concerned that there is an increased risk of a serious adverse respiratory event
during sedation and discuss the plan with your team; you want to pay particular attention to ventilation. Of
the following, given your concerns, the BEST way to monitor this patient during sedation is with
 a) capnography
 b) electrocardiography
 c) plethysmography
 d) pulse oximetry
MCQ17
18

19. 18) 12 An 8-year-old boy comes to the ED with an arm injury. The patient reports that his much larger cousin fell
onto his arm while they were practicing wrestling moves. The boy is crying, and his left forearm is markedly
deformed. He has distal pulses, there are no lacerations or skin breaks, and the motor function of his hand is intact.
He rates his pain as a 10 out of 10. You immobilize the arm and order analgesia. Of the following, the MOST
appropriate medication to give this patient at this time is
 a) buccal midazolam
 b) intramuscular meperidine
 c) intranasal fentanyl
 d) oral acetaminophen with codeine
MCQ18
19

20. 19) A 10-year-old boy is brought to the ED by EMSs after injuring his right arm in a fall. His arm was splinted
at the scene, and intravenous access was established. There were no other injuries, no loss of
consciousness, and no lacerations to the injured area. His vital signs on arrival in the ED are a heart rate of
120 beats/min, a respiratory rate of 22 breaths/min, and blood pressure of 120/75 mm Hg. He is
uncomfortable but not in distress. The findings of his examination other than the right upper extremity are
normal. The right forearm is diffusely tender, with significant dorsal angulation and swelling distally. There is
no overlying laceration at the suspected fracture site. The hand and elbow are nontender. He is
neurovascularly intact. Radiographs confirm your suspicion of an angulated and displaced distal forearm
fracture. Of the following, the BEST single intravenous agent to facilitate this patient’s fracture reduction is
 a) fentanyl
 b) ketamine
 c) midazolam
 d) propofol
MCQ19
20

21. 20) A neonate is brought to the emergency department shortly after delivery en route to the emergency
department. Upon presentation to triage, he is apneic and pulseless. Cardiopulmonary resuscitation is initiated and
endotracheal intubation is performed. Cardiopulmonary resuscitation is continued, but attempts for intravascular
access are not successful. At 6 minutes into resuscitation efforts, his pulses are still not palpable and the cardiac
monitor is showing asystole. Of the following, the BEST next step in management for the resuscitation of the
neonate is to
 a) administer epinephrine 0.1 mg/kg (0.1 mL/kg; 1:1,000) via intramuscular route
 b) administer epinephrine 0.1 mg/kg (1 mL/kg; 1:10,000) via endotracheal route
 c) administer epinephrine 0.1 mg/kg (0.1 mL/kg; 1:1,000) via endotracheal route
 d) administer epinephrine 0.1 mg/kg (1 mL/kg; 1:10,000) via intramuscular route
 e) tempt intraosseous access and then administer epinephrine 0.1 mg/kg (0.1 mL/kg; 1:1,000) via intraosseous
route
MCQ20
21

22. MCQ21
21) A pregnant teen presents to the ED in labor and has a precipitous vaginal delivery. The delivery itself is
uncomplicated, but the physician notes meconium staining in the amniotic fluid. After drying and stimulating the
newborn, the physician notes that he has gasping respirations and poor tone. His heart rate is 55 beats/min. No
secretions are noted in his mouth. The nurse is setting up monitor leads and a pulse oximeter. Of the following, the
BEST next step in the treatment of this newborn is
 a) administering intravenous epinephrine
 b) performing chest compressions
 c) performing endotracheal intubation
 d) providing positive-pressure ventilation
15/01/1444

23. MCQ22
22) A 30-year-old woman who states she is at 38 2/7 weeks’ estimated gestation brings her 2-year-old son to the ED
for evaluation of an upper respiratory tract infection. As the family is brought into the room, the mother starts to
have regular contractions every 2 to 3 minutes. The pregnant woman is brought to the critical care room where it is
discovered that she is crowning; within minutes, she delivers a male infant covered in meconium. The infant is
immediately dried and warmed but continues to be floppy, with gasping respirations, poor chest rise, and a
persistent heart rate of 88 beats/min. Of the following, the BEST next treatment for this infant is
 a) chest compressions
 b) bag-mask ventilation
 c) intravenous atropine
 d) intravenous epinephrine
15/01/1444

24. 23) A newborn is found on a bench outside the ED. The infant is wrapped in a bath towel and is still covered with
vernix. You note that he is limp, appears gray, and is not crying. His temperature is 35°C, his heart rate is 84
beats/min, and his respiratory rate is 8 breaths/min. You provide initial newborn resuscitation (warm, dry, position,
suction, stimulate) for 1 min without apparent improvement. Active rewarming and assisted ventilation are initiated.
Heel stick blood sampling is unsuccessful, but you are able to establish emergent vascular access via an intraosseous
line and obtain only 1 cc of blood for diagnostic testing. Of the following laboratory studies, the MOST appropriate
use of the available sample is
 a) blood culture
 b) blood sugar
 c) blood type
 d) hemoglobin
MCQ23
24

25. 24) A 7–year–old boy is brought to the emergency department by his parents after sustaining a laceration to his right
arm when he pushed on a glass door. On arrival in triage, he is pale, with a heart rate of 140 beats/min, respiratory
rate of 18 breaths/min, and blood pressure of 90/38 mm Hg. There is a large, complex laceration of his right
antecubital fossa and medial arm with active, pulsatile bleeding. The parents had tried to keep pressure on the
wound en route but have not been able to stop the bleeding. Of the following, the MOST appropriate first step in
emergency department management is to:
 a. apply a tourniquet and obtain vascular access
 b. apply direct pressure on the wound and obtain vascular access
 c. obtain vascular access and administer 20 mL/kg 0.9% saline
 d. obtain vascular access and transfuse with O-negative blood
MCQ24
25

26. 25) A 12-year-old boy is brought to the ED after a high-speed motor vehicle collision. He was found at the scene,
lying next to the family vehicle. EMS personnel placed him on long board with cervical spine immobilization and
provided high-flow oxygen. In the ED, he has a heart rate of 58 beats/min, respiratory rate of 12 breaths/min, and
blood pressure of 160/80 mm Hg. Primary survey reveals a depressed mental status, with eyes only open to pain, no
speech, and flexion to painful stimulus. There are significant signs of trauma to the front of his head. Of the
following, the MOST important action is to:
 a. decrease cerebral perfusion
 b. prevent cerebral herniation
 c. prevent hypocarbia
 d. reverse neuronal damage
MCQ25
26

27. 26) A 10-year-old boy is brought to the emergency department 2 hours after being crushed by a refrigerator he was helping
to move. He was reportedly trapped for more than 1 hour while his brother went to get help. His brother states that the
boy was answering questions after the initial injury, but when he returned with another friend to free the boy, his brother
was lethargic and confused. On exam, the teenager is obtunded and difficult to arouse, with a heart rate of 142 beats/min,
respiratory rate of 38 breaths/min, BP of 137/93 mm Hg, and pulse oximetry reading of 99% in room air. He has extensive
petechiae on both lower legs and feet and bruising and swelling of both lower extremities from the groin to the ankles. You
place a catheter and obtain only 100 mL of rusty-colored urine. Urine dipstick results are +ve for blood, but RBC are not
visible on microscopy. While awaiting the remainder of laboratory results, the initial bolus of normal saline finishes and the
nurse asks what fluids you want hung next. In your decision process, you try to anticipate laboratory results. Of the
following, the MOST likely laboratory abnormality for this boy is
 a. hypercalcemia
 b. hyperphosphatemia
 c. hypokalemia
 d. metabolic alkalosis
MCQ26
27