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Pediatric Primary Care (CPNP-PC)

Certified Pediatric NP - Primary Care Certification Exam


The Anatomy of a Question


A 4-year-old girl with allergic rhinitis has been compliant with daily oral antihistamine use for the past six weeks but continues to have daily complaints of nasal itching and discharge. She also has complaints of itchy eyes with redness and tearing at least once weekly. Which of the following interventions would be the most appropriate next step in her symptom management?

Answer choice options
  • A. Immunotherapy
  • B. Intranasal fluticasone
  • C. Intranasal oxymetazoline
  • D. Oral montelukast

The incorrect options (distractors) are not totally wrong. These options can be diagramed as follows:

Most Correct
Least Correct
  • B.
    Intranasal fluticasone Most effective therapy for allergic rhinitis.
  • C.
    Intranasal oxymetazoline May be considered for short-term symptom management but cause rebound nasal congestion with prolonged or frequent use.
  • D.
    Oral montelukast Has limited effects on rhinitis symptoms like rhinorrhea.
  • A.
    Immunotherapy Reserved for patients who have failed to achieve adequate symptom control with pharmacotherapy.

The Anatomy of an Explanation

Allergic rhinitis results from environmental exposure of the nasal mucosa to an allergen, causing inflammation that leads to rhinorrhea, nasal congestion, nasal itching, and sneezing. Nasal symptoms are frequently associated with concomitant conjunctival complaints, including edema, itching, tearing, and hyperemia. Symptoms are commonly classified as either intermittent or persistent. Persistent symptoms are those that are experienced four or more days per week or for four or more weeks at a time, consistent with the child described in the vignette. Symptoms may also be stratified according to severity, with attention to the degree of impact on a patient’s quality of life, including sleep impairment, disruption of daily activities, and effect on school or work performance. Minimizing allergen exposure as a preventative measure should not be overlooked as an approach to symptom control and should be undertaken in addition to any necessary pharmacotherapy. For intermittent or mild symptoms, oral antihistamines (in particular, the less-sedating second-generation agents) are an acceptable treatment. For children failing this intervention or who have persistent or moderate-severe symptoms, intranasal corticosteroids, such as intranasal fluticasone, are more effective therapy than oral antihistamines. In combination with oral antihistamines, they are also effective treatment for allergic conjunctivitis symptoms

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