Chapter 20: Musculoskeletal Disorders

27. A 9-year-old patient is complaining of skin irritation from the edges of a cast that was applied the previous day. The nurse should take which of the following actions? 1. Petal the cast edges with adhesive tape. 2. Massage the skin at the rim of the cast. 3. File the edges until smooth. 4. Apply more casting material to make the edges softer.

1 (1. Petaling will make the edges of the cast soft and help decrease the irritation to the skin. 2. Massaging the rim may stretch or break the casting. 3. Filing the edges will cause dust to lodge inside the cast, creating a potential for skin breakdown. 4. More casting materials will not stop the roughness of the cast. It will create more.)

54. The school nurse is screening children for scoliosis. Identify the age range that is most at risk for developing the disease. 1. 12 year olds 2. 2 year olds 3. 5 year olds 4. 18 year olds

1 (1. The increased rate of growth during this period has the higher incidence of scoliosis. 2. There is a very low incidence of scoliosis at this age. 3. There is a low incidence of scoliosis at this age because the rate of growth has slowed. 4. After puberty, the rate of growth has slowed, thus decreasing the chance for scoliosis.)

48. Which of the following is the leading therapy for lateral tibial torsion? 1. A tibial osteotomy 2. A femur osteotomy 3. Tibial decorticate positioning 4. Range of motion exercises

1 (1. The tibial osteotomy will aid in correcting the tibia torsion. 2. Therapy needs to occur with the tibia, not the femur. 3. The decorticate positioning will cause more damage. 4. Range of motion exercise will not effectively treat the issue.)

58. Osteogenesis Imperfecta causes social workers to be involved with the case. Children with this disease process present to the emergency rooms similar to a child with/experiencing __________. 1. Abuse. 2. Mental illness. 3. Malnutrition. 4. Congenital deformities

1 (1. The types and frequency of fractures of a child with Osteogenesis Imperfecta are similar to children who are abused. 2. The child would not present with a mental illness characteristic. 3. Osteogenesis Imperfecta can cause the child to be small in stature, but generally well nourished. 4. Social work does not need to be involved for a child with congenital deformities.)

47. A 14 year old has been diagnosed with Blount's disease. The nurse knows that the greatest risk factor for this disease process is: 1. Juvenile Idiopathic Arthritis. 2. Obesity. 3. Diabetes. 4. Asthma.

2 (1. Not a risk factor for Blount's disease 2. Increased weight adds pressure to the legs and can increase the amount of bowing. 3. Not a risk factor for Blount's disease 4. Not a risk factor for Blount's disease)

35. A new pediatric orthopedic nurse is learning about the most common areas for a child to have a fracture. She knows all are common sites except the: 1. Tibia. 2. Radius. 3. Femur. 4. Clavicle.

3 (1. Easily fractures because of children's activities 2. Easily fractures because of the children's activities and how a child will attempt to protect himself/herself when falling. 3. Not easily fractured because of the size of the bone 4. Easily fractures because of the bone size and the activities of children)

59. Deandra is a 3 year old with a mild form of Osteogenesis Imperfecta. She is coming to the pediatric clinic for a routine checkup. The nurse knows that Deandra's bowing legs are a result of: 1. Slipped capital femoral epiphysis. 2. A previous broken femur. 3. Microfractures of the femoral head. 4. Growth plate deformities.

4 (1. The femoral epiphysis does not dislocate. 2. Previous breaks do not cause the bowing of the legs. 3. The microfractures will cause pain, but not bowing. 4. Injuries to the growth plate will increase the chance for bowing of the legs.)

53. A pediatric patient has been brought to the emergency room because of hip pain, erythema, and edema, with a high heart rate and low-grade fever. The child will not bear weight on his left side. The diagnosis is osteomyelitis of the hip. The parents ask the nurse how the medical team plans to keep an IV in their child for at least three weeks for antibiotics. The nurse knows that: 1. The best solution will be for a PICC line to be placed in the child so that he/she does not need as many IV starts. 2. The IV sites will last up to 72 hours before needing changed, so this should not cause much pain for the child. 3. The child's arm will be immobilized so that an IV stays in. 4. The child will receive the antibiotics via injection if the IV site cannot be maintained.

1 (1. A PICC line will not require multiple IV starts, but will have to be maintained by the family and a professional. 2. Not all IV sites last 72 hours, and thus are not a good recommendation for long-term IV therapy. 3. Immobilization may cause loss of function in the extremity and should be avoided. 4. Multiple injections would be required for the medication, creating pain, fear, and non-compliance.)

32. The school nurse has been called to the playground for an emergency. When she arrives, she notes that a young girl is laying on the ground, holding her arm with a bone fragment protruding from her skin. What is the priority assessment at this time? 1. Neurovascular check 2. Elevation of the extremity 3. Providing ice 4. Pain management

1 (1. Assessing blood flow, capillary refill, color, and pain will help identify the priority for the child. 2. The arm should be immobilized to decrease risk for further damage. 3. Ice can be applied after a neurovascular check is performed. 4. Pain management can be given after a neurovascular assessment is performed.)

29. The development of the musculoskeletal system occurs during fetal development. Originally, bones begin as: 1. Cartilage. 2. Osteoclasts. 3. Osteoblasts. 4. Tendons.

1 (1. Cartilage is the first step in bone development in utero. 2. Osteoclasts are part of the bone formation. 3. Osteoblasts are the cells that form the bone. 4. Tendons are developed toward the end of fetal development.)

19. A 4-year-old female status post left supracondylar elbow pinning presents to the clinic with a chief complaint of increased swelling to the fingers, a change in color from pink to pale, numbness and tingling, and increased pain from 24 hours ago. Her fiberglass cast was applied immediately after surgery. The mother is concerned and anxious. With your knowledge about neurovascular status post surgery and fracture care, you are concerned about which of the following conditions? 1. Compartment syndrome 2. Refracture 3. Nothing. These are normal findings. 4. The mom is crazy and needs a dose of valium.

1 (1. Classic signs of compartment syndrome are the 5 Ps: Pain, Pulse, Pallor, Parasthesia, and Paralysis. 2. Refracture will not need to occur at this time. 3. These are classic signs of compartmental syndrome. 4. The mother is responding appropriately to her child's needs.)

14. A 1-year-old toddler presents to the outpatient clinic with the parents concerned about their child being "pigeon-toed." The grandparents state a positive family history of clubfoot. The family is sure it's clubfoot, and that the child is going to be deformed and disabled now. Upon physical examination, the child would have which of the following characteristics? 1. Fixed deformity in equinus, tight heel cords, inability to place foot flat on the ground, or walking on supinated feet 2. Tight hamstrings and walking on tiptoes 3. Forefoot abduction and heel in neutral alignment 4. Inward rotated tibia shafts

1 (1. Clubfoot is a rigid, fixed deformity that cannot be corrected by manipulation alone. It needs to be treated in the newborn phase with Ponseti technique. Failed conservative treatment in older infant/toddler results in tight heel cords and supination of the foot. 2. Failed conservative treatment in older infants/toddlers results in tight heelcords and supination of foot. 3. The heel will not have neutral alignment. 4. The tibial shafts will not be rotated inward.)

34. Janice, an adult orthopedic nurse, has been asked to float to the pediatric orthopedic floor for the next two weeks. It is important for Janice to remember that children have more complicated issues with fractures because: 1. Fractures can occur along an immature growth plate. 2. Children have a lower pain tolerance. 3. Children do not understand how to use crutches, and it takes more time to do discharge teaching. 4. A child's bone takes many more weeks to heal than an adult.

1 (1. Fractures in this area may take longer to heal or can form calcification, causing incorrect placement of the bone. 2. Pain is individualized. 3. Children can learn how to adapt to the use of crutches and should be given time to practice prior to discharge. 4. Because of the rapid growth of a child, the healing process usually does not take as long as an adult.)

8. A 2-year-old with Down's syndrome presents to the clinic with a chief complaint of unsteady walking. The physical therapist wants to use orthotics to help with ambulation. The main uses of assistive aids in neuromuscular conditions are: 1. To prevent deformity and improve function. 2. To stop mobility and use a stroller. 3. To cover their feet and keep them warm. 4. To relax muscles in a child with ligament laxity.

1 (1. Hallmark uses of assistive devices in neuromuscular conditions are to improve function and prevent further deformity. 2. The goal is to maintain mobility as long as possible. 3. Attempting to maintain adequate mobility is the most important factor. 4. The muscles are too relaxed, and strength needs to be built.)

15. A 1-year-old toddler presents to the outpatient clinic with parents concerned about "pigeon-toes." The grandparents state a positive family history of clubfoot. The family is sure it's clubfoot, and that the child is going to be deformed and disabled now. What is the likely diagnosis? 1. Metatarsus Adductus 2. Tibial Torsion 3. Femoral Anteversion 4. Blount's Disease

1 (1. Metatarsus Adductus typically presents with the chief complaint of in-toeing, yet the child can put his/her foot flat on the floor and the forefoot is turned inward. This is often considered a packaging disorder, but it is easily corrected with stretching and placing shoes on the opposite feet. 2. The tibia is not affected. 3. The femur is not involved. 4. Blount's disease is not demonstrated in this patient's history.)

13. A 3-year-old male presents to the clinic, post-hospital discharge, for osteomyelitis. The mother states that "he just stopped walking on his left leg for no reason, he had a high fever, and was in extreme pain. We went to the emergency room and laboratory tests and an MRI were done. He is on IV antibiotics, but I think we should stop the medicine now. He is much better." Your understanding of the care and treatment of osteomyelitis enables you to respond with which of the following? 1. "Typically speaking, depending on the organism being treated, most patients with osteomyelitis are treated with 6 to 8 weeks of IV antibiotics minimum, followed by a course of oral antibiotics directed by the infection control team." 2. "Sure, you can stop the antibiotics anytime. I am glad he is much better." 3. "If you stop the antibiotics now, your child will die." 4. None of the above responses are correct.

1 (1. Osteomyelitis is diagnosed by laboratory values and diagnostic imaging. It typically will not resolve without acute care, including IV antibiotics, pain medication, and rest/immobilization. 2. It typically will not resolve without acute care, including IV antibiotics, pain medication, and rest/immobilization. 3. The infection can spread and cause the patient to lose a limb. 4. Osteomyelitis is diagnosed by laboratory values and diagnostic imaging. It typically will not resolve without acute care, including IV antibiotics, pain medication, and rest/immobilization.)

17. A mother with a 12-month-old male African American child is in the clinic to discuss his "bowed legs." She states that the child's father and grandfather both have it, and it was never treated. She doesn't want him to look funny. With your knowledge of infantile Blount's disease, you know that which of the following is true? 1. Infants that are early walkers are more prone to infantile Blount's disease. 2. Typically, hereditary factors are involved. 3. Long-leg, cumbersome braces are well tolerated. 4. Blount's disease should not be treated until after age 4.

1 (1. Risk factors for infantile Blount's disease include early walkers and heavier children. 2. Heredity is not a factor. 3. Long-leg braces are rarely used, and other forms of therapy are recommended. 4. Treatment occurs early in life to achieve the best possible outcome.)

22. If an immature child presents to the clinic with point tenderness over the distal physis of the wrist or ankle, but negative fracture by X-ray report or observation of films, your knowledge of the Salter-Harris fracture classification would identify which of the following fractures? 1. Salter Harris I 2. Salter Harris II 3. Salter Harris III 4. Salter Harris IV

1 (1. Salter Harris I fracture classification describes injury through the growth plate in a skeletally immature child. This is not visible via radiographs, but pain and tenderness over the growth plate would be the best clinical exam. 2. Salter Harris I fracture classification describes injury through the growth plate in a skeletally immature child. 3. Salter Harris I fracture classification describes injury through the growth plate in a skeletally immature child. 4. Salter Harris I fracture classification describes injury through the growth plate in a skeletally immature child.)

11. General cast care considerations would include which of the following? 1. Keep cast clean and dry, monitor integrity of cast materials, and elevate the involved extremity for 24 to 48 hours as recommended. Monitor neurovascular status per doctor's orders and shower as instructed. 2. Allow the cast to get wet and follow up in 4 to 6 weeks for cast removal. 3. Spray the cast with Febreze if a foul smell occurs. 4. All of the above

1 (1. Standard care of casts includes: keeping the cast clean and dry at all times, elevation within 24 to 48 hours to prevent increased swelling and pain, and neurovascular checks are important to alert the provider of problems that need immediate medical attention. Casts should not become cracked, broken, or cause rubbing. A foul smell may be benign or a sign of infection. 2. Standard care of casts include keeping the cast clean and dry at all times. 3. A foul smell may be benign or a sign of infection. 4. Only one answer is correct.)

44. An 8 year old has a left femur fracture due to a motor vehicle accident and is placed in skin traction until surgery in the morning. During the nurse's assessment, she notices that the dorsalis pedis pulse is absent. What is the priority for the nurse to do next? 1. Notify the doctor immediately. 2. Give the ordered pain medication. 3. Release the skin traction. 4. Apply ice and elevate the foot.

1 (1. The absence of the pulse is a concern for lack of blood flow to the extremity. 2. The pain medication will not help regain blood flow. 3. Skin traction is not to be released without a doctor's order. 4. Ice and elevation decrease swelling and do not help to regain a pulse.)

61. A child comes to the nurse's office at school during recess and states that she was swinging on the monkey bars when she felt a pop in her shoulder. The nurse should: 1. Notify the parents to have the child taken to the doctor. 2. Tell the girl to go back to the playground because this is normal. 3. Encourage the girl to do range of motion exercises to make her arm feel better. 4. Get ice for her shoulder and send her to class after recess.

1 (1. The child is at risk for dislocation to the extremity and will need to be checked by a doctor. 2. This is not a normal occurrence and should be addressed. 3. Range of motion exercises could do further damage to the shoulder. 4. Ice may help with pain, but the child needs to have medical attention.)

33. Discharge teaching is being sent home with a girl who had a right radial fracture and has a cast. The nurse is teaching the family about PRICE. The nurse knows that the family understands the teaching when the mother states: 1. "We will make sure to rest the arm, apply ice, and keep it elevated. The important part is to keep the cast for protection." 2. "We will be able to let her return to her normal activities when we get home." 3. "We will get some pencils so she can put them down the cast to scratch her skin. We should also have her elevate her arm at least two times a day with ice." 4. "We will allow her friends to write on the cast with a permanent marker."

1 (1. The mother stated the concepts of PRICE. 2. Pain and swelling will continue or become worse if the arm is not rested. 3. No objects should be placed into the cast because of the chance for skin breakdown and losing the item inside the cast. 4. Writing on the cast can degrade the material and cause cracking.)

6. An 11-year-old boy with a tibia shaft fracture presents for his first follow-up visit after an injury. He is placed into a non-weight bearing, long leg cast with instructions about cast care. Your knowledge about cast care reveals that you should include which of the following statements in your instructions? 1. Keep the cast clean and dry, do not insert objects into the cast, and call the doctor if the cast becomes loose, cracked, or ill fitting. 2. You may take a shower in the cast, just don't put weight on it. 3. It's okay to put coins down the cast. 4. Do not call the office for a foul smell or skin irritation.

1 (1. The proper teaching for care of the cast is to keep the cast clean and dry, follow weight-bearing instructions, do not place objects in the cast or use anything to scratch inside the cast, call the office if problems with the cast, like pain, foul smell, skin irritation, cracking, loosening etc., occur. 2. The proper teaching for care of the cast is to keep the cast clean and dry. 3. Do not place objects in the cast or use anything to scratch inside the cast. 4. Call the office if problems with the cast like pain, foul smell, skin irritation, cracking, loosening etc., occur.)

37. A new pediatric nurse asks why the pediatric floor has had an increase in the number of femur fractures during the month of July. A veteran staff nurse knows that: 1. An increase in femur fractures is common in summer months because of the outdoor activities children participate in. 2. An increase in femur fractures is common after school gets out because children are not watched as closely. 3. This increase is abnormal. Usually the increase is seen in the winter months with sledding accidents. 4. This increase is abnormal because most children do not receive femur fractures.

1 (1. The types of summer activities increase the incidence of fractures to the femur. 2. This is an assumption, not a fact. 3. Femur fractures are less likely to happen in sledding accidents. 4. Children can receive femur fractures with summer activities.)

39. The most common age for femur fractures related to falls are children between the ages of: 1. 12 to 24 months. 2. 36 months to 4 years. 3. 5 to 6 years old. 4. 15 to 17 years old.

1 (1. When children are learning to walk, there is an increase in falls that are attributed to femur fractures. 2. These fractures have a lower incidence at this age. 3. These fractures have a lower incidence at this age. 4. These fractures have a lower incidence at this age.)

65. Allison has fractured her left tibia. The nurse should assess which of the following? Select all that apply. 1. Skin color distal to the fracture 2. Pain in the extremity 3. Pulses distal to the fracture 4. Paresthesia proximal to the fracture 5. Paralysis proximal to the fracture

1, 2, 3 (1. Skin color will indicate if circulation has been damaged with the injury. 2. Pain needs to be recognized because of the nerve damage to the area. 3. The lack of pulses will indicate that circulation to the affected area has been blocked. 4. The assessment should occur distal to the fracture. 5. Paralysis occurs because of injury to the spinal cord, not the tibia.)

64. Jackie's parents are concerned that her legs do not look symmetrical. As the nurse is assisting the doctor, it is noted that the child has Genu Varum. The nurse knows that the difference in Genu Varum and normal bowing of the legs is: (Select all that apply.) 1. A difference in symmetry 2. No worsening with growth 3. Radiological changes are severe 4. That Genu Varum occurs before the age of two. 5. That most issues occur after puberty.

1, 2, 3 (1. Symmetry of the extremities could differ. 2. Growth will occur. 3. Serial X-rays will be required in order to measure curvature. 4. Usually occurs after the age of 2 5. The majority of the issues occur during the school-age years.)

66. Adam has been brought to the pediatric outreach center for his kindergarten checkup. The nurse knows that she must assess which of the following areas to achieve a complete musculoskeletal assessment? Select all that apply. 1. Physical head-to-toe exam 2. History of birth and since for any major/minor injuries 3. Height and weight 4. Family expectations 5. A Denver II study

1, 2, 3, 4 (1. A head-to-toe assessment allows for all major body systems to be assessed in a systematic manner, not one that confuses or scares the child. 2. The history allows for information on anything that may influence findings. 3. Growth and nutrition can be assessed. 4. Family values and morals influence the child's cognitive, social, and physical well-being. 5. The Denver II is given in situations where there is concern for cognitive ability impairment This test takes substantial amount of time and is usually done with a doctor or therapist.)

68. A mother in labor has told the nursing staff that her child has been diagnosed in utero with Osteogenesis Imperfecta. Upon birth, it will be important for the nursery nurse to assess for which bones to possibly be broken? (Select all that apply.) 1. Femur 2. Phalanges 3. Clavicle 4. Radius 5. Humerus

1, 3, 5 (1. Because of the positioning during labor, it will be important for the femur to be assessed. 2. The phalanges are not a risk for fracture. 3. The clavicle is at high risk for fracture because of the delivery of the shoulders during labor. 4. The radius is at a low risk for fracture during labor. 5. The humerus is at a high risk for fracture because of the pressure when delivering the neonate's shoulders.)

63. The nurse at the high school is providing education to the athletes participating in fall sports practices. In the education, the nurse should include: (Select all that apply.) 1. Warm-up exercises before playing any sport. 2. Cool down exercises are only needed if long distance running has occurred. 3. Telling the coaches if you are hurt or have a possible injury. 4. Anticipating that the body will be able to have a high exercise level within one week of practice staring. 5. Instructions on hydration.

1, 3, 5 (1. Warming up increases blood flow to the muscles, which decreases injury to the area. 2. Cool down exercises should be done with any amount of exercise to decrease strain to the muscles. 3. Injuries should be taken seriously so that no further damage is caused during a sport. 4. Several weeks will be needed to build a high level of exercise endurance. 5. Hydration will help muscles maintain the adequate electrolyte balance.)

21. A 2-year-old male presents to clinic with his caregiver stating that "he slipped and fell running on the hardwood floor with the dog." He cried immediately and refused to bear weight on his left side. X-rays were taken in the emergency room of his hip, knee, and ankle. The report was negative. The caregiver states that he is still uncomfortable and is not walking on it. Laboratory tests were done and came back negative for elevated ESR, CRP, and CBC. Upon physical examination, he has pain and immediately withdraws his leg on palpation of his anterior tibia shaft. He says "ouchie" and "no hurt my leg." Your knowledge and the exam would lead you to diagnose the child with which of the following conditions? 1. Juvenile Idiopathic Arthritis 2. Toddler's Fracture 3. Hip Dysplasia 4. Sprained ankle

2 (1. A toddler's fracture is not typically visible on initial X-rays, but point tenderness on the tibia shaft and refusal to bear weight would be common in this age group following a witnessed injury. 2. A toddler's fracture is not typically visible on initial X-rays, but point tenderness on the tibia shaft and refusal to bear weight would be common in this age group following a witnessed injury. 3. The hip dysplasia would be notable with one hip higher than the other or a click when examined. 4. A toddler's fracture is not typically visible on initial X-rays, but point tenderness on the tibia shaft and refusal to bear weight would be common in this age group following a witnessed injury.)

56. Adolescent Idiopathic Scoliosis (AIS) has been diagnosed in a 12-year-old girl. The nurse working with the family discusses the difference between this type of scoliosis and the congenital form. The main difference is: 1. AIS has the S-shaped curve and congenital scoliosis does not. 2. AIS is seen in children over the age of 9, and congenital scoliosis is usually seen before the age of 6 months. 3. AIS is the most common type, and congenital scoliosis is usually caused by environmental agents, such as alcohol exposure in utero. 4. AIS tends to affect more girls, and congenital usually affects more boys.

2 (1. Congenital scoliosis has the S-shaped curve. 2. AIS occurs in older children, and congenital usually occurs during infancy. 3. AIS is not the most common form of scoliosis. 4. Congenital scoliosis affects more girls than boys.)

25. John, a 12-year-old with a fracture of the femur, has developed chest pain and shortness of breath. The nurse suspects a pulmonary embolism. The priority nursing action is to: 1. Elevate the affected extremity. 2. Administer oxygen. 3. Administer pain medication. 4. Start an IV infusion of heparin.

2 (1. Elevating may make more clots move and increase the risk for more pulmonary emboli. 2. The child needs oxygen to keep the alveoli open within the lungs to prevent respiratory collapse. 3. Pain medication may decrease the respiratory rate and does not aid in decreasing the shortness of breath. 4. The IV heparin needs to be ordered by the doctor.)

60. A child has been admitted to the emergency room after sliding into third base with his right leg during a baseball game. An X-ray has confirmed a broken right tibia. The child complains of severe pain in his right leg. Upon assessment, the nurse would anticipate seeing: 1. Ecchymosis of the left leg. 2. Ecchymosis to the right leg. 3. A bone puncturing the skin. 4. All of the above would be possible due to this injury.

2 (1. Injury occurred to the right leg, not the left. 2. The ecchymosis may develop quickly with a fracture. 3. An X-ray would not be needed to confirm a fracture if the bone was puncturing the skin. 4. Ecchymosis occurs with the fracture.)

23. A 10-year-old female gymnast fell off the balance beam, landing on her forearm. She has swelling, pain, and deformity. What diagnostic test would be the most helpful for the physician? 1. Rheumatoid laboratory tests 2. Radiographs of her forearm 3. MRI 4. CT Scan

2 (1. Rheumatoid laboratory tests are not needed at this time because this was an acute injury. 2. Diagnosis of fractures includes not only a clinical exam, but also a radiographic examination. MRI and CT scans are more helpful in ligament tears or other soft tissue evaluations. 3. MRI scans are more helpful in ligament tears or other soft tissue evaluations. 4. CT scans are more helpful in ligament tears or other soft tissue evaluations.)

12. A 12-year-old female is seen in the clinic for a chief complaint of in-toeing and being teased at school for the last six months. She had been seen as a toddler who "W" sat, and the doctor told her parents that she would outgrow this. However, she is still in-toeing a lot. The mom is concerned that she will grow up and not be able to wear high heels or walk down the stairs without tripping and falling. Your knowledge about femoral anteversion leads you to state which of the following? 1. "She will outgrow this by the time she is 20 years old." 2. "She will not outgrow this now. It usually resolves by the time children are 8 or 9 years of age, so only surgery will correct this now." 3. "She will never be able to play running sports." 4. "She should try gymnastics since she is so flexible."

2 (1. The child should outgrow this by the time they are 8 or 9 years old. 2. Hallmark signs of femoral anteversion are unresolved in-toeing, ligament laxity, history of tripping and falling, and "W-sitting." 3. She will be able to run and play sports. 4. She will be able to participate in sports.)

41. A neonate is brought to the nursery three hours after birth for an assessment. The child was diagnosed with a unilateral club foot in utero. During the nursing assessment, a priority will be assessing: 1. The size of the quadricep muscles in comparison to the calf muscles. 2. Dorsiflexion and plantar flexion of the affected foot. 3. Family history. 4. Vital signs.

2 (1. The difference in muscle mass at this age will not be a contributing factor to the child's status. 2. The amount of flexion can indicate the severity of the malformation. 3. Family history does not influence the care for this patient. 4. Vital signs will need to be taken, but the focus should be on the flexion capabilities of the foot.)

10. If a child is diagnosed with Juvenile Idiopathic Arthritis (JIA), which of the following statements is true? 1. Usually, a child outgrows the disorder. 2. NSAIDs are the treatment of choice. 3. The child should not participate in sports. 4. All of the children of these parents will have the disorder.

2 (1. The disorder lasts for the life of the child. 2. Activity helps the joints stay mobile, and anti-inflammatory medications are the treatment of choice for Juvenile Idiopathic Arthritis. 3. Participation in sports will help maintain mobility. 4. Activity helps the joints stay mobile, and anti-inflammatory medications are the treatment of choice for Juvenile Idiopathic Arthritis.)

45. A nurse is assisting the doctor with the examination of a 2 week old with developmental dysplasia of the hip. The doctor has ordered a Pavlik harness for the child's hips. The nurse knows that the teaching for the parent should include that: 1. The harness should be worn 24 hours a day. 2. The harness should only be removed for bathing. 3. The harness needs to be removed when feeding the infant. 4. The infant should remain immobile when in the harness.

2 (1. The harness should be worn 16 to 23 hours a day. 2. The harness does not need to be worn during bathing. 3. The harness should remain on during feedings. 4. The infant can move and be as mobile as he/she wants.)

50. A child has been diagnosed with toxic synovitis. The mother asks the nurse about the signs and symptoms she should be aware of because she does not want any of her other children to have the same diagnosis. The nurse discusses the disease process with the mother. She knows that the mother understands the teaching when she states: 1. "My other children are at high risk for the next 7 to 14 days." 2. "My other children are not at risk because this is usually caused by an allergy or minor trauma." 3. "My other children are not at risk because they are older than 10." 4. "This disease is very rare, and my other children are healthy, so there is little risk for them."

2 (1. This is not a contagious disease, so the other children are not at risk. 2. The disease process usually occurs because of an allergy or trauma, so her other children will not be affected. 3. Age is not a risk factor for the disease. 4. This is not a contagious disease, so the other children are not at risk.)

49. A 7-year-old boy has been diagnosed with Legg Calve Perthes disease. The femoral head is noted to be in the necrosis state. During this phase, the nurse knows that the child will be: 1. In pain. 2. Asymptomatic. 3. Limping. 4. Unable to bear any weight on the leg.

2 (1. This stage is usually asymptomatic. 2. No symptoms are usually noted during this phase. 3. Limping occurs in the later stages of degeneration. 4. This is the furthest damage for the disease process, but not for this state.)

7. A 2-week-old infant with Developmental Dislocated Hips (DDH) is currently being treated in a Pavlick harness. The mom calls and is concerned that the child is not kicking like before and seems to be in pain. She has a history of colic. Although the harness seemed to fit well in clinic last week, you are concerned. Therefore, the proper statement to the mother would be: 1. "Try some Tylenol and call her pediatrician." 2. "Remove the harness and we will see you in clinic ASAP." 3. "Go to the nearest emergency department to have the child seen." 4. "Remove the harness and call for an appointment in three months."

2 (1. When in doubt, removing the harness is the least invasive intervention. 2. Hip subluxation or dislocation is not painful. The anxiety of a new parent with a new diagnosis is high. Reassure the mother everything will be okay and that more education and reevaluation will be warranted. Sometimes the next step is casting if the child or the family fail harness treatment. Following up with the primary care physician would be okay to rule out other reasons for pain, like her abdominal issues, ear infection, GERD, etc. When in doubt, removing the harness is the least invasive intervention. 3. Hip subluxation or dislocation is not painful. The anxiety of a new parent with a new diagnosis is high. When in doubt, removing the harness is the least invasive intervention. 4. Hip subluxation or dislocation is not painful. The anxiety of a new parent with a new diagnosis is high. When in doubt, removing the harness is the least invasive intervention.)

67. Classic signs of juvenile scoliosis include: (Select all that apply.) 1. Pain when standing. 2. A forward bend of the rib hump. 3. The pelvis is thrust forward, and the shoulders are thrust backward on the body. 4. Asymmetrical shoulder heights. 5. The abdomen has a decrease in the range of motion.

2, 4, 5 (1. The child may be asymptomatic. 2. The forward bend occurs because of the curvature. 3. The pelvis is tipped back and the shoulders forward. 4. Asymmetry will occur because of the curvature. 5. The abdomen does not have range of motion.)

24. When offering treatment options for a minor fracture (buckle fracture) care to a child, especially an athlete that wants to continue playing, what are the best recommendations for immobilization? 1. Do not immobilize the fracture. 2. Removable splint 3. Fiberglass cast 4. Ace bandage

3 (1. Active athletes can potentially continue sports participation if immobilization in a well-padded cast is allowed by game rules/regulations. 2. A removable splint typically has metal stays in it that would injure another player and are not permitted. 3. A fiberglass cast will allow for immobilization and has less chance of harming other players. 4. An ace bandage, ice, and NSAIDs are treatment modalities better served for initial care to reduce pain and swelling, but not for fracture care.)

46. A mother with a child with Juvenile Idiopathic Arthritis calls the clinic nurse because the child is having a pain exacerbation. The mother asks the nurse if the child can continue with her range of motion exercises at the time. The appropriate nursing response is: 1. "Range of motion exercises should be done every day." 2. "Have the child do isometric exercises during this time." 3. "Administer additional pain medication before doing the exercises." 4. "Avoid exercises during this time."

3 (1. Pain control will be important when doing the exercises and should be addressed prior to the activity. 2. Isometrics can increase the pain. Non-weight-bearing exercises would be a better choice for the child. 3. Pain medication should be provided to aid in the child getting the most out of the therapy. 4. Exercising will be important to maintain as high of a function as possible.)

28. A nurse in the pediatric orthopedic clinic is giving discharge teaching to the parents of a child with scoliosis on how to use a brace. Which statement by the parent would indicate the need for further education? 1. "I will encourage my child to practice the physical therapy exercises." 2. "I will have my child wear soft clothing under her brace to prevent skin breakdown." 3. "I should apply lotion under the brace to help prevent skin breakdown." 4. "I should not use powder under the brace because it can cause a buildup and be irritating."

3 (1. Physical therapy will help maintain optimum health for the child. 2. Soft clothing will help reduce irritation with the brace. 3. Lotion causes moisture to build up and create more skin damage. 4. Powder buildup can be irritating to the skin with a brace.)

38. A 6 month old is brought to the ER by her babysitter. The babysitter explains that the child has been irritable all morning and will not bear weight on her right leg since she was dropped off at 8 a.m. The babysitter has attempted to contact the mother, but has not been able to reach her. After the examination, the child is diagnosed with spiral femur fracture. The nurse will need to contact Social Services because: 1. Any time a child enters the ER, Social Services needs to be contacted. 2. The mother did not bring the child in, and the babysitter does not have medical power of attorney, so a social worker will determine the needs of the child. 3. A femur fracture is abnormal unless trauma or abuse has occurred. Social Services will help to rule out child abuse. 4. The social worker will be of no help until the mother asks for services.

3 (1. Social Services needs to be contacted when suspected child abuse has occurred. 2. The best interest of the child needs to be accounted for, and the babysitter can have the child examined. 3. Femur fractures are rare in this age of a child, except in abuse situations. 4. Social Services will act in the best interests of the child in this situation.)

42. The Ponseti technique for the treatment of clubfoot consists of: 1. Wrapping the foot with ace wraps for 12 hours a day. 2. Serial casting of the foot beginning at the age of 2. 3. Serial castings beginning within the first week of life. 4. Letting the child adapt to the foot, and then treat later in life if the family/child choose to do so.

3 (1. The ace wrap is not effective. The child will need casting to help correct the deformity. 2. Serial casting should begin before the age of 2. 3. Correction as early as possible in the child's life will increase the chances of full function. 4. Adaptation will occur at any stage, but if correction is going to be made, it needs to be done prior to the bones increasing in calcification.)

55. A school nurse is assessing children for scoliosis. The nurse knows that a major curve is: 1. 15 to 25 degrees. 2. 10 to 14 degrees. 3. More than 25 degrees. 4. Less than 5 degrees.

3 (1. The curve will be larger for a major curve. 2. This curve is considered minimal. 3. This large degree of curve will be a cause for concern for the child. 4. A curve of this size is minimal and does not cause concern.)

30. During fetal development, several factors can affect the outcome of bone development. All of the following influence the development except: 1. Fifth's disease. 2. Exposure to cat feces. 3. Caffeine consumption. 4. Contaminated water.

3 (1. The disease is known to cause bone deformities if the mother has contracted the illness while pregnant. 2. Toxoplasmosis is found in cat feces and can infect the mother, thus causing deformities in the fetus. 3. No research supports bone issues with bone development. 4. Contaminated water can have bacteria, fungi, and viruses that attach to the fetus, causing bone deformities.)

18. A 14-year-old male hockey player presents to the clinic with a right clavicle fracture. The mother reports that he doesn't want to keep still and wear the splint. Your response should be: 1. "We can try a sling/swathe or a figure 8 splint. Splints are mostly for comfort." 2. "It takes about 2 to 3 weeks for the bones to become 'sticky,' then the pain decreases. He should avoid contact sports for about 6 to 8 weeks." 3. "Diversion activities are good to try, like movies or video games." 4. All of the above are correct.

4 (1. A sling provides supportive care. The patient and parents must also be reminded that the child should not do too much while bone is healing. 2. The pain will decrease in this time span, but still must be protected. 3. Diversional activities will help reduce pain. 4. Clavicle fractures are common in contact sports and heal well unless really translated or comminuted. A sling provides supportive care. The patient and parents must also be reminded that the child should not do too much while bone is healing.)

62. Children have an immature skeleton, so a child has all of the following except: 1. Increased resilience to stress. 2. Shorter healing times. 3. Thinner periosteum. 4. Higher incidence of tendon and ligament issues.

4 (1. Children have a higher resilience to stress because the skeleton has not reached full calcification. 2. Children have decreased healing times because of the rapid growth process of children. 3. The thinner periosteum allows for bone to handle pressure and bend instead of break. 4. Children do not have as high a rate of tendon and ligament issues as adults.)

5. A 5-year-old boy presents to the emergency department with a history of a motor vehicle accident. He was restrained in the backseat, and the car was hit head on. He has a swollen and deformed left thigh. He is in extreme pain. He has frequent muscle spasms. X-rays reveal a midshaft femur fracture. As you prepare the child prior to surgery, you will assist with anticipatory guidance as well as show and discuss a spica cast. What information will be helpful to this young boy? 1. A hard cast from your waist to your toes will protect your leg so it can heal. 2. We can put a cast like yours on your bear. 3. The IV will give you medicine to make you sleep, wake up, and help with the pain. 4. All of the above.

4 (1. Clear explanations in easy to understand language for this age group will help this child cope with new and uncomfortable experiences. Using hands-on demonstrations and familiar play things assist with decreasing anxiety about the unknown. 2. Placing a cast on a stuffed animal may help decrease the anxiety of the patient. 3. Using hands-on demonstrations and familiar play things assist with decreasing anxiety about the unknown. 4. Clear explanations in easy to understand language for this age group will help this child cope with new and uncomfortable experiences. Using hands-on demonstrations and familiar play things assist with decreasing anxiety about the unknown.)

9. A 7-year-old is having on and off knee, ankle, wrist, and hip pain. The family history is positive for rheumatoid arthritis. No injury has taken place, and the child has occasional swelling of joints. Pain resolves with rest, ice, and NSAIDs. The primary care physician ran labs with positive rheumatoid factor ANA and ESR. This child is a soccer player and a violinist. Your differential diagnosis would be: 1. Juvenile Idiopathic Arthritis (JIA), septic arthritis, osteomyelitis, and fracture. 2. Juvenile Idiopathic Arthritis (JIA), toxic synovitis, osteomyelitis, and Developmental Dislocated Hips (DDH). 3. Juvenile Idiopathic Arthritis (JIA), chronic inflammatory arthritis, chronic osteomyelitis, and Developmental Dislocated Hips (DDH). 4. Juvenile Idiopathic Arthritis (JIA) only.

4 (1. Juvenile Idiopathic Arthritis (JIA) is characterized by a long-standing history of pain and swelling to more than one joint. This can be hereditary. Lab oratory tests are normal in chronic osteo, toxic synovitis, and Developmental Dislocated Hips (DDH). 2. All are factors in Juvenile Idiopathic Arthritis. 3. Juvenile Idiopathic Arthritis (JIA) is characterized by a long-standing history of pain and swelling to more than one joint. This can be hereditary. Laboratory tests are normal in chronic osteo, toxic synovitis, and Developmental Dislocated Hips (DDH). 4. Juvenile Idiopathic Arthritis (JIA) is characterized by a long-standing history of pain and swelling to more than one joint. It can be hereditary. Laboratory tests are normal in chronic osteo, toxic synovitis, and Developmental Dislocated Hips (DDH).)

16. A 5-year-old female falls off the swings at the school playground. Her elbow is swollen and painful. She is seen in the ER and goes to the OR for a supracondylar elbow pinning. The parents are upset and think she will not be able to do gymnastics again. You respond: 1. "This is a common type of fracture for this age group. The children recover really well and often have no long-term side effects to the treatment." 2. "She will be casted for three weeks, and then the pins will be removed. She should work on range of motion exercises after the cast is removed. She can do gymnastics again in about 4 to 6 weeks." 3. "Her doctor will evaluate her progress with X-rays and let you know when she is ready for activities." 4. All the above

4 (1. Many children recover fully and can resume all activities without any complications. 2. Following the plan of care will help the child gain strength and mobility in the arm. 3. Supracondylar humerus fractures are very common in the pediatric setting. Many children recover fully and can resume all activities without any complications. 4. All of the responses are correct. Supracondylar humerus fractures are very common in the pediatric setting. Many children recover fully and can resume all activities without any complications.)

40. Keyanna, a 7-year-old girl, has been placed in a leg spica case because of injuries she sustained in a motor vehicle accident. The nurse has created a plan of care for Keyanna while she is an inpatient on the pediatric floor. The plan of care should address: 1. Neurovascular checks. 2. Checking to make sure two fingers can be inserted along the abdomen of the cast to make sure that it is not too tight. 3. Constipation prevention. 4. All of the above should be in the plan of care.

4 (1. Neurovascular checks will identify complications earlier rather than later. 2. Two fingers widths is the measurement to not have the cast too tight and cause skin and circulation issues. 3. Because of the inactivity, there is a higher chance of developing constipation, so prevention measures should be started. 4. Because of the inactivity, there is a higher chance of developing constipation, so prevention measures should be started.)

1. A mother brings into the emergency department a frail-looking infant with blue sclera and arm and leg deformities. The mom said she was changing her diaper and heard a "snap." She put her shirt on and she heard another "snap." She says that the baby has been crying, but eating a little. Mom reports a clavicle fracture in the delivery room, but the doctors told her it was nothing and would heal fine. The nurse notes a small lump on her right clavicle. It is not painful to the touch. The infants' left forearm and right femur appear swollen and deformed. Based on your clinical knowledge of birth defects, your best answer to the mother would be: 1. "We will call the doctor to do a skeletal survey." 2. "We will call the Child Protective Services team to rule out abuse." 3. "We will call Genetics to see if any genetic birth defects run in your family." 4. All of the above.

4 (1. Often, children with osteogenesis imperfect (OI) are misdiagnosed; therefore, all children should undergo steps to rule out abuse, then proceed with genetic counseling, testing to verify a genetic disorder. The blue sclera and fractures without severe trauma are signs of OI. 2. Often, children with osteogenesis imperfect (OI) are misdiagnosed; therefore, all children should undergo steps to rule out abuse. 3. Often, children with osteogenesis imperfect (OI) are misdiagnosed; therefore, all children should undergo steps to rule out abuse, then proceed with genetic counseling, testing to verify a genetic disorder. 4. All of the responses are correct. Often, children with osteogenesis imperfect (OI) are misdiagnosed; therefore, all children should undergo steps to rule out abuse, then proceed with genetic counseling, testing to verify a genetic disorder. The blue sclera and fractures without severe trauma are signs of OI.)

57. A pediatric nurse caring for a child with Osteogenesis Imperfecta (OI) knows that he must be aware that: 1. Care must be taken when repositioning the child. 2. Blood pressure could potentially cause a fracture. 3. Gentle holding should occur during feedings. 4. All of these are pertinent to the care of a child with OI.

4 (1. Positioning is important because fractures can easily occur with movement. 2. Increased blood pressure causes instability in the body and increases the chance for fracture. 3. Gentle holding helps to decrease the chance for fractures. 4. Positioning is important because fractures can easily occur with movement. Increased blood pressure causes instability in the body and increases the chance for fracture. Gentle holding helps to decrease the chance for fractures.)

4. A 21-one-year old basketball player comes to the emergency department with a swollen, ecchymotic, painful right ankle. He states he went up for a jump shot and twisted it. He reports pain over the medial malleolus. He cannot walk on it and was assisted off the court at the game. He reports that he has done this before, but it is different this time. He wants an air cast splint and crutches, but no x-rays. What statement indicates that this young athlete may not understand the difference between a fracture and a sprain? 1. "I will be fine in 3 days." 2. "I can play if you give me the splint." 3. "I don't need x-rays today. I've done this before." 4. All of the above.

4 (1. Sprains, strains, and fractures can all have the same symptoms of pain, swelling, inability to bear weight, and ecchymosis that may last a few days. 2. An x-ray will assist with fracture detection at this time. 3. An x-ray will assist with fracture detection. 4. Sprains, strains, and fractures can all have the same symptoms of pain, swelling, inability to bear weight, and ecchymosis. An x-ray will assist with fracture detection.)

43. Kali has prepared the discharge teaching for a 3 year old after a repair to the Achilles tendon due to clubfoot. Kali knows that the parents understand the teaching when they say which of the following statements: 1. "We will need to make sure to keep the regime set out for us, otherwise her feet could go back to the same position." 2. "We will need to watch to make sure she is walking on her tiptoes." 3. "It will be important for us to use the angle-foot orthotics as prescribed." 4. "We will want her to walk on the lateral border of her shoes."

4 (1. Teaching the proper way to walk will be the important factor in keeping the foot in the right position. 2. Walking on tiptoes causes the tendon to shorten, causing more damage. 3. This technique is not used with Achilles tendon issues. 4. Walking on the lateral boarder will help strengthen the tendon.)

3. A 16-year-old soccer player comes into the ER with left knee effusion and extreme pain. The child claims that while kicking the ball away from an opponent, she felt a "pop" and fell to the ground. She had to be assisted off the field. She is in the playoffs and wants to play again. X-rays are normal, but as the nurse, you know which of the following about sports injuries? 1. X-rays can help classify fractures, but cannot classify tissue, tendons, and ligaments. 2. She probably has an ACL tear based on the symptoms of swelling, pain, inability to bear weight, and hearing a "pop" before she went down. 3. She will need an MRI. 4. She will need crutches and a knee immobilizer as well as to rest, ice, compress, and elevate the injury.

4 (1. The X-ray can see some damage to the ligaments and swollen areas. 2. The "pop" does not classify the injury. 3. A CT scan would help identify the injured area. 4. Care of acute sports-related injuries include PRICE: protect from further injury, rest, ice, compression, and elevation to relieve pain.)

26. A family has received the diagnosis of Osteogenesis Imperfecta for their 2-month-old daughter. The parents are asking several questions to the nurse. The nurse knows the child is a Type 1 classification because of all but one of the following characteristics. 1. Blue sclera 2. Normal dentition of teeth 3. Type 1 is responsible for two-thirds of all OI diagnosis. 4. Type 1 classification will be lethal within a few weeks.

4 (1. The sclera is commonly blue with this diagnosis. 2. Type 2 has the abnormal dentition. 3. The majority of diagnoses are type 1. 4. Type 2 is lethal in a shorter period of time than type 1.)

36. Ella, an 18 month old, is brought to the clinic because the mother states that her daughter has not been putting weight on her left leg for most of the day. The doctor says that the tibia is broken after reading an X-ray. The nurse is asked to finish the discharge teaching for Ella. The nurse knows that she must discuss all of the following except: 1. Care for the cast. 2. Care for the skin. 3. Discuss signs and symptoms if the cast is too tight or there is an increase in swelling. 4. Schedule only one follow appointment in six weeks.

4 (36. Ella, an 18 month old, is brought to the clinic because the mother states that her daughter has not been putting weight on her left leg for most of the day. The doctor says that the tibia is broken after reading an X-ray. The nurse is asked to finish the discharge teaching for Ella. The nurse knows that she must discuss all of the following except: 1. Care for the cast. 2. Care for the skin. 3. Discuss signs and symptoms if the cast is too tight or there is an increase in swelling. 4. Schedule only one follow appointment in six weeks.)

20. A 15-year-old basketball player presents to the clinic with a history of colliding with another player at yesterday's game. He was planted, and his right knee went out after the collision. He has pain and swelling to his knee. He is using crutches and an ace wrap. His mother is concerned and thinks he won't play basketball again. The emergency department told the mother that the x-rays were normal. What other treatment modalities may assist this young athlete? 1. Protect, rest, ice, compression, and elevation (PRICE) 2. A knee Immobilizer 3. Non-steroidal, anti-inflammatory drugs (NSAIDs) 4. All of the above

4 (1. Sports injuries are treated initially with PRICE. NSAIDs are anti-inflammatories, which would decrease the pain and swelling. 2. A knee immobilizer would protect the injured knee and provide easier ambulation to decrease pain. 3. NSAID's are anti-inflammatories, which would decrease the pain and swelling. 4. Sports injuries are treated initially with PRICE. NSAIDs are anti-inflammatories, which would decrease the pain and swelling. A knee immobilizer would protect the injured knee and provide easier ambulation to decrease pain.)

52. Lucy is performing an assessment on a child who has been admitted with osteomyelitis of the hip. Lucy knows that while doing the assessment, the patient may exhibit: 1. No signs of pain. 2. Erythema and edema to the hip. 3. Normal vital signs. 4. A good appetite.

2 (1. The child will be in pain and require intervention. 2. Erythema and edema will be prominent, along with pain. 3. Vital signs may be elevated because of the pain, erythema, and edema to the hip. 4. The appetite may be decreased because of the pain.)

51. The nurse has been asked to aid in diagnostic testing for transient monoarticular synovitis. The nurse prepares the supplies for the procedure because she knows that the child will: 1. Need to have X-rays performed. 2. Need to have blood drawn for an ESR. 3. Need to be sedated for a spinal tap. 4. Need to have a cardiac monitor during the procedure.

2 (1. X-rays are not used as diagnostics for this diagnosis. 2. An ESR is the main diagnostic test for monoarticular synovitis because it measures inflammation. 3. A spinal tap is more invasive for a first line of diagnostics tests for this disease process. 4. This disease does not affect the heart, so a cardiac monitor is not required.)

31. A student nurse is performing a musculoskeletal assessment on a 2 year old. When doing the assessment, it is important for the student nurse to start with: 1. Palpating the bony prominences of the body. 2. Participating in a range of motion exercises. 3. Participating in weight-bearing exercises. 4. Inspecting the body visually.

4 (1. Palpation should be done last because it is the most invasive for the child. 2. Range of motion should be done after inspection. 3. Participation should occur after inspection. 4. Starting with the least invasive assessment first will allow the nurse to build trust with the child.)

2. A 13-year-old boy, who has played baseball for three years, comes in complaining of left elbow pain and swelling. He is a pitcher. He plays baseball all year. X-rays reveal medial epicondyle irritation. There is no avulsion fracture. Based on these findings, you explain to the child that he can: 1. Swim. It's a safer sport. 2. Resume baseball gradually with pain-free motion. 3. Change positions in baseball for the season. 4. Protect, rest, ice, compress, and elevate the injury as well as stop baseball for three weeks

4 (1. The repetitive motion of swimming can cause the same irritation. 2. Sports injuries are common in adolescents, especially overuse injuries. Open growth plates are locations for overuse injuries. Little Leaguer's elbow is characterized by pain, swelling, and repetitive motions. 3. The child may not have an interest in other positions. A modification to his pitching may need to be made. 4. Sports injuries are common in adolescents, especially overuse injuries. Open growth plates are locations for overuse injuries. Little Leaguer's elbow is characterized by pain, swelling, and repetitive motions.)

True/False 69. Torus fractures are more common in adults than in children.

F (This fracture is more common in children because the growth plate is still changing.)