Chapter 24 Practice Questions

A yellow bruise is approximately: 1. 2 days old 2. 5 to 7 days old 3. 7 to 10 days old 4. 10 to 14 days old

3. 7 to 10 days old - Staging of a yellow bruise is 7-10 days old, 2 days are swollen and tender, 5-7 are green, and 10-14 are brown

Approximately how old does the nurse assess a large green bruise on the thigh of a 4-year old to be? a. 2 days b. 4 days c. 6 days d. 8 days

c. 6 days - Bruise heal in various stages that are indicated according to color; after 5-7 days bruises are green

What will the nurse include when caring for a child in Buck's extension? a. Position the child with hips flexed 90 degrees at all times b. Keeping the weight in contact with the floor c. Checking for skin irritation from traction equipment d. Releasing weights on a schedule

c. Checking for skin irritation from traction equipment - This helps prevent pressure wounds and skin breakdown, a. describes 90-90 degree traction

What characteristic manifestation does the nurse caring for a child with Duchenne's muscular dystrophy document? a. Ambulates by holding onto furniture b. Exhibits atrophy of the calf muscles c. Falls frequently and is clumsy d. Has delayed fine-motor development

c. Falls frequently and is clumsy

what neurovascular assessments are involved in a neurovascular check?

- peripheral pulse and quality - color of extremity - warmth - movement and sensation - capillary refill time

A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse should perform which emergency actions in the care of the child? Select all that apply. 1. Elevate the right arm. 2. Apply warm packs to the right arm. 3. Check the neurovascular status of the right extremity. 4. Check the range of motion of the right arm and shoulder. 5. Determine the level of pain using a pediatric pain assessment tool.

1, 3, 5 - Remember than the arm or injured area must be immobilized so that the area won't be further damaged and can heal easier

A "neurovascular check" for tissue perfusion includes which of the following observations? (SATA.) 1. Pulse 2. Color and capillary refill 3. Movement and sensation 4. Equal pupil size of eyes

1. Pulse 2. Color and capillary refill 3. Movement and sensation - Equal pupil size does not describe or check for neurovascular function

How does the pediatric skeletal system differ from that of an adult? (SATA.) a. Lower mineral content b. More ossification c. Open epiphyses d. Less porosity e. Greater strength

- a, c, e - Child has less mineral content, greater porosity, open epiphyses, greater bone strength, and a thicker periosteum

A teenager who had a cast applied after a tibia fracture complains that his pain medication is not working and his pain is still a 9 or 10. The nurse notices some edema of the toes and a capillary refill of 6 seconds. The priority action of the nurse would be: 1.) call the health care provider immediately 2.) check if there is an order for a stronger pain medication 3.) try nonpharmacological techniques of pain relief 4.) explain to the teen that a new fracture is expected to be painful the first day

1.) call the health care provider immediately - This is a sign of compartment syndrome, which can result in permanent nerve damage

The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching? 1. "I will inspect the skin under the brace for redness or breakdown." 2. "I will encourage my child to do their exercises to maintain strength." 3. "I understand that my child needs to wear this brace for 12 hours a day." 4. "I understand that this brace is not a cure for scoliosis, it only slows the progression of the curvature."

3. "I understand that my child needs to wear this brace for 12 hours a day." - The parent is correct in that the brace is not curative, it just slows its progression - The brace has to be worn longer, for 16-23 hours a day

The nurse explains that Bryant's traction is reserved for children who weight less than ______________ pounds.

30 - Greater weight causes too much counterbalance and can cause damage to soft tissues

The nurse is assisting a primary health care provider (PHCP) during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data should the nurse expect to note during the examination? 1. Full range of motion of the legs 2. Marked asymmetry on the affected side 3. The unstable femoral head pops out of the acetabulum 4. The dislocated femoral head pops back into the acetabulum

4. The dislocated femoral head pops back into the acetabulum - the acetabulum moves into and over the acetabular ring - The Barlow maneuver is where the femoral head is pushed out of the acetabulum

The nurse reinforces home care instructions for parents of a child who has had an above the knee cast applied. a. Use fingertips to lift the cast until its fully dry. b. Keep small toys out of child's reach. c. Place a heating pad on the toes if they feel cold d. Elevate the legs on pillows. e. Contact the health care provider if the child complains of numbness. 1. a, b, and e 2. a, c, and d 3. b, c, and e 4. b, d, and e

4. b, d, and e - toys must be kept out of reach since the child may put them inside the cast and cause pressure injuries, elevating the legs are done to prevent edema (RICE), and contacting the provider is necessary bc of risk of compartment syndrome

An abnormal S-shaped curvature of the spine seen in school-age children is: 1. sclerosis 2. sciatica 3. scabies 4. scoliosis

4. scoliosis - the other diseases describe skin or eye conditions.

A type of fracture in a young child may be indicative of child abuse is A. greenstick fracture of the tibia B. spiral fracture of the femur C. pathological fracture of the fibula D. aligned fracture of the wrist

B. spiral fracture of the femur - This type of fracture where there's continuous healing and fracturing indicates child abuse.

A nurse assessing welts on the body of a 2-year old Vietnamese child should consider the skin lesions might be the result of the cultural practice of ________.

Coining - Heated coins are used to cure disease, which may be confused with child abuse

The nurse recognizes the signs of __________________ syndrome in a child with 90-90 degree traction when the toes are pale and edematous and have a very slow capillary refill.

Compartment - When limb in traction has been cast, the caregiver must check for tissue perfusion of the limb, syndrome occurs if the edema compromises circulation, must be corrected before permanent damage occurs

The child with Duchennes muscular dystrophy must push on his legs and walk up the leg in order to rise to a standing position. The nurse recognizes this characteristic behavior as ______________ maneuver.

Gowers - Unique way of rising from the floor by walking up the leg to get the body to standing position

_____________ is a condition in which neck motion is limited and the cervical spine is rotated bc of the shortening of the sternocleidomastoid muscle.

Torticollis - (think turtle) neck motion is limited and cervical spine is rotated bc of shortening of muscle, can be congenital or acquired and can be acute or chronic.

The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (SATA). a. Pulse is equal to uncasted limb. b. Patient is aware of touch and warm and cold application. c. Limb is cool to the touch. d. Capillary refill is 5 seconds. e. Distal limbs can flex and extend.

c, d - Limb is expected to be warm, have equal pulse, and capillary refill less than 3 seconds, if its cool to the touch then it can be indicated of compromised circulation

The nurse demonstrates which similarities among all traction devices? (SATA.) a. Pull the limb into extension b. Decrease muscle spasm c. Reduce pain d. Align two bone fragments e. Immobilize the limb

a, b, d e - Tractions are designed to immobilize and pull limbs into extension, align broken bones, and decrease muscle spasms, but tractions may cause pain

What factor(s) may trigger abuse in a parent? (SATA). a. Being abused as a child b. High self-esteem c. Substance abuse d. Overwhelming responsibility e. Knowledge deficit related to child care

a, c, d, e

The nurse is checking for capillary refill on a child in Bryant's traction. How long does it take for the toe to regain color if adequate perfusion is assessed? a. 3 seconds b. 4 seconds c. 5 seconds d. 6 seconds

a. 3 seconds - Capillary refill is always checked for color return occurring in less than 3 seconds

The nurse is providing instructions about how to treat a sprained ankle. What statement by the mother does the nurse recognize as indicative of a need for additional teaching? a. Apply warm compresses to the ankle for the 1st 24 hours. b. Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off. c. Wrap the ankle in an Ace bandage for support. d. Keep the leg elevated when sitting.

a. Apply warm compresses to the ankle for the 1st 24 hours. - Follow RICE, ice is used to reduce inflammation of the injury not heat, because the injury is already radiating heat from RBCs rushing to the area for repair

What intervention is appropriate for a nurse assessing a preadolescent child for scoliosis? a. Ask the child to bend forward at the waist and observe the child's back for asymmetry. b. Observe the gait while the child is walking forward heel to toe. c. Have the child flex the knees and look for uneven knee height. d. Look at the child's shoulders and hips while fully clothed.

a. Ask the child to bend forward at the waist and observe the child's back for asymmetry. - The nurse looks at the child's back bends forward for general body alignment and asymmetry

On entering the room of a child in Buck's traction, the nurse makes all of the following observation. Which observation requires a nursing intervention? a. Child heels are placed firmly against the foot of the bed. b. Head of bed is elevated 20 degrees. c. Weights are hanging freely. d. Ropes are on pulleys.

a. Child heels are placed firmly against the foot of the bed. - Bucks traction is dependent on the child as a counter weight. The heels should be elevated above the level of the foot of the bed.

What nursing action will significantly decrease the risk of serious complications for a child in Bryant's traction? a. Neurovascular checks are done frequently. b. Bandages are wrapped tightly c. The child is restrained from rolling over. d. The child's buttocks are resting on the bed.

a. Neurovascular checks are done frequently. - The nurse caring for child in traction must be alert for Volkmann's ischemia, which occurs when circulation is obstructed.

Which observation may cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs? a. Red, green, and yellow bruise on his body b. Bruise are dispersed on his head, arms, and legs c. A broken arm last year, and the child being described as accident-prone d. The mother is very anxious for her son to get medical attention

a. Red, green, and yellow bruise on his body - This indicates repeated bruises sustained over time, and not an accident or one-time event

Which nursing diagnosis would be a priority when preparing a plan of care for a child in a leg cast? a. Risk for altered peripheral tissue perfusion b. Risk for altered urine elimination c. Knowledge deficit d. Risk for infection

a. Risk for altered peripheral tissue perfusion - Child is at most risk of compartment syndrome from increased pressure, edema, and swelling on the tissues, so neurovascular checks are a priority

A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to know when the antibiotic protocol will end. How long will the nurse indicate that antibiotic therapy will probably last? a. 2 weeks b. 6 weeks c. 2 months d. 3 months

b. 6 weeks - Antibiotics are administered IV for 4-6 weeks

Which interventions would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis? a. Wearing splints at night to prevent extension contractures b. Applying moist heat packs upon awakening c. Taking a warm tub bath the evening before d. Sleeping with two pillow under the head

b. Applying moist heat packs upon awakening - Application of moist heat, with a compress or by tub bath helps lessen stiffness

What intervention will the nurse caring for a child in Buck's skin traction implement? a. Position in high fowlers b. Assist the child to be pulled up in bed. c. Keep childs heel on the bed surface d. Maintain child's feet against the foot of the bed

b. Assist the child to be pulled up in bed. - Child should be pulled up in bed and not touch foot or bed surface, since it defeats the purpose of having the child as a counterweight for the traction

A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. Which nursing diagnosis take highest priority for this child? a. Pain resulting from tissue trauma b. High risk for impaired skin integrity resulting from immobility c. Altered growth and development related to separation from family d. Altered urinary eliminated related to immobility and traction

b. High risk for impaired skin integrity resulting from immobility - Although all these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm and tissue trauma is the highest priority.

A 13-year-old girl is diagnosed w/ functional scoliosis. What does the nurse explain as the cause of this spinal curvature defect? a. Juvenile rheumatoid arthritis b. Poor posture c. Heredity d. Myelomeningocele

b. Poor posture - Functional is caused by poor posture and can be corrected

The parent of a child with osteomyelitis asks why his child is in so much pain. What will the nurse respond causes the pain experienced with osteomyelitis? a. Pressure of inelastic bone b. Purulent drainage in the bone marrow c. The cast applied on the extremity d. Circulatory congestion of the skin

b. Purulent drainage in the bone marrow - Osteomyelitis is infection of the bone, inflammation produces an exudate that collects under the marrow and cortex of the bone, the vessels are compressed and thrombosis occurs, producing ischemia and pain

What would the nurse consider an abnormal finding on a musculoskeletal assessment of a 4 year old child? a. Has inward turned knees while standing b. Walks on the toes c. Appears to have flat feet d. Swings his arms when walking

b. Walks on the toes - Toe walking after 3 years of age may indicate a muscle problem

A child is sent to the school nurse for assessment because she comes to school every day disheveled, unbathed, and hungry. The assessment does not indicate any bruises or marks on the body. What do these finding indicate? a. Sexual abuse b. Physical abuse c. Physical neglect d. Emotional abuse

c. Physical neglect - Physical neglect is the failure to provide for the basic physical needs of the child, including food, clothing, shelter, and basic cleanliness

The nurse assessing a child with juvenile rheumatoid arthritis notes the child's right knee and ankle are swollen, warm, and tender. The child has a temperature of 38.8 C (102 F) and abdominal pain. What type of juvenile rheumatoid arthritis do these findings suggest? a. Psoriatic b. Enthesitis c. Systemic d. Acute febrile

c. Systemic - Systemic is associated w/ elevated temp., erythrocyte sedimentation rate (ESR) and C-reactive protein, abdominal pain, and a macular rash

What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace? a. Wear the brace directly against the skin b. Wear the brace over regular clothing c. Wear the brace over a T-shirt 23 hours a day d. Remove the brace before sleeping

c. Wear the brace over a T-shirt 23 hours a day - Milwaukee brace is worn approx. 23 hrs a day over a T-shirt to protect the skin

Why does a child's fracture heal more rapidly than the adult's? a. A child's bones are less porous than adult bone. b. A child's bones are covered by a thicker periosteum. c. A child's bones are not affected by bone overgrowth. d. A child's bones have faster callus formation.

d. A child's bones have faster callus formation. - Callus forms more rapidly in the child than the adult.

What finding would the nurse assessing the neurovascular status of a child in Russell traction report immediately? a. Skin that's warm to the touch b. Capillary refill less than 3 seconds c. Ability to wiggle toes d. Bluish coloration of skin

d. Bluish coloration of skin - Cyanosis and pallor must be reported immediately since its a risk factor to compartment syndrome, warm is normal, however hot is a warning sign

What intervention is appropriate for a nurse assessing a preadolescent child for scoliosis? a. Ask the child to bend forward at the waist and observe the child's back for symmetry. b. Observe the gait while the child is walking forward heel to toe. c. Ability to wiggle toes d. Bluish coloration of skin

d. Bluish coloration of skin - Cyanosis or pallor noted in an extremity is an indication off circulatory impairment

Which assessment performed by a nursing student performing a neurovascular check alerts the instructor that further education is necessary? a. Pulses b. Capillary refill c. Movement d. Pupils

d. Pupils - Pupils are not part of the neurovascular, emphasis on vascular, meaning it checks for blood circulation and tissue perfusion, pupils are checked just for neurological.

How does Russell traction provide adequate skin traction? a. Subluxates the tibia b. Doesn't interfere w/ ROM c. Prevents the knee from flexing d. Supplies continuous pull in 2 directions

d. Supplies continuous pull in 2 directions - Continuous pull in 2 directions, one from weight of person and the other from a weight away