chap 39 child musculoskeletal

36. A child with juvenile idiopathic arthritis (JIA) is started on a nonsteroidal antiinflammatory drug (NSAID). Nursing considerations include: a. monitor heart rate. b. administer NSAIDs between meals. c. check for abdominal pain and bloody stools. d. expect inflammation to be gone in 3 or 4 days.

ANS: C NSAIDs are the first-line drugs used in JIA. Potential side effects include gastrointestinal, renal, and hepatic side effects. The child is at risk for gastrointestinal bleeding and elevated blood pressure. The heart rate is not affected by this drug class. NSAIDs should be given with meals to minimize gastrointestinal problems. The antiinflammatory response usually takes 3 weeks before effectiveness can be evaluated. DIF: Cognitive Level: Comprehension REF: p. 1678 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

6. The nurse is caring for an immobilized preschool child. Which of the following is helpful during this period of immobilization? a. Encourage wearing pajamas. b. Let child have few behavioral limitations. c. Keep child away from other immobilized children if possible. d. Take child for a "walk" by wagon outside the room.

ANS: D Transporting the child outside of the room by stretcher, wheelchair, or wagon increases environmental stimuli and provides social contact. Street clothes are preferred for hospitalized children. This decreases the sense of illness and disability. The child needs appropriate limits, for both adherence to the medical regimen and developmental concerns. It is not necessary to keep the child away from other immobilized children. DIF: Cognitive Level: Analysis REF: p. 1629 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity

2. The nurse stops to assist an adolescent who has experienced severe trauma when hit by a motorcycle. The emergency medical system (EMS) has been activated. The first person who provided assistance applied a tourniquet to the child's leg because of arterial bleeding. The nurse should do which of the following related to the tourniquet? a. Loosen the tourniquet. b. Leave the tourniquet in place. c. Remove the tourniquet and apply direct pressure if bleeding is still present. d. Remove the tourniquet every 5 minutes, leaving it off for 30 seconds each time.

ANS: B A tourniquet is applied only as a last resort, and then it is left in place and not loosened until definitive treatment is available. Once the tourniquet is applied, skin and tissue necrosis occur below the site. Loosening or removing the tourniquet allows toxins from the tissue necrosis to be released into the circulation. This can induce systemic, deadly tourniquet shock. DIF: Cognitive Level: Analysis REF: p. 1622 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

34. Which of the following statements is true concerning osteogenesis imperfecta (OI)? a. It is easily treated. b. It is an inherited disorder. c. Braces and exercises are of no therapeutic value. d. Later-onset disease usually runs a more difficult course.

ANS: B OI is a heterogeneous, autosomal dominant disorder characterized by fractures and bone deformity. Treatment is primarily supportive. Several investigational therapies are being evaluated. Primary goal of therapy is rehabilitation. Lightweight braces and splints help support limbs, prevent fractures, and aid in ambulation. The disease is present at birth. Prognosis is affected by the type of OI. DIF: Cognitive Level: Comprehension REF: p. 1676 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

33. An appropriate nursing intervention when caring for the child with osteomyelitis is which of the following? a. Encourage frequent ambulation. b. Administer antibiotics with meals. c. Move and turn child carefully and gently to minimize pain. d. Provide active range-of-motion exercises of affected extremity.

ANS: C During the acute phase, any movement of the affected limb causes discomfort to the child. Careful positioning with the affected limb supported is necessary. Weight bearing is not permitted until healing is well under way to avoid pathologic fractures. Intravenous antibiotics are used initially. Food is not necessary with parenteral therapy. Active range of motion would be painful for the child. DIF: Cognitive Level: Comprehension REF: p. 1674 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

4. Which of the following can result from the bone demineralization associated with immobility? a. Osteoporosis b. Pooling of blood c. Urinary retention d. Susceptibility to infection

ANS: A Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Pooling of blood is a result of the cardiovascular effects of immobilization. Urinary retention is secondary to the effect of immobilization on the urinary tract. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems. DIF: Cognitive Level: Comprehension REF: p. 1631 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

35. Major goals for the therapeutic management of juvenile idiopathic arthritis (JIA) include: a. control pain; preserve joint function. b. minimize use of joint; achieve cure. c. prevent skin breakdown; relieve symptoms. d. reduce joint discomfort; regain proper alignment.

ANS: A The goals of therapy are to control pain, preserve joint range of motion and function, minimize the effects of inflammation, and promote normal growth and development. There is no cure for JIA at this time. Skin breakdown is not an issue for most children with JIA. Symptom relief and reduction in discomfort are important. Once the joints are damaged, it is often irreversible. DIF: Cognitive Level: Comprehension REF: p. 1678 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

9. Which of the following is characteristic of fractures in children? a. Fractures rarely occur at the growth plate site because it absorbs shock well. b. Rapidity of healing is inversely related to the child's age. c. Pliable bones of growing children are less porous than those of adults. d. Periosteum of a child's bone is thinner, is weaker, and has less osteogenic potential compared with the adult.

ANS: B Healing is more rapid in children. The younger the child, the more rapid the healing process. Nonunion of bone fragments is uncommon except in severe injuries. The epiphyseal plate is the weakest point of long bones and a frequent site of injury during trauma. Children's bones are more pliable and porous than those of adults. This allows them to bend, buckle, and break. The greater porosity increases the flexibility of the bone and dissipates and absorbs a significant amount of the force on impact. The adult periosteum is thinner, is weaker, and has less osteogenic potential than that of a child. DIF: Cognitive Level: Comprehension REF: p. 1637 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

39. The nurse is teaching the parent of a 4-year-old with a cast on the arm about care at home. Which of the following statement by the parent would indicate a correct understanding of the teaching? a. "I should have the affected limb hang in a dependent position." b. "I will use an ice pack to relieve the itching." c. "I should avoid keeping the injured arm elevated." d. "I will expect the fingers to be swollen for the next 3 days."

ANS: B Teaching the parent to use an ice pack to relieve the itching is an important aspect when planning discharge for a child with a cast. The affected limb should not be allowed to hang in a dependent position for more than 30 minutes. The affected arm should be kept elevated as much as possible. If there is swelling or redness of the fingers, the parent should notify the health care provider. DIF: Cognitive Level: Application REF: p. 1645 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

12. A 7-year-old has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which of the following should be included in the home care instructions? a. No restrictions of activity are indicated. b. Elevate casted arm when both upright and resting. c. The shoulder should be kept as immobile as possible to avoid pain. d. Swelling of the fingers is to be expected. Notify a health professional if it persists more than 48 hours.

ANS: B The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. The child should not engage in strenuous activity for the first few days. Rest with elevation of the extremity is encouraged. Joints above and below the cast on the affected extremity should be moved. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours. DIF: Cognitive Level: Application REF: p. 1645 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

16. An appropriate nursing intervention when caring for a child in traction would be which of the following? a. Removing adhesive traction straps daily to prevent skin breakdown b. Assessing for tightness, weakness, or contractures in uninvolved joints and muscles c. Providing active range-of-motion exercises to affected extremity three times a day d. Keeping child prone to maintain good alignment

ANS: B Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released or replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement is expected with children. Each time the child moves, the nurse should check to ensure that proper alignment is maintained. DIF: Cognitive Level: Application REF: p. 1649 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

29. When does idiopathic scoliosis become most noticeable? a. Newborn period b. When child starts to walk c. During preadolescent growth spurt d. Adolescence

ANS: C Idiopathic scoliosis is most noticeable during the preadolescent growth spurt. It is seldom apparent before age 10 years. DIF: Cognitive Level: Comprehension REF: p. 1668 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

28. Which of the following terms is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? a. Scoliosis b. Lordosis c. Kyphosis d. Ankylosis

ANS: C Kyphosis is an abnormally increased convex angulation in the curvature of the thoracic spine. Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Lordosis is an accentuation of the cervical or lumbar curvature beyond physiologic limits. Ankylosis is the immobility of a joint. DIF: Cognitive Level: Comprehension REF: p. 1667 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

32. Which of the following is the primary method of treating osteomyelitis? a. Joint replacement b. Bracing and casting c. Intravenous antibiotic therapy d. Long-term corticosteroid therapy

ANS: C Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus. The treatment of choice is antibiotics. Joint replacement, bracing and casting, and long-term corticosteroid therapy are not indicated for infectious processes. DIF: Cognitive Level: Comprehension REF: p. 1674 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

20. A young girl has just injured her ankle at school. In addition to notifying the child's parents, the most appropriate, immediate action by the school nurse is which of the following? a. Apply ice. b. Observe for edema and discoloration. c. Encourage child to assume a position of comfort. d. Obtain parental permission for administration of acetaminophen or aspirin.

ANS: A Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have compression applied. The nurse observes for the edema while placing a cold pack. The application of ice can reduce the severity of the injury. Maintaining the ankle at a position elevated above the heart is important. The nurse helps the child be comfortable with this requirement. The nurse obtains parental permission for administration of acetaminophen or aspirin after ice and rest are assured. DIF: Cognitive Level: Analysis REF: p. 1657 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

30. A preadolescent has been diagnosed with scoliosis. The planned therapy is the use of a thoracolumbosacral orthotic. The patient asks how long she will have to wear the brace. The appropriate answer is: a. for as long as you have been told. b. most preadolescents use the brace for 6 months. c. until your vertebral column has reached skeletal maturity. d. it will be necessary to wear the brace for the rest of your life.

ANS: C Bracing can halt or slow the progress of most curvatures. They must be used continuously until the child reaches skeletal maturity. Telling the child "For as long as you have been told" does not answer the child's question and does not promote involvement in care. Six months is unrealistic, since skeletal maturity is not reached until adolescence. Once skeletal growth is complete, bracing is no longer effective. DIF: Cognitive Level: Application REF: p. 1667 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

1. An 8-year-old child is hit by a motor vehicle in the school parking lot. The school nurse notes that the child is responding to verbal stimulation, but is not moving extremities when requested. The first action the nurse should take is to: a. wait for the child's parents to arrive. b. move the child out of the parking lot. c. have someone notify the emergency medical services (EMS) system. d. help the child stand to return to play.

ANS: C The child was involved in a motor vehicle collision and at this time is not able to move his extremities. The child needs immediate attention at a hospital for assessment of the possibility of a spinal cord injury. Since the child cannot move the extremities, the child should not be moved until the cervical and vertebral spines are stabilized. The EMS team can appropriately stabilize the spinal column for transport. Although it is important to notify the parents, the EMS system should be activated and transport arranged for serious injuries. The only indication to move the child is to prevent further trauma. DIF: Cognitive Level: Analysis REF: p. 1622 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

18. Which of the following statements is correct regarding sports injuries during adolescence? a. Conditioning does not help prevent many sports injuries. b. The increase in strength and vigor during adolescence helps prevent injuries related to fatigue. c. More injuries occur during organized athletic competition than during recreational sports participation. d. Adolescents may not possess insight and judgment to recognize when a sports activity is beyond their capabilities.

ANS: D Injuries occur when the adolescent's body is not suited to the sport or when he or she lacks the insight and judgment to recognize that an activity exceeds his or her physical abilities. More injuries occur when their muscles and body systems (respiratory and cardiovascular) are not conditioned to endure physical stress. Injuries do not occur from fatigue, but rather from overuse. All sports have the potential for injury to the participant, whether the youngster engages in serious competition or in sports for recreation. More injuries occur during recreational sports than during organized athletic competition. DIF: Cognitive Level: Comprehension REF: p. 1653 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

31. A 17-year-old is returning to the surgical unit following Luque instrumentation for scoliosis repair. In addition to the usual postoperative care, the nurse knows that initially: a. position changes are made by log rolling. b. assistance is needed to use the bathroom. c. head of bed is elevated to minimize spinal headache. d. passive range of motion is instituted to prevent neurologic injury.

ANS: A After scoliosis repair using a Luque procedure, the adolescent is turned by log rolling to prevent damage to the fusion and instrumentation. The patient is kept flat in bed for the first 12 hours and is not ambulatory until the second or third postoperative day. A urinary catheter is placed. The head of the bed is not elevated until the second postoperative day. Range-of-motion exercises are begun on the second postoperative day. DIF: Cognitive Level: Comprehension REF: p. 1671 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

14. A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. Which of the following should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub leg. c. Carefully pick material off leg. d. Apply powder to absorb material.

ANS: A Simply soaking in the bathtub is usually sufficient for removal of the desquamated skin and sebaceous secretions. Several days may be required to eliminate the accumulation completely. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child. DIF: Cognitive Level: Application REF: p. 1645 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

21. A student athlete was injured during a basketball game. The nurse observes significant swelling. The player states he thought he "heard a pop," that the pain is "pretty bad," and the ankle feels "as if it is coming apart." Based on this description, the nurse suspects a: a. sprain. b. fracture. c. dislocation. d. stress fracture.

ANS: A Sprains account for approximately 75% of all ankle injuries in children. A sprain results when the trauma is so severe that a ligament is either stretched or partially or completely torn by the force created as a joint is twisted or wrenched. Joint laxity is the most valid indicator of the severity of a sprain. A fracture involves the cross section of the bone. Dislocations occur when the force of stress on the ligaments disrupts the normal positioning of the bone ends or the bone ends in the socket. Stress fractures result from repeated muscular contraction and are seen most often in sports involving repetitive weight bearing such as running, gymnastics, and basketball. DIF: Cognitive Level: Analysis REF: p. 1657 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

5. Which of the following measures is important in managing hypercalcemia in a child who is immobilized? a. Provide adequate hydration. b. Change position frequently. c. Encourage diet high in calcium. d. Provide diet high in calories for healing.

ANS: A Vigorous hydration is indicated to prevent problems with hypercalcemia. Suggested intake for an adolescent is 3000 to 4000 ml/day of fluids. Diuretics are used to promote the removal of calcium. Changing position is important for skin and respiratory concerns. Calcium in the diet is restricted when possible. A high-protein diet served as frequent snacks with favored foods is recommended. A high-calorie diet without adequate protein will not promote healing. DIF: Cognitive Level: Comprehension REF: p. 1631 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. In teaching a 16-year-old adolescent who was recently diagnosed with systemic lupus erythematosus (SLE), which of the following statements should the nurse include? Select all that apply. a. "You should use a moisturizer with a sun protection factor (SPF) of 30." b. "You should avoid pregnancy, since this can cause a flare up." c. "You should not receive any immunizations in the future." d. "You may need to be on a low-protein, high-carbohydrate diet." e. "You should expect to lose weight while taking steroids." f. "You may need to modify your daily recreational activities."

ANS: A, B, F Teaching an adolescent with SLE should foster adaptation and self-advocacy and includes using a moisturizer with an SPF of 30, avoiding pregnancy since it can produce a flare up, and modifying recreational activities but continuing with daily exercise as an essential part of the treatment plan. The adolescent should continue to receive immunizations as scheduled, should expect to gain weight while on steroid therapy, and would not have a specialized diet. DIF: Cognitive Level: Analysis REF: p. 1682 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

19. The middle school nurse is speaking to parents about prevention of injuries as a goal of the physical education program. This is accomplished through: a. use of protective equipment at the family's discretion. b. education of adults to recognize signs that indicate a risk for injury. c. sports medicine program to help student-athletes work through overuse injuries. d. arrangements for multiple sports to use same athletic fields to accommodate more children.

ANS: B Adults close to sports activities need to be aware of the early warning signs of fatigue, dehydration, and risk for injury. School policy should require mandatory use of protective equipment. Proper sports medicine therapy does not support "working through" overuse injuries. Too many students involved in different activities create distractions, which contribute to the child losing focus. This is a contributing factor to injury. DIF: Cognitive Level: Application REF: p. 1655 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

8. Immobilization causes which of the following effects on metabolism? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased levels of stress hormones

ANS: B Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake. Immobilization leads to hypercalcemia and a negative nitrogen balance secondary to muscle atrophy. Decreased production of stress hormones occurs with decreased physical and emotional coping capacity. DIF: Cognitive Level: Comprehension REF: p. 1631 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

22. An adolescent comes to the school nurse after experiencing shin splints during a track meet. The nurse should offer reassurance that: a. shin splints are expected in runners. b. ice, rest, and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve pain. c. it is generally best to run around and "work the pain out." d. moist heat and acetaminophen are indicated for this type of injury.

ANS: B Shin splints result when the ligaments tear away from the tibial shaft and cause pain. Actions that have an antiinflammatory effect are indicated for shin splints. Ice, rest, and NSAIDs are the usual treatment. Shin splints are rarely serious, but they are not expected, and preventive measures are taken. Rest is important to heal the shin splints. Continuing to place stress on the tibia can lead to further damage. DIF: Cognitive Level: Analysis REF: p. 1658 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

15. A child with a hip spica cast is being prepared for discharge. Recognizing that caring for a child at home is complex, the nurse should include which of the following in the parents' instructions for home care? a. Turn every 8 hours. b. Specially designed car restraints are necessary. c. Diapers should be avoided to reduce soiling of the cast. d. Use abduction bar between legs to aid in turning.

ANS: B Standard seat belts and car seats may not be readily adapted for use by children in some casts. Specially designed car seats and restraints meet safety requirements. The child must have position changes much more frequently than every 8 hours. During feeding and play activities, the child should be moved for both physiologic and psychosocial benefit. Diapers and other strategies are necessary to maintain cleanliness. The abduction bar is never used as an aid for turning. Putting pressure on the bar may damage the integrity of the cast. DIF: Cognitive Level: Application REF: p. 1645 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

27. A 4-year-old is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses the skin of his right foot and sees that it is pale with an absence of pulse. What should the nurse do first? a. Reposition the child and notify practitioner. b. Notify the practitioner of the changes noted. c. Give the child medication to relieve the pain. d. Chart the observations and check the extremity again in 15 minutes.

ANS: B The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. This is an emergency condition. Pain medication should be given after the practitioner is notified. The findings should be documented with ongoing assessment. DIF: Cognitive Level: Analysis REF: p. 1649 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

24. The recommended drink for athletes during practice and competition is: a. sports drinks to replace carbohydrates. b. cold water for gastrointestinal tract rapid absorption. c. carbonated beverages to help with acid-base balance. d. enhanced performance carbohydrate-electrolyte drinks.

ANS: B Water is recommended for most athletes, who should drink 4 to 8 oz every 15 to 20 minutes. Cold water facilitates rapid gastric emptying and intestinal absorption. Most carbohydrate sports drinks have 6% to 8% carbohydrate, which can cause gastrointestinal upset. Carbonated beverages are discouraged. There is no evidence that these drinks enhance function. DIF: Cognitive Level: Analysis REF: p. 1660 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

17. The nurse is caring for a hospitalized adolescent whose femur was fractured 18 hours ago. The adolescent suddenly develops chest pain and dyspnea. The nurse should suspect which of the following? a. Sepsis b. Osteomyelitis c. Pulmonary embolism d. Acute respiratory tract infection

ANS: C Fat emboli are of greatest concern in individuals with fractures of the long bones. Fat droplets from the marrow are transferred to the general circulation where they are transported to the lung or brain. This type of embolism usually occurs within the second 12 hours after the injury. Sepsis would manifest with fever and lethargy. Osteomyelitis usually is seen with pain at the site of infection and temperature. A child with an acute respiratory tract infection would have nasal congestion, not chest pain. DIF: Cognitive Level: Analysis REF: p. 1652 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

23. The nurse at a summer camp recognizes the signs of heatstroke in an adolescent girl. Her temperature is 40° C (104° F). She is slightly confused but able to drink water. Nursing care while waiting for transport to the hospital should include which of the following? a. Administer antipyretics. b. Administer salt tablets. c. Apply towels wet with cool water. d. Sponge with solution of rubbing alcohol and water.

ANS: C Heatstroke is a failure of normal thermoregulatory mechanisms. The onset is rapid with initial symptoms of headache, weakness, and disorientation. Immediate care is relocation to a cool environment, removal of clothing, and application of cool water (wet towels or immersion). Antipyretics are not used because they are metabolized by the liver, which is already not functioning. Salt tablets are not indicated and may be harmful by increasing dehydration. Rubbing alcohol is not used. DIF: Cognitive Level: Analysis REF: p. 1660 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

11. Parents bring a 7-year-old to the clinic for evaluation of an injured wrist after a bicycle accident. The parents and child are upset, and the child will not allow an examination of the injured arm. The priority nursing intervention is: a. send the child to radiology so that an x-ray film can be taken. b. initiate an intravenous line and administer morphine for the pain. c. calmly ask the child to point to where the pain is worst and to wiggle fingers. d. have the parents hold the child so that the nurse can examine the arm thoroughly.

ANS: C Initially, assessment is the priority. Since the child is alert but upset, the nurse should work to gain the child's trust. Initial data are gained by observing the child's ability to move the fingers and to point to the pain. Other important observations at this time are pallor and paresthesias. The child needs to be sent to radiology for x-ray film, but initial assessment data need to be obtained. Sending the child to radiology will increase the child's anxiety, making the examination difficult. It is inappropriate to ask parents to restrain their child. These parents are upset about the injury. If restraint is indicated, the nurse should obtain assistance from other personnel. DIF: Cognitive Level: Comprehension REF: p. 1639 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

13. The nurse uses the five Ps to assess ischemia in a child with a fracture. Which of the following findings is considered a late and ominous sign? a. Petaling b. Posturing c. Paresthesia d. Positioning

ANS: C Paresthesia distal to the injury or cast is an ominous sign that requires immediate notification of the practitioner. Permanent muscle and tissue damage can occur within 6 hours. The other signs of ischemia that need to be reported are pain, pallor, pulselessness, and paralysis. Petaling is a method of placing protective or smooth edges on a cast. Posturing is not a sign of peripheral ischemia. Finding a position of comfort can be difficult with a fracture. It would not be an ominous sign unless pain was increasing or uncontrollable. DIF: Cognitive Level: Application REF: p. 1644 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

25. The nurse is teaching the girls' varsity sports teams about the "female athlete triad." Essential information to include is: a. they should take low to moderate calcium to avoid hypercalcemia. b. they have strong bones because of the athletic training. c. pregnancy can occur in the absence of menstruation. d. a diet high in carbohydrates accommodates increased training.

ANS: C Sexually active teenagers, regardless of menstrual status, need to consider contraceptive precautions. Increased calcium (1500 mg) is recommended for amenorrheic athletes. The decreased estrogen in girls with the female athlete triad, coupled with potentially inadequate diet, leads to osteoporosis. Diets high in protein and calories are necessary to avoid potentially long-term consequences of intensive, prolonged exercise programs in pubertal girls. DIF: Cognitive Level: Analysis REF: p. 1662 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

37. An important nursing consideration when caring for a child with juvenile idiopathic arthritis (JIA) would be which of the following? a. Apply ice packs to relieve acute swelling and pain. b. Administer acetaminophen to reduce inflammation. c. Teach child and family correct administration of medications. d. Encourage range-of-motion exercises during periods of inflammation.

ANS: C The management of JIA is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that nonsteroidal antiinflammatory drugs should not be given on an empty stomach and to be alert for signs of toxicity. Warm, moist heat is best for relieving stiffness and pain. Acetaminophen does not have antiinflammatory effects. Range-of-motion exercises should not be done during periods of inflammation. DIF: Cognitive Level: Planning REF: p. 1678 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

38. Essential teaching for adolescents with systemic lupus erythematosus (SLE) include: a. high-calorie diet because of increased metabolic needs. b. home schooling to decrease risk of infections. c. protection from sun and fluorescent lights to minimize rash. d. intensive exercise regimen to build up muscle strength and endurance.

ANS: C The photosensitive rash is a major concern for individuals with SLE. Adolescents who spend time outdoors need to use sunscreens with a high SPF, hats, and clothing. Uncovered fluorescent lights can also cause a photosensitivity reaction. The diet should be sufficient in calories and nutrients for growth and development. The use of steroids can cause increased hunger, resulting in weight gain. This can present additional emotional issues for the adolescent. Normal functions should be maximized. The individual with SLE is encouraged to attend school and participate in peer activities. A balance of rest and exercise is important; excessive exercise is avoided. DIF: Cognitive Level: Application REF: p. 1685 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity: Physiologic Adaptation

3. Which of the following is a physiologic effect of immobilization on children? a. Metabolic rate increases. b. Venous return improves, since child is in supine position. c. Circulatory stasis can lead to thrombus and embolus formation. d. Bone calcium increases, releasing excess calcium into the body (hypercalcemia).

ANS: C The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with immobilization. With the loss of muscle contraction, there is a decreased venous return to the heart. Calcium leaves the bone during immobilization, leading to bone demineralization and increasing the calcium ion concentration in the blood. DIF: Cognitive Level: Comprehension REF: p. 1625 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

10. A 14-year-old is admitted to the emergency department with a fracture of the right humerus epiphyseal plate through the joint surface. The nurse knows that this fracture will: a. create difficulty, since the child is left handed. b. heal slowly, since this is the weakest part of the bone. c. require different management to prevent bone growth complications. d. necessitate complete immobilization of the shoulder for 4 to 6 weeks.

ANS: C This type of fracture (Salter type III) can cause problems with growth in the affected limb. Early and complete assessment is essential to prevent angular deformities and longitudinal growth problems. The difficulty for the child does not depend on the location at the epiphyseal plate. Any fracture of the dominant arm presents obstacles for the individual. Healing is usually rapid in the epiphyseal plate area. Complete immobilization is not necessary. Often these injuries are surgically repaired with open reduction and internal fixation. DIF: Cognitive Level: Comprehension REF: p. 1638 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

26. Parents are considering treatment options for their 5-year-old with Legg-Calvé-Perthes disease. Both surgical and conservative therapies are appropriate. They are able to verbalize the differences between the therapies when they state: a. "All therapies require extended periods of bed rest." b. "Conservative therapy will be required until puberty." c. "Our child cannot attend school during the treatment phase." d. "Surgical correction requires a 3- to 4-month recovery period."

ANS: D Surgical correction involves additional risks of anesthesia, infection, and possibly blood transfusion. The recovery period is only 3 to 4 months rather than the 2 to 4 years of conservative therapies. The use of non-weight bearing appliances and surgical intervention does not require prolonged bed rest. Conservative therapy is indicated for 2 to 4 years. The child is encouraged to attend school and engage in activities that can be adapted to therapeutic appliance. DIF: Cognitive Level: Application REF: p. 1666 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential

7. The nurse is teaching parents the proper use of a hip-knee-ankle-foot orthosis (HKAFO) for their 4-year-old child. The parents demonstrate basic essential knowledge by stating: a. alcohol will be used twice a day to clean the skin around the brace. b. weekly visits to the orthotist are scheduled to check screws for tightness. c. initially, a burning sensation is expected and the brace should remain in place. d. condition of the skin in contact with the brace should be checked every 4 hours.

ANS: D This type of brace has several contact points with the child's skin. To minimize the risk of skin breakdown and facilitate use of the brace, vigilant skin monitoring is necessary. Alcohol should not be used on the skin. It is drying. Parents are capable of checking and tightening the screws when necessary. If a burning sensation occurs, the brace should be removed. If several complaints of burning occur, the orthotist should be contacted. DIF: Cognitive Level: Comprehension REF: p. 1633 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential