Chapter 48: Musculoskeletal or Articular Dysfunction NCLEX

Which of the following is an advantage to using a fiberglass cast instead of a plaster of Paris cast? a. Cheaper b. Dries rapidly c. Molds closely to body parts d. Smooth exterior

B (A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry.)

What is most descriptive of rhabdomyosarcoma? A. Most common sites are head and neck B. Common hereditary neoplasm of childhood C. Most common bone tumor of childhood D. Benign tumor; not commonly found in children

C (Although striated muscle fibers from which this tumor arises can be found anywhere in the body, the most common sites are the head and neck. It is not known to be hereditary. It arises from skeletal muscle tissue, not bone. It is highly malignant.)

The nurse is preparing an adolescent girl for an instrumentation procedure to treat scoliosis. Which of the following should the nurse include? a. Nasogastric intubation and urinary catheter may be required. b. Ambulation will not be allowed for up to 3 months. c. Surgery eliminates the need for casting and bracing. d. Discomfort can be controlled with nonpharmacologic methods.

A (Harrington instrumentation is a surgical procedure. Nasogastric intubation and urinary catheterization may be required.)

An advantage to using a fiberglass cast instead of a plaster cast is that a fiberglass cast: a. Is less expensive. b. Dries rapidly. c. Molds closely to body parts. d. Has a smooth exterior.

B (A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry. Synthetic casts are more expensive. Plaster casts mold closer to body parts. Synthetic casts have a rough exterior, which may scratch surfaces.)

Osteosarcoma is the most common bone cancer in children. Where are most of the primary tumor sites? a. Femur b. Humerus c. Pelvis d. Tibia

A (Osteosarcoma is the most frequently encountered malignant bone cancer in children. The peak incidence is between ages 10 and 25 years. More than half occur in the femur.)

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

A (Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days 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.)

The nurse is caring for an infant with developmental dysplasia of the hip. Which clinical manifestations should the nurse expect to observe (Select all that apply)? a. Positive Ortolani sign b. Unequal gluteal folds c. Negative Babinski's sign d. Trendelenburg's sign e. Telescoping of the affected limb f. Lordosis

A, B (A positive Ortolani sign and unequal gluteal folds are clinical manifestations of developmental dysplasia of the hip seen from birth to 2 to 3 months. Negative Babinski's sign, Trendelenburg's sign, telescoping of the affected limb, and lordosis are not clinical manifestations of developmental dysplasia of the hip.)

A school-age child is diagnosed with systemic lupus erythematosus (SLE). The nurse should plan to implement which interventions for this child (Select all that apply)? a. Instructions to avoid exposure to sunlight b. Teaching about body changes associated with SLE c. Preparation for home schooling d. Restricted activity

A, B (Key issues for a child with SLE include therapy compliance; body-image problems associated with rash, hair loss, and steroid therapy; school attendance; vocational activities; social relationships; sexual activity; and pregnancy. Specific instructions for avoiding exposure to the sun and ultraviolet B light, such as using sunscreens, wearing sun-resistant clothing, and altering outdoor activities, must be provided with great sensitivity to ensure compliance while minimizing the associated feeling of being different from peers. The child should continue school attendance in order to gain interaction with peers and activity should not be restricted, but promoted.)

What effect does immobilization have on the cardiovascular system? a. Venous stasis b. Increased vasopressor mechanism c. Normal distribution of blood volume d. Increased efficiency of orthostatic neurovascular reflexes

A (Because of decreased muscle contraction, the physiologic effects of immobilization include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased cerebral blood flow, and tachycardia. An altered distribution of blood volume is found, with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency of orthostatic neurovascular reflexes, with an inability to adapt readily to the upright position and pooling of blood in the extremities in the upright position.)

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

A (Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of immobilization on the urinary tract. Pooling of blood is a result of the cardiovascular effects of immobilization. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems.)

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

A (Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi.)

When assessing the child with osteogenesis imperfecta, the nurse should expect to observe: a. Discolored teeth. b. Below-normal intelligence. c. Increased muscle tone. d. Above-average stature.

A (Children with osteogenesis imperfecta have incomplete development of bones, teeth, ligaments, and sclerae. Teeth are discolored because of abnormal enamel. Despite their appearance, children with osteogenesis imperfecta have normal or above-normal intelligence. The child with osteogenesis imperfecta has weak muscles and decreased muscle tone. Because of compression fractures of the spine, the child appears short.)

An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. The nurse's approach should include which of the following? a. Answer questions with straightforward honesty. b. Avoid discussing the seriousness of the condition. c. Explain that although the amputation is difficult, it will cure the cancer. d. Assist adolescent in accepting the amputation as better than a long course of chemotherapy.

A (Honesty is essential to gain the child's cooperation and trust. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared for the surgery so he or she has time to reflect on the diagnosis and subsequent treatment. This allows questions to be answered.)

An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. The nurse's approach should include: a. Answering questions with straightforward honesty. b. Avoiding discussing the seriousness of the condition. c. Explaining that, although the amputation is difficult, it will cure the cancer. d. Assisting the adolescent in accepting the amputation as better than a long course of chemotherapy.

A (Honesty is essential to gain the cooperation and trust of the child. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared in advance for the surgery so that there is time for reflection about the diagnosis and subsequent treatment. This allows questions to be answered. To accept the need for radical surgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will not guarantee a cure. Chemotherapy is an integral part of the therapy with surgery. The child should be informed of the need for chemotherapy and its side effects before surgery.)

Which measure is important in managing hypercalcemia in a child who is immobilized? A. Promoting adequate hydration B. Changing position frequently C. Encouraging a diet high in calcium D. Providing a diet high in protein and calories

A (Hydration is extremely important to help remove the excess calcium from the body. This can help prevent hypercalcemia. Changing position frequently will help manage skin integrity but will not affect calcium levels. The calcium will not be incorporated into bone because of the lack of weight bearing. The child is at risk of developing hypercalcemia. The child's metabolism is slower because of the immobilization. A diet with sufficient calories and nutrients for healing is important.)

Which term is used to describe a type of fracture that does not produce a break in the skin? a. Simple b. Compound c. Complicated d. Comminuted

A (If a fracture does not produce a break in the skin, it is called a simple or closed fracture. A compound or open fracture is one with an open wound through which the bone protrudes. A complicated fracture is one in which the bone fragments damage other organs or tissues. A comminuted fracture occurs when small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue. These are rare in children.)

Which of the following terms is used to describe a type of fracture that does not produce a break in the skin? a. Simple b. Compound c. Complicated d. Comminuted

A (If a fracture does not produce a break in the skin, it is called a simple, or closed, fracture.)

The nurse is preparing an adolescent with scoliosis for a Luque-rod segmental spinal instrumentation procedure. Which consideration should the nurse include? a. Nasogastric intubation and urinary catheter may be required. b. Ambulation will not be allowed for up to 3 months. c. Surgery eliminates the need for casting and bracing. d. Discomfort can be controlled with nonpharmacologic methods.

A (Luque-rod segmental spinal instrumentation is a surgical procedure. Nasogastric intubation and urinary catheterization may be required. Ambulation is allowed as soon as possible. Depending on the instrumentation used, most patients walk by the second or third postoperative day. Casting and bracing are required postoperatively. The child usually has considerable pain for the first few days after surgery. Intravenous opioids should be administered on a regular basis.)

Osteosarcoma is the most common bone cancer in children. Where are most of the primary tumor sites? a. Femur b. Humerus c. Pelvis d. Tibia

A (Osteosarcoma is the most frequently encountered malignant bone cancer in children. The peak incidence is between ages 10 and 25 years. More than half occur in the femur. After the femur, most of the remaining sites are the humerus, tibia, pelvis, jaw, and phalanges.)

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. Apply powder to absorb material. d. Carefully pick material off leg.

A (Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days to eliminate the accumulation completely.)

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

A (Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have compression applied. Observing for edema and discoloration, encouraging the child to assume a comfortable position, and obtaining parental permission or administration of acetaminophen or aspirin are not immediate priorities.)

A young girl has just injured her ankle at school. In addition to calling 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.

A (Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have compression applied.)

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

A (The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. Pain medication should be given after the practitioner is notified. This is an emergency condition; immediate reporting is indicated. The findings should be documented with ongoing assessment.)

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

A (The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner.)

What is most descriptive of the therapeutic management of osteosarcoma? a. Treatment usually consists of surgery and chemotherapy. b. Amputation of the affected extremity is rarely necessary. c. Intensive irradiation is the primary treatment. d. Bone marrow transplantation offers the best chance of long-term survival.

A (The optimal therapy for osteosarcoma is a combination of surgery and chemotherapy. Amputation is frequently required. Intensive irradiation and bone marrow transplantation are usually not part of the therapeutic management.)

Which of the following is most descriptive of the therapeutic management of osteosarcoma? a. Treatment usually consists of surgery and chemotherapy. b. Amputation of affected extremity is rarely necessary. c. Intensive irradiation is the primary treatment. d. Bone marrow transplantation offers the best chance of long-term survival.

A (The optimal therapy for osteosarcoma is a combination of surgery and chemotherapy.)

Immobilization causes which of the following effects on the cardiovascular system? a. Venous stasis b. Increased vasopressor mechanism c. Normal distribution of blood volume d. Increased efficiency of orthostatic neurovascular reflexes

A (The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi.)

Discharge planning for the child with juvenile arthritis includes the need for: a. Routine ophthalmologic examinations to assess for visual problems. b. A low-calorie diet to decrease or control weight in the less mobile child. c. Avoiding the use of aspirin to decrease gastric irritation. d. Immobilizing the painful joints, which are the result of the inflammatory process.

A (The systemic effects of juvenile arthritis can result in visual problems, making routine eye examinations important. Children with juvenile arthritis do not have problems with increased weight and often are anorexic and in need of high-calorie diets. Children with arthritis are often treated with aspirin. Children with arthritis are able to immobilize their own joints. Range-of-motion exercises are important for maintaining joint flexibility and preventing restricted movement in the affected joints.)

Kristin, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell off of a tree. When discussing this injury with her parents, the nurse should consider which statement? a. Healing is usually delayed in this type of fracture. b. Growth can be affected by this type of fracture. c. This is an unusual fracture site in young children. d. This type of fracture is inconsistent with a fall.

B (Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or epiphyseal plate present special problems in determining whether bone growth will be affected. Healing of epiphyseal injuries is usually prompt. The epiphysis is the weakest point of the long bones. This is a frequent site of damage during trauma.)

Kristin, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell out of a tree. When discussing this injury with her parents, the nurse should consider which of the following? a. Healing is usually delayed in this type of fracture. b. Bone growth can be affected by this type of fracture. c. This is an unusual fracture site in young children. d. This type of fracture is inconsistent with a fall.

B (Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or epiphyseal plate present special problems in determining whether bone growth will be affected.)

A youngster has just returned from surgery in a hip spica cast. The PRIORITY nursing intervention is to: A. elevate the head of the bed. B. check circulation. C. turn the child to the right side. D. offer sips of water.

B (Elevating the head of the bed might help with comfort. The nurse must be observant to the risk of increased swelling in the extremities. The chief concern is that the extremity may continue to swell. This must be assessed to ensure that the cast does not become a tourniquet. The child's position should be changed every 2 hours. This is acceptable, but only after the assessment of the extremities is completed.)

The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complications should the nurse monitor? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased production of stress hormones

B (Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake, leads to hypercalcemia, and causes a negative nitrogen balance secondary to muscle atrophy. A decreased production of stress hormones occurs with decreased physical and emotional coping capacity.)

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

B (Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake.)

Which statement is true concerning osteogenesis imperfecta? A. It is easily treated. B. It is an inherited disorder. C. Later-onset disease usually runs a more difficult course. D. Braces and exercises are of no therapeutic value.

B (It is a lifelong problem caused by defective bone mineralization, abnormal bone architecture, and increased susceptibility to fracture. Osteogenesis imperfecta is an inherited disorder. The type of disease determines the course it will take. Lightweight braces and splints can help support limbs and fractures.)

Which interaction is part of the discharge plan for a school-age child with osteomyelitis who is receiving home antibiotic therapy? a. Instructions for a low-calorie diet b. Arrangements for tutoring and schoolwork c. Instructions for a high-fat, low-protein diet d. Instructions for the parent to return the child to team sports immediately

B (Promoting optimal growth and development in the school-age child is important. It is important to continue schoolwork and arrange for tutoring if indicated. The child with osteomyelitis should be on a high-calorie, high-protein diet. The child with osteomyelitis may need time for the bone to heal before returning to full activities.)

Which 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 age of the child. C. Pliable bones of growing children are less porous than those of the adult. D. Periosteum of a child's bone is thinner, weaker, and has less osteogenic potential compared with that of the adult.

B (The cartilage epiphyseal plate is the weakest point of the long bone. Therefore, it is a frequent site of damage. Fractures heal in children in less time than they do in adults. As the child ages, the healing time increases. The periosteum is thickened, and there is a great production of osteoclasts when a bone injury occurs. Bone healing in children is rapid because of the thickened periosteum and generous blood supply.)

An infant is born with one lower limb deficiency. When is the optimum time for the child to be fitted with a prosthetic device? A. As soon as possible after birth B. When the infant begins sitting up and can maintain balance C. At about age 12 to 15 months, when most children are walking D. At about 4 years, when the healthy limb is not growing so rapidly

B (The device will not be useful until the child is developmentally ready to use the leg. This is the most optimum time for the child to be fitted with a prosthetic device. The child is ready to stand, and the prosthetic device will be integrated into his or her capabilities.This may be too late. The device should be provided when the child is showing readiness to stand. This is too late.)

An appropriate nursing intervention when caring for a child in traction is to: a. Remove adhesive traction straps daily to prevent skin breakdown. b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles. c. Provide active range-of-motion exercises to affected extremity 3 times a day. d. Keep child in one position to maintain good alignment.

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/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.)

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

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.)

An adolescent is in traction. The purpose of the traction is to fatigue the muscle and reduce muscle spasm so that the bones can be realigned. Nursing actions should include which of the following? a. Maintain continuous traction until muscle spasm ceases. b. Maintain continuous traction to prevent muscle from contracting. c. Release traction every hour to allow muscle to briefly regain its contractibility. d. Release traction once every 8 hours to allow muscle to briefly regain its contractibility.

B (When the muscles are stretched, muscle spasm ceases and permits realignment of the bone ends. The continued maintenance of traction is important during this phase because releasing the traction allows the muscle's normal contracting ability to again cause of malpositioning of the bone ends.)

A clinic nurse is conducting a staff in-service for other clinic staff regarding the signs and symptoms of a rhabdomyosarcoma tumor. Which should be included in the teaching session (Select all that apply)? a. Bone fractures b. Abdominal mass c. Sore throat and ear pain d. Headache e. Ecchymosis of conjunctiva

B, C, E (The initial signs and symptoms of rhabdomyosarcoma tumors are related to the site of the tumor and compression of adjacent organs. Some tumor locations, such as the orbit, manifest early in the course of the illness. Other tumors, such as those of the retroperitoneal area, only produce symptoms when they are relatively large and compress adjacent organs. Unfortunately, many of the signs and symptoms attributable to rhabdomyosarcoma are vague and frequently suggest a common childhood illness, such as "earache" or "runny nose." An abdominal mass, sore throat and ear pain, and ecchymosis of conjunctiva are signs of a rhabdomyosarcoma tumor. Bone fractures would be seen in osteosarcoma and a headache is a sign of a brain tumor.)

The nurse manager on the orthopedic unit is preparing an in-service about types of traction at the next staff meeting. The nurse manager should include which information in the presentation? (Select all that apply.) A. Skeletal traction is most likely used when closed reduction is performed. B. Skin traction can be applied using a pulling mechanism attached with adhesive material. C. Soft, foam-backed traction straps are used to distribute manual traction pull. D. Pins are commonly used with skeletal traction. E. Manual traction involves using wires or tongs inserted through the diameter of the bone distal to the fracture.

B, D (Manual traction—Applied to the body part by the hands placed distal to the fracture site. Manual traction may be provided during application of a cast but more commonly when a closed reduction is performed. Skin traction—Applied directly to the skin surface and indirectly to the skeletal structures. The pulling mechanism is attached to the skin with adhesive material or an elastic bandage. Both types are applied over soft, foam-backed traction straps to distribute the traction pull. Skeletal traction—Applied directly to the skeletal structure by a pin, wire, or tongs inserted into or through the diameter of the bone distal to the fracture.)

Which statement is accurate concerning a child's musculoskeletal system and how it may be different from an adult's? a. Growth occurs in children as a result of an increase in the number of muscle fibers. b. Infants are at greater risk for fractures because their epiphyseal plates are not fused. c. Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. d. Children's bones have less blood flow.

C (Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. A child's growth occurs because of an increase in size rather than an increase in the number of the muscle fibers. Fractures in children younger than 1 year are unusual because a large amount of force is necessary to fracture their bones. A child's bones have greater blood flow than an adult's bones.)

When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess the family's safety practices. Fractures in infants usually result from falls. c. Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.

C (Fractures in infants warrant further investigation to rule out child abuse. Fractures in children younger than 1 year are unusual because of the cartilaginous quality of the skeleton; a large amount of force is necessary to fracture their bones. Infants should be cared for in a safe environment and should not be falling. Fractures in infancy are usually nonaccidental rather than related to a genetic factor.)

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

C (Idiopathic scoliosis is most noticeable during the preadolescent growth spurt and is seldom apparent before age 10 years.)

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

C (Idiopathic scoliosis is most noticeable during the preadolescent growth spurt.)

The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip. What should be included? a. Apply lotion or powder to minimize skin irritation. b. Remove the harness several times a day to prevent contractures. c. Return to the clinic every 1 to 2 weeks. d. Place a diaper over harness, preferably using a superabsorbent disposable diaper that is relatively thin.

C (Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness. The harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.)

The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip. Which of the following should be included? a. Apply lotion or powder to minimize skin irritation. b. Remove harness several times a day to prevent contractures. c. Return to clinic every 1 to 2 weeks. d. Place diaper over harness, preferably using a superabsorbent disposable diaper that is relatively thin.

C (Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments.)

Major goals of the therapeutic management of juvenile rheumatoid arthritis are to: A. prevent joint discomfort and regain proper alignment. B. prevent loss of joint function and achieve cure. C. prevent physical deformity and preserve joint function. D. prevent skin breakdown and relieve symptoms.

C (Once the joint is damaged, it may not be possible to regain proper alignment. It may not be possible to achieve a cure. These are the goals of treatment. A third goal is to control pain. Skin breakdown is usually not an issue in juvenile rheumatoid arthritis.)

The primary method of treating osteomyelitis is: a. Joint replacement. b. Bracing and casting. c. Intravenous antibiotic therapy. d. Long-term corticosteroid therapy.

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 corticosteroids are not indicated for infectious processes.)

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

C (Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus. The treatment of choice is antibiotics.)

Which type of traction uses skin traction on the lower leg and a padded sling under the knee? a. Dunlop b. Bryant's c. Russell d. Buck's extension

C (Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position. Dunlop traction is an upper extremity traction used for fractures of the humerus. Bryant's traction is skin traction with the legs flexed at a 90-degree angle at the hip. Buck's extension traction is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, before surgery with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease.)

Which of the following types of traction uses skin traction on the lower leg and a padded sling under the knee? a. Dunlop b. Bryant c. Russell d. Buck extension

C (Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position.)

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should explain that: a. traction is tried first. b. surgical intervention is needed. c. frequent, serial casting is tried first. d. children outgrow this condition when they learn to walk.

C (Serial casting is begun shortly after birth before discharge from nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy.)

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should explain that: a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk.

C (Serial casting, the preferred treatment, is begun shortly after birth before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.)

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

C (The management of JIA is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of a 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.)

An important nursing consideration when caring for a child with JIA would be which of the following? a. Apply ice packs to relieve stiffness 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.

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 NSAIDs should not be given on an empty stomach and to be alert for signs of toxicity.)

A nurse is conducting discharge teaching for parents of an infant with osteogenesis imperfecta (OI). Further teaching is indicated if the parents make which statement? a. "We will be very careful handling the baby." b. "We will lift the baby by the buttocks when diapering." c. "We're glad there is a cure for this disorder." d. "We will schedule follow-up appointments as instructed."

C (The treatment for OI is primarily supportive. Although patients and families are optimistic about new research advances, there is no cure. The use of bisphosphonate therapy with IV pamidronate to promote increased bone density and prevent fractures has become standard therapy for many children with OI; however, long bones are weakened by prolonged treatment. Infants and children with this disorder require careful handling to prevent fractures. They must be supported when they are being turned, positioned, moved, and held. Even changing a diaper may cause a fracture in severely affected infants. These children should never be held by the ankles when being diapered but should be gently lifted by the buttocks or supported with pillows. Follow-up appointments for treatment with bisphosphonate can be expected.)

A nurse is caring for an infant with developmental dysplasia of the hip (DDH). Based on the nurse's knowledge of DDH, which clinical manifestation should the nurse expect to observe? (Select all that apply.) A. Lordosis B. Negative Babinski sign C. Asymmetric thigh and gluteal folds D. Positive Ortolani and Barlow tests E. Shortening of limb on affected side

C, D, E (Asymmetric thigh and gluteal folds are a clinical manifestation of DDH and seen from birth to 2 months old. Positive Ortolani and Barlow tests are clinical manifestations of DDH. Ortolani test is the abducting of the thighs to test for hip subluxation or dislocation. Barlow test is the adducting to feel if the femoral head slips out of the socket posterolaterally. Shortening of limb on affected side is another clinical manifestation of DDH. Lordosis is the inward curve of the lumbar spine just above the buttocks and is not a clinical manifestation of DDH. A negative Babinski sign is not a clinical manifestation of DDH. It is a neurologic reflex.)

The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome (Select all that apply)? a. Palpable distal pulse b. Capillary refill to extremity of <3 seconds c. Severe pain not relieved by analgesics d. Tingling of extremity e. Inability to move extremity

C, D, E (Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity of <3 seconds are expected findings.)

Which nursing intervention is appropriate to assess for neurovascular competency in a child who fell off the monkey bars at school and hurt his arm? a. The degree of motion and ability to position the extremity. b. The length, diameter, and shape of the extremity. c. The amount of swelling noted in the extremity and pain intensity. d. The skin color, temperature, movement, sensation, and capillary refill of the extremity.

D (A neurovascular evaluation includes assessing skin color and temperature, ability to move the affected extremity, degree of sensation experienced, and speed of capillary refill in the extremity. The degree of motion in the affected extremity and ability to position the extremity are incomplete assessments of neurovascular competency. The length, diameter, and shape of the extremity are not assessment criteria in a neurovascular evaluation. Although the amount of swelling is an important factor in assessing an extremity, it is not a criterion for a neurovascular assessment.)

An appropriate nursing intervention when caring for the child with chronic osteomyelitis is to: A. provide active range-of-motion exercises for the affected extremity. B. administer antibiotics with meals. C. encourage frequent ambulation. D. move and turn the child carefully and gently to minimize pain.

D (Active range of motion is contraindicated until pain has subsided. Pain medication should be administered as needed. Ambulation is contraindicated until pain has subsided. Osteomyelitis is extremely painful. Movement is carried out only as needed and then carefully and gently.)

Which of the following is a type of skin traction with legs in an extended position? a. Dunlop b. Bryant c. Russell d. Buck extension

D (Buck extension traction is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, preoperatively with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease.)

The callus that develops at the fracture site is important because it provides: A. functional use of injured part. B. sufficient support for weight bearing. C. means for adequate blood supply. D. means for holding bone fragments together.

D (Functional use cannot occur until the fracture site is stable. Functional use cannot occur until the fracture site is stable. The callus does not provide an adequate blood supply. New bone cells are formed in large numbers and are stimulated to maximum activity. They are found at the site of the injury. In time, calcium salts are absorbed to form the callus.)

What would cause a nurse to suspect that an infection has developed under a cast? a. Complaint of paresthesia c. Increased respirations b. Cold toes d. "Hot spots" felt on cast surface

D (If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so a window can be made in the cast to observe the site. The "five Ps" of ischemia from a vascular injury include pain, pallor, pulselessness, paresthesia, and paralysis. Paresthesia is an indication of vascular injury, not infection. Cold toes may be indicative of too tight a cast and need further evaluation. Increased respirations may indicate a respiratory infection or pulmonary emboli. This should be reported, and the child should be evaluated.)

Which of the following would cause a nurse to suspect that an infection has developed under a cast? a. Complaint of paresthesia b. Cold toes c. Increased respirations d. "Hot spots" felt on cast surface

D (If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so that a window can be made in the cast to observe the site.)

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

D (Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine. Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Ankylosis is the immobility of a joint. Lordosis is an accentuation of the cervical or lumbar curvature beyond physiologic limits.)

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

D (Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine.)

Which is a secondary effect when a child experiences decreased muscle strength, tone, and endurance from immobilization? A. Increased metabolism B. Increased venous return C. Increased cardiac output D. Decreased exercise tolerance

D (Metabolism decreases during periods of immobility. There is decreased venous return because of decreased muscle activity. There is decreased cardiac output. Muscle disuse leads to tissue breakdown and loss of muscle mass. It may take weeks or months to recover.)

Which medication is usually tried first when a child is diagnosed with juvenile idiopathic arthritis (JIA)? a. Aspirin b. Corticosteroids c. Cytotoxic drugs such as methotrexate d. Nonsteroidal antiinflammatory drugs (NSAIDs)

D (NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, and tolmetin are approved for use in children. Aspirin, once the drug of choice, has been replaced by the NSAIDs because they have fewer side effects and easier administration schedules. Corticosteroids are used for life-threatening complications, incapacitating arthritis, and uveitis. Methotrexate is a second-line therapy for JIA.)

Which of the following medications is usually tried first when a child is diagnosed with juvenile idiopathic arthritis (JIA)? a. Aspirin b. Corticosteroids c. Cytotoxic drugs such as methotrexate d. Nonsteroidal antiinflammatory drugs (NSAIDs)

D (NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, and tolmetin are approved for use in children.)

An adolescent who had a lower leg amputated after a motorcycle accident complains of pain in the missing extremity. The nurse's MOST appropriate action is to: A. withhold pain medications because narcotic addiction. B. refer the patient for psychological counseling. C. teach the parents and adolescent child about nerve damage. D. reassure the child that it is normal and is called phantom limb sensation.

D (Phantom limb sensation is an expected phenomena following amputation of an extremity. The other choices are not relevant. Phantom limb sensation is an expected phenomena following amputation of an extremity. The other choices are not relevant. Phantom limb sensation is an expected phenomena following amputation of an extremity. The other choices are not relevant. Phantom limb sensation is an expected experience because the nerve-brain connections are still present. They gradually fade. This should be discussed before surgery with the child.)

The nurse is caring for an immobilized preschool child. During this period of immobilization, the nurse's BEST action is to: A. encourage wearing pajamas. B. let the 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.

D (The child should be encouraged to wear street clothes during the daytime. Limit setting is necessary with all children. There is no reason to segregate children who are immobilized unless there are other medical issues that need to be addressed. It is important for children to have activities outside of the room if possible. This increases environmental stimuli and provides social contact with others.)

A 4-year-old child is newly diagnosed with Legg-Calvé-Perthes disease. Nursing considerations should include which action? a. Encouraging normal activity for as long as is possible b. Explaining the cause of the disease to the child and family c. Preparing the child and family for long-term, permanent disabilities d. Teaching the family the care and management of the corrective appliance

D (The family needs to learn the purpose, function, application, and care of the corrective device and the importance of compliance to achieve the desired outcome. The initial therapy is rest and non-weight bearing, which helps reduce inflammation and restore motion. Legg-Calvé-Perthes is a disease with an unknown etiology. A disturbance of circulation to the femoral capital epiphysis produces an ischemic aseptic necrosis of the femoral head. The disease is self-limiting, but the ultimate outcome of therapy depends on early and efficient therapy and the child's age at onset)

A 4 year old is newly diagnosed with Legg-Calvé-Perthes disease. Nursing considerations include which of the following? a. Encourage normal activity for as long as is possible. b. Explain the cause of the disease to the child and family. c. Prepare child and family for long-term, permanent disabilities. d. Teach family the care and management of the corrective appliance.

D (The family needs to learn the purpose, function, application, and care of the corrective device and the importance of compliance to achieve the desired outcome.)

The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which instructions should be included in the teaching? a. Swelling of the fingers is to be expected for the next 48 hours. b. Immobilize the shoulder to decrease pain in the arm. c. Allow the affected limb to hang down for 1 hour each day. d. Elevate casted arm when resting and when sitting up.

D (The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours. Joints above and below the cast on the affected extremity should be moved. The child should not engage in strenuous activity for the first few days. Rest with elevation of the extremity is encouraged.)

The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which of the following instructions should be included in the teaching? a. Swelling of the fingers is to be expected for the next 48 hours. b. Immobilize the shoulder to decrease pain in the arm. c. Allow the affected limb to hang down for 1 hour each day. d. Elevate casted arm when resting and when sitting up.

D (The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return.)

Which of the following is a physiologic effect of immobilization on children? a. Metabolic rate increases. b. Increased joint mobility can lead to contractures in a short time. c. Bone calcium increases, releasing excess calcium into the body (hypercalcemia). d. Venous stasis can lead to thrombi or emboli formation.

D (The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi.)

What is the rationale for elevating an extremity after a soft tissue injury such as a sprained ankle? A. Increases the pain threshold. B. Increases metabolism in the tissues. C. Produces a deep tissue vasodilation. D. Reduces edema formation.

D (This should have no effect on the pain threshold. This should not affect metabolism. Venous return to the heart, not vasodilation, is facilitated. Elevating the extremity uses gravity to facilitate venous return to reduce edema.)

Therapeutic management of the patient with systemic lupus erythematosus includes: A. cold salts to suppress the inflammatory process. B. a high-protein, low-salt diet. C. an exercise regimen to build up muscle strength and endurance. D. corticosteroids to control inflammation.

D (This will not affect the inflammatory process. A balanced diet without exceeding caloric expenditures is recommended. Exercise should be done in moderation. Currently this is the primary mode of therapy.)

The nurse uses the palms of the hands when handling a wet cast for which of the following reasons? a. To assess dryness of the cast b. To facilitate easy turning c. To keep the patient's limb balanced d. To avoid indenting the cast

D (Wet casts should be handled by the palms of the hands, not the fingers, to avoid creating pressure points.)

The nurse uses the palms of the hands when handling a wet cast to: a. Assess dryness of the cast. c. Keep the patient's limb balanced. b. Facilitate easy turning. d. Avoid indenting the cast.

D (Wet casts should be handled by the palms of the hands, not the fingers, to prevent creating pressure points. Assessing dryness, facilitating easy turning, or keeping the patient's limb balanced are not reasons for using the palms of the hand rather than the fingers when handling a wet cast.)