Exam 8 (week 9)- Chapter 51: Nursing Care of a Family When a Child Has a Musculoskeletal Disorder

16. The nurse is evaluating a school-age child's ability to crutch walk so that no weight is placed on an injured leg. Which walking technique indicates that teaching has been effective? A. walking gait B. two-point gait C. single-crutch support gait D. three-point swing-through gait

Answer: D Rationale: A three-point swing-through gait is used when no weight bearing is allowed on one foot. A two-point gait is used when a child needs support for weakened muscles or balance but may bear weight on both lower extremities. Walking gait and single-crutch support gait are not identified crutch walking approaches.

18. The nurse is concerned that a preschool-age child is demonstrating signs of Duchenne muscular dystrophy. What did the nurse assess in this child? A. Gower sign B. facial weakness C. inability to whistle D. inadequate use of respiratory muscles

Answer: A Rationale: Children with Duchenne muscular dystrophy usually have a history of meeting motor milestones, but by about 3 years of age, symptoms are more acute and obvious. Rising from the floor is done by rolling onto the stomach and then pushing up to the knees. To stand, the hands are pressed against the ankles, knees, and thighs. This is the Gower sign. Facial weakness and inability to whistle are manifestations of facioscapulohumeral muscular dystrophy. Inadequate use of respiratory muscles is a manifestation of congenital myotonic dystrophy.

3. A child with pauciarticular juvenile idiopathic arthritis is scheduled for an eye examination every 6months. When stressing the importance of the visit, which instruction is most accurate? A. Uveitis is possible, leading to severe blindness. B. The eye globe does not continue to grow, impacting sight. C. Continuous drug therapy causes corneal opacity. D. Eye infection may develop easily due to medication administration.

Answer: A Rationale: Children with pauciarticular arthritis need screening with a slit-lamp examination every 6 months for uveitis (inflammation of the iris, ciliary body, and choroid membrane of the eye) because severe uveitis can lead to blindness The other choices are not impacted by the JIA diagnosis.

6. A 14-year-old adolescent is suspected of having scoliosis. When doing scoliosis screening, what observation would be important for the nurse to note? A. The posterior spine when bending forward B. The angle of the iliac crest when bending forward C. The posterior spine when bending sideways D. The angle of the lower chest when sitting down

Answer: A Rationale: Diagnosis of scoliosis is best made with inspection and observation. When inspecting the back with the child in a standing position, the nurse should note asymmetries such as shoulder elevation, the prominence of one scapula, an uneven curve at the waistline, or a rib hump on one side. A lateral curvature of the spine is best revealed when the child bends forward. The child should bend forward with the arms hanging freely. The curve and asymmetry of the back can be observed. The height of the iliac crest, not the angle, is measured on both sides and the difference is noted. Bending to the side would not provide an accurate assessment of the spine because the curvature cannot be seen from the side. The lower chest angle would not be an accurate assessment as it would be more associated with the ribs as opposed to the spine.

26. The nurse is preparing an educational session for adolescents to best ensure a lifelong healthy musculoskeletal system. Which teaching will be beneficial to the most attendees? A. importance of daily exercise B. need for early diagnosis of painful joints C. need for at least 8 hours of sleep each night D. adequate intake of calcium in dietary or supplement form

Answer: A Rationale: Everyone benefits by understanding the need for physical activity throughout the lifespan. The nurse can help the adolescents achieve musculoskeletal health by educating them at this time on the importance of physical activity. Physical activity strengthens the bones and muscles and develops healthy habits. The other options are important but not as important. Diagnosis of painful joints allows for early diagnosis and treatment for those who may have future problems. Sleeping at least 8 hours per night provides for repair of body tissues, restores focus, and reenergizes the body. Dietary calcium intake, which is important in bone and muscle health, is not the most important information to teach to ensure a healthy musculoskeletal system.

17. The nurse is caring for a child who has just received a cast for a broken wrist. The parents ask, "Why do we need to keep the arm up on a pillow?" Which response by the nurse is appropriate? A. "Keeping the arm raised helps to lessen the swelling." B. "Using a pillow helps to promote healing." C. "There is less chance of infection when the arm is kept elevated." D. "Positioning the arm like upward helps to make sure the bones stay aligned."

Answer: A Rationale: If an extremity has been casted, the client should keep it elevated with a pillow to prevent edema in the fractured area. Elevating a casted extremity does not promote healing or discourage infection. The cast will ensure proper bone alignment.

7. An adolescent wears a body brace for scoliosis. Which client education should the nurse provide? A. to continue with age-appropriate activities B. to stand absolutely still when not wearing the brace C. to wear the brace a maximum of 20 hours each day D. that secondary sex changes will stop until the brace is removed

Answer: A Rationale: The treatment for scoliosis is aimed at preventing progression of the curve and decreasing the impact on the pulmonary and cardiac function. Bracing is one way to do that. The brace should be worn for 23 hours per day. Wearing a body brace should not interfere with normal activities, which are necessary to maintain adolescent self-esteem. It is extremely important that the adolescent has compliance with the brace usage. The nurse can help by teaching the adolescent ways to help peers understand the need for the brace. Sex changes continue with or without bracing.

20. The nurse is caring for a school-age child newly diagnosed with juvenile idiopathic arthritis. Which diagnosis would be a priority for this client? A. Knowledge deficit related to care needs B. Risk for inefficient peripheral tissue perfusion C. Ineffective coping related to physical limitations D. Imbalanced nutrition: less than body requirements

Answer: A Rationale: With newly diagnosed juvenile idiopathic arthritis, the child and family will need to learn how to manage the symptoms by planning exercise and medication programs around school or other activities. Juvenile idiopathic arthritis does not affect peripheral tissue perfusion. Because the child is newly diagnosed, it is premature to use the diagnosis of ineffective coping. There is no evidence that the child has imbalanced nutrition.

19. The nurse is instructing the mother of a school-age child with a leg cast about cast care at home. What should the nurse include in this teaching? Select all that apply. A. Cover the cast with a plastic bag to bathe. B. Remind the mother that nothing is to be put down the cast. C. Recommend using magic markers for autographs. D. Use the cool setting on a hair dryer to ease itchy skin. E. Encourage usual activities but restrict strenuous actions.

Answer: A, B, D, E Rationale: When teaching the mother about cast care at home, the nurse should include covering the cast with a plastic bag while bathing so the cast does not get wet; not placing anything down the cast; using the cool setting on a hair dryer to ease itching; and encourage usual activities but reducing strenuous activities while the cast is in place. Magic markers should not be used for autographs because the ink can seep into the cast material.

23. The nurse is caring for a school-age child recovering from an open reduction for a fractured femur. Which assessment findings indicate that the child is developing an infection? Select all that apply. A. lethargy B. increased pulse rate C. reduced pulse in the ankle D. cyanosis of the casted foot E. increased body temperature

Answer: A, B, E Rationale: Children with an open reduction are prone to infection. The nurse should suspect an infection if the systemic symptoms of increased pulse, increased temperature, and lethargy are present. Reduced pulse in the ankle and cyanosis of the casted foot are manifestations of compartment syndrome.

11. The nurse meets a child with a slipped capital femoral epiphysis. In what type of child does this usually occur? A. Tall, thin girls B. Obese adolescent boys C. Preadolescent girls D. Active school-age children

Answer: B Rationale: A slipped capital epiphyseal femur injury occurs when the femoral head dislocates from the neck and the shaft of the femur at the level of the epiphyseal plate. The epiphysis slips downward and backward. This occurs in boys aged 9 to 16 years who are sedentary and overweight. It is thought that with a teenage growth spurt the femoral head weakens and is less resistant to stressors. Hormones are also thought to play a role. This problem is generally not seen in girls or children who are active.

4. The nurse is caring for a child with a broken wrist that has just been placed in a cast. The nurse would elevate the arm to: A. promote healing. B. prevent edema. C. discourage infection. D. ensure proper bone alignment.

Answer: B Rationale: Edema tends to be dependent. Elevating the arm, therefore, would reduce swelling from the injury. Elevation of the arm would not promote healing or discourage infection. The cast will maintain proper bone alignment.

22. The nurse is planning teaching for the parents of a child with Legg-Calvé-Perthes disease. On what should the nurse emphasize when conducting this teaching? A. Surgery is needed with supporting rods. B. The child will have a non-weight-bearing period. C. The child will need passive range-of-motion exercises three times a day. D. The child will need to exercise to increase muscle strength of the knee joint.

Answer: B Rationale: For Legg-Calvé-Perthes disease, both parents and the child need thorough education about treatment and care because it can be difficult for young children to accept the extended treatment period involved with this disorder. There are long-term consequences if rest is not followed conscientiously. Parents may need assistance with devising appropriate activities for the child during the time that activity is limited and weight bearing is not allowed. Surgery with supporting rods is used to treat scoliosis. The child will not have passive range-of-motion exercises nor knee joint exercises in the treatment of this disease.

14. A toddler is diagnosed with osteomyelitis. What should the nurse anticipate as a priority intervention when planning this child's care? A. assisting the child with crutch walking B. maintaining intravenous antibiotic therapy C. keeping the child quiet while in skeletal traction D. restricting fluid to encourage red cell production

Answer: B Rationale: For osteomyelitis, medical therapy includes administration of intravenous antibiotics, which is usually initiated in the hospital and then continued at home for as long as 2 weeks; an intermittent infusion device or peripherally inserted central catheter may be used. After this, the child will be prescribed an oral antibiotic for 3 to 4 more weeks. There is not enough information to determine the location of the infection so crutch walking may not be applicable. Skeletal traction is not needed to treat osteomyelitis. Fluid restriction does not encourage red blood cell production and may be harmful to the care of this child.

25. A preadolescent girl with scoliosis is prescribed a body brace. What should the nurse teach the child about the purpose of the brace? A. prevents torticollis B. improves spinal stability C. corrects existing spinal curvature D. prevents herniation of a spinal disk

Answer: B Rationale: The goal of mechanical bracing is to maintain spinal stability and prevent further progression of the deformity until bone growth is complete. Bracing will not prevent torticollis, correct the curvature, or prevent herniation of a spinal disk.

1. A 7-year-old is seen with pauciarticular juvenile idiopathic arthritis. She notices extreme pain when she wakes in the morning. The best advice the nurse can give her parents would be to: A. have her take 325 mg of aspirin immediately on arising. B. encourage her to take a warm bath each morning before school. C. have her do isotonic exercises until the pain is gone. D. encourage her to remain in bed until the pain is gone.

Answer: B Rationale: Warmth is soothing to arthritic joints. Taking aspirin on an empty stomach could lead to gastric irritation. Exercise may worsen the pain. Slow movement and warm, moist heat are the best options to assist in relieving the pain.

24. The nurse is caring for a child diagnosed with scoliosis. What actions by the child would indicate a need for intervention by the nurse? Select all that apply. A. placement of the brace over a t-shirt B. removal of the brace at bedtime C. Reports of, "I feel taller with the brace on." D. Loosening of the straps on the brace prior to bedtime. E. removal of the brace while playing a soccer game

Answer: B, D Rationale: The placement of the brace over a t-shirt helps to prevent skin excoriation. The brace should only be removed 1 hour a day, during showering and participating in a sports activity. Straps should never be loosened on the braces. Children may state they feel taller with the brace on.

12. When assisting parents in a home care plan for a child with Legg-Calvé-Perthes disease (LCPD), the nurse would teach the parents that which is anticipated? A. Surgery with supporting rods B. Passive range-of-motion exercises 3x per day C. A non-weight-bearing period initially occurs. D. Exercise to increase muscle strength of the knee joint

Answer: C Rationale: Resting the affected femoral epiphysis aids healing.

8. An adolescent girl has spinal instrumentation surgery at 16 years of age. Immediately after this procedure, the nurse would teach her to: A. sit up, although this may hurt. B. always sleep prone. C. wait to be log-rolled before turning from one side to the other. D. plan on 6 months of hospitalization.

Answer: C Rationale: Spinal instrumentation means rods are placed beside the spine, and the vertebrae are fused. Log-rolling is necessary to prevent injury until the fusion is complete. She will be flat for a specific period of time depending on the amount of fusion in the surgery; she will be allowed to sleep in different positions, and the hospital stay is not 6 months.

9. The most important assessment of neurovascular status to make after spinal surgical instrumentation is: A. check the nailbeds of the fingers for capillary refill. B. determine the presence of brachial pulses. C. assess the legs for warmth. D. ask if the child has pain.

Answer: C Rationale: The edema that accompanies spinal instrumentation surgery can impair circulation to lower extremities. The lower extremities are affected and need to be assessed over the nail beds of the fingers. The brachial pulse is in the arm. Most children will have pain after surgery.

21. The nurse receives a report from the admission department that a child with a slipped capital femoral epiphysis is in route to the care area. The nurse would likely have received which description of the child to plan care? A. tall, thin female B. preadolescent female C. active school-age male D. obese preadolescent male

Answer: D Rationale: A slipped femoral epiphysis is a slipping of the femur head in relation to the neck of the femur at the epiphyseal line. This disorder occurs most frequently in preadolescence and its highest incidence is in obese children. It is twice as frequent in boys as girls.

13. An infant is placed in Bryant traction. For Bryant traction to be effective, the infant must be positioned on the: A. back with hips flat on the bed. B. stomach with both legs extended. C. back with the injured hip flexed and the uninjured one extended. D. back with hips up off the bed.

Answer: D Rationale: Bryant traction is used to reduce fractures or with developmental dysplasia of the hip (DDH) in children younger than 2 years of age. In this type of traction, both legs are extended vertically with the child's weight serving as the counterbalance. For there to be traction, the infant's hips must be off the bed. The position of having the child on the back with the hips flat is describing Buck traction. The position where the hip is flexed on the injured side and the uninjured extended is 90-90 traction. There is no traction when the child would be on the stomach.

2. The physician of a child with juvenile idiopathic arthritis asks the nurse to telephone the school to arrange a new activity program for her. A change the nurse would anticipate arranging for the child is to: A. be excused from all extracurricular activities. B. begin school earlier in the day than other children. C. be excused from all swimming classes. D. modify her physical exercise program.

Answer: D Rationale: Children with arthritis should be encouraged to maintain a school program that is as near to normal as possible; this will help maintain self-esteem. Some physical activities may need to be modified because of pain or joint contractures. She needs to participate in activities; an earlier start is not a good change and swimming might be one of the best activities to consider.

10. Fractures in children are always potentially serious injuries. Which child with a fracture would you observe most closely for complication? A. one who has a greenstick radial injury B. one who has an ulnar fracture C. one who has a fractured patella D. one who has an elbow fracture

Answer: D Rationale: Elbow injuries are particularly dangerous because edema can interfere with blood vessels and nerves that pass beside the joint. The radius and ulna are long bones and would not be at increased risk for complications. The patella is the knee and can be maintained in a straight position for casting.

15. During a visit, the parents of a school-age child diagnosed with pauciarticular juvenile idiopathic arthritis tell the nurse, "There are times when the joint pain is really severe, Is there anything that might help?" Which response by the nurse would be appropriate? A. "Have your child lie still for about 1/2 hour when the pain gets bad." B. "Let me show you how to do sotonic exercises until the pain is gone." C. "Give your child a dose of aspirin on an empty stomach immediately when the pain occurs." D. "Apply a warm moist compress or heating pad to the area for 20 minutes."

Answer: D Rationale: Heat reduces pain and inflammation in joints and increases comfort and motion. Heat can be applied by the use of a heating pad or warm water soaks/compreses for 20 to 30 minutes. Bed rest will not help reduce the pain. Isotonic exercises will not reduce the pain and could make the pain worse. Aspirin taken on an empty stomach could lead to gastric irritation.

5. The nurse assists with the application of a full-body plaster cast to a child. The child immediately becomes diaphoretic and reports feeling hot. Which nursing intervention would be indicated? A. Observe the child for infection. B. Suggest removal of the cast to the orthopedist. C. Moisten the cast with cool water. D. Advise the child that this is to be expected.

Answer: D Rationale: Plaster becomes hot as it sets. Even with fiberglass casts, there will be a warm feeling inside the cast when it is drying. This is a normal expectation about which to educate the child before the application of the cast. If discomfort continues, the nurse should notify the health care provider. Infection would not present in this way with a cast application. A cast should not be moistened. If it does become wet, the cast should be dried with a hair dryer. There are some newer types of casts which can get wet but the nurse should know this before applying any moisture.