Mobility Ch 51

The nurse is caring for a child who is using crutches due to a leg injury. The child's parents state that the child reports pain in the axilla when using the crutches. What is the best response by the nurse?

"We need to make sure the crutches are not too tall; there should be about an inch of space between the crutch pad and the axilla."

The nurse is creating a care plan for a child with a leg cast. What interventions would be appropriate for the nursing diagnosis of Risk for ineffective peripheral tissue perfusion related to pressure from cast? Select all that apply.

-Assess foot and toes every 4 hours for color, warmth, and presence of pedal pulses. -Keep leg elevated by a pillow at all times. -Assess capillary refill of toes every 4 hours.

A preschool-aged client is in an external fixator for a fractured pelvis and the mother is frightened of performing pin site care for the child. How would the nurse help this parent learn to care for her child? Select all that apply.

-Have the mother do a return demonstration of cleaning the pins. -Observe for any signs of inflammation such as odor or drainage.

A client has recently been diagnosed with juvenile idiopathic arthritis (JIA). The nurse is providing teaching to the client and family about the disease. Which facts are accurate and should be shared with this family? Select all that apply.

-JIA can affect any number of joints. -The client will need to take several medications, including NSAIDS. -Administer NSAIDS with food to decrease the incidence of gastric irritation.

When the nurse performs the Ortolani maneuver, which action(s) is appropriate? Select all that apply.

-Listen for a click when the legs are abducted. -Place the newborn in a supine position. -Attempt to abduct the hips 180 degrees while applying upward pressure.

The school nurse has performed scoliosis screening. Based on this assessment, which child(ren) requires the nurse to implement a referral to the health care provider? Select all that apply.

-child with asymmetric shoulder elevation -child with a limb length discrepancy -child with a one-sided hump upon bending over -child with a lateral curve of the spine

The nurse educates the parent regarding their child's risk for developing ______ and _______

-impaired cognitive function -respiratory infections

The nurse is caring for a child with an external fixator in the right humerus. When evaluating if the fixator has been effective in meeting the goals of the treatment plan, which assessment finding(s) confirms effectiveness? Select all that apply.

-lengthening of the bone -a diminished angular or rotational style defect -a structural alignment of the bone position

A young boy is being evaluated for muscular dystrophy. What physical symptoms would be assessed for in this client? Select all that apply.

-mild intellectual disability -difficulty rising from the floor -progressive muscle weakness

A nurse is treating an 8-year-old boy for a supracondylar fracture of the humerus. The boy will be receiving a cast. Which intervention should the nurse implement to prevent Volkmann's ischemic contracture in this client?

Apply a cast incompletely for 24 hours, with the elbow being simply splinted.

When assessing a child who has recently had a cast removed from the arm, the child states that the elbow is sore and it hurts to move it. What is the appropriate action by the nurse?

Tell the child that this is normal and will get better as the child moves the elbow.

The nurse is observing a child walk down stairs using a swing-through gait. What action by the child is correct?

The child places the crutches on the lower step before placing the good foot down between the crutches.

A nurse is providing care for several children on the unit. Which child would the nurse identify as being most at risk for sensory deprivation?

a child, 6 years old, with moderate hearing loss on bed rest with skeletal traction for a fractured femur

A baby with developmental dysplasia of the hip is placed in a Pavlik harness. The harness positions the hip in which position?

a flexed, abducted position to press the femur head against the acetabulum

A 7-year-old client is in skeletal traction for a fractured femur and is on bed rest. When providing the child with play materials, which is most appropriate?

electronic tablet

The nurse is educating a group of caregivers about fractures seen in children. One of the caregivers states, "I have heard that if a bone breaks it can cause permanent damage and stop the growth of the bone." This statement is accurate if the break occurs in the:

epiphyseal plate.

A child diagnosed with muscular dystrophy has recently developed kyphosis. The home health nurse stresses to the caregivers that the child is at an increased risk for which injury?

possibility of respiratory infection

The charge nurse is observing a student nurse perform skeletal traction pin care. What action by the student nurse would indicate a need for intervention by the charge nurse?

unhooking a weight while providing pin care