Chapter 44: Nursing Care of the Child With an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder

The nurse receives a report on a child admitted with severe muscular dystrophy. The nurse suspects the child has been diagnosed with the most severe form of the disease, known as: A. myotonia B. facioscapulohumeral C. Duchenne D. limb-girdle

C. Duchenne Studies have shown that Duchenne is the most severe form of muscular dystrophy. Myotonia isn't a form of the disease; it's a symptom.

A nurse is providing care to a child diagnosed with cerebral palsy who is experiencing painful muscle spasms. The health care provider has prescribed baclofen 40 mg/day PO in three divided doses. How many milligrams should the nurse administer in each dose? Record your answer using one decimal place.

13.3 mg

The nurse is caring for a child diagnosed with osteomyelitis in the tibia. What prescription would the nurse question? Select all that apply. A. IV antibiotics for 3 days B. ambulating QID C. blood cultures prior to administration of antibiotics D. oral antibiotics for 4 weeks after completion of the IV antibiotics E. CT scan of the lower leg

A. IV antibiotics for 3 days B. ambulating QID Diagnostic exams for osteomyelitis include blood cultures, white blood cell count, CT scans, and potentially an MRI. Medical therapy includes a limitation on weight-bearing on the affected part, bed rest, immobilization, IV antibiotics for up to 2 weeks, and then oral antibiotics for an additional 3 to 4 weeks.

The nurse is caring for a 10-year-old girl in traction. The girl is experiencing muscle spasms associated with the traction. What would the nurse expect to administer if ordered? A. pamidronate B. diazepam C. alendronate D. opioid analgesics

B. Diazepam Diazepam is an antianxiety drug that also has the effect of skeletal muscle relaxation; it is used for the treatment of muscle spasm associated with traction or casting. Opioid analgesics are used for pain relief. Alendronate increases bone mineral density for children with osteogenesis imperfecta. Pamidronate increases bone mineral density for children with osteogenesis imperfecta.

A nurse is caring for a newborn client who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury? A. Place petroleum jelly gauze on the spinal sac to keep it moist. B. Place a urine collection bag on newborn for the continuous leakage. C. Delay the parents from holding the newborn. D. Place the newborn in a prone or lateral position.

D. Place the newborn in a prone or lateral position. The nurse should place the newborn in a prone or lateral position to keep pressure off the spinal sac and avoid newborn injury. Parents should be allowed to hold the stable infant with assistance. The spinal sac should be kept covered and moist until surgery to avoid rupture. Collecting urine decreases the risk of urine stasis, which is sometimes common in spinal defects.

The nurse is discussing types of treatment used when working with children who have orthopedic disorders. Which form of treatment covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open? A. Spica cast B. Ex-fix device C. Internal-fix device D. Stockinette

A. Spica cast The hip spica cast covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open. The cast maintains the legs in a frog-like position. Usually, there is a bar placed between the legs to help support the cast.

Through which mechanism is Duchenne muscular dystrophy acquired? A. environmental toxins B. heredity C. virus D. autoimmune factors

B. heredity Muscular dystrophy is hereditary and acquired through a recessive sex-linked trait. Therefore, it isn't caused by viral, autoimmune, or environmental factors.

In understanding the development of the musculoskeletal system, the nurse recognizes that what is implanted in a gel-like substance during fetal life? A. Cartilage B. Tendons C. Ligaments D. Joints

A. Cartilage During fetal life, tissue called cartilage, which is a type of connective tissue consisting of cells implanted in a gel-like substance, gradually calcifies and becomes bone.

The nurse is caring for a child who fractured the arm in an accident. A cast has been applied to the child's right arm. Which action(s) should the nurse implement? Select all that apply. A. Check capillary refill time in both arms B. Wear sterile gloves when removing or touching the cast C. Monitor the color of the nail beds in the right hand D. Wear a protective gown when moving the child's arm E. Document any signs of pain

A. Check capillary refill time in both arms C. Monitor the color of the nail beds in the right hand E. Document any signs of pain The most important function for the nurse in caring for a child in a cast is frequent neurovascular checks. The nurse should monitor for increased pain and edema, a pale or blue color to the extremities, skin coolness, numbness or tingling, poor capillary refill, and decreased pulse strength. Increased pain, especially unrelieved with pain medications, can indicate serious complications such as compartment syndrome. Wearing a gown or sterile gloves is unnecessary as the cast is not sterile.

The nurse is caring for a child with rickets. Which diagnostic test result would the nurse expect to find in the child's medical record? A. low serum calcium levels B. high serum phosphate levels C. x-ray confirmation of adequate bone shape D. low alkaline phosphate levels

A. low serum calcium levels With rickets, serum calcium and phosphate levels are low and alkaline phosphate levels are elevated. Radiographs show changes in the shape and structure of the bone.

A nurse is preparing a plan of care for an infant who has undergone surgery to repair a myelomeningocele. The nurse would include placing the infant in which positions postoperatively? Select all that apply. A. prone B. supine C. left side lying D. right side lying E. Semi-Fowler

A. prone C. left side lying D. right side lying Postoperatively, the nurse would position the infant in the prone or side-lying position to allow the incision to heal.

The type of fracture often seen in young children is one in which there is not complete ossification of the bone, and the bone bends and just partially breaks. What type of fracture is this? A. complete B. epiphyseal C. Greenstick D. spiral

C. Greenstick Greenstick fractures are one kind of incomplete fracture, caused by incomplete ossification, common in children. The bone bends and often just partially breaks. Spiral fractures are seen when the fracture goes around the bone instead of through (i.e., looks like someone twisted the bone, and can occur in skiing injuries, falls, or abuse). A complete fracture is when the bone is actually broken in two pieces. An epiphyseal fracture occurs at the epiphyseal growth plate.

The young boy has fractured his left leg and has had a cast applied. The nurse educates the boy and his parents prior to discharge from the hospital. The parents should call the physician when which incidents occur? Select all that apply. A. The boy has had a fever of greater than 102° F (38.9°C) for the last 36 hours. B. New drainage is seeping out from under the cast. C. The boy's toes are light blue and very swollen. D. The outside of the boy's cast got wet and had to be dried using a hair dryer. E. The boy experiences mild pain when wiggling his toes.

A. The boy has had a fever of greater than 102° F (38.9°C) for the last 36 hours. B. New drainage is seeping out from under the cast. C. The boy's toes are light blue and very swollen. The parents should call the physician when the following things occur: The child has a temperature greater than 101.5° F (38.7° C) for more than 24 hours, there is drainage from the casted site, the site distal to the casted extremity is cyanotic, or severe edema is present.

The nurse is assessing a child and notes S-shaped curvature of the spine. What terminology would the nurse use when documenting this assessment finding? A. idiopathic scoliosis B. kyphosis C. sway back D. lordosis

A. idiopathic scoliosis Idiopathic scoliosis is an S-shaped curvature of the spine. Kyphosis is an outward curvature of the cervical spine. Lordosis is an inward curving of the lumbar spine. Sway back is another term used for lordosis.

The parents of an infant born with an abnormality on the back are told by the neonatologist that their child has a myelomeningocele. They ask the nurse what exactly that means. Which would be the nurse's best reply? A. "The contents of the sac you see only has fluid in it and should cause the child no problem." B. "It is a herniation through the skin of the back of your child with both the spinal cord and nerve roots involved." C. "The sac is a very small cyst and should resolve within the first year of life." D. "Your child's defect involves only the nerves to the bladder and bowel and can be easily repaired."

B. "It is a herniation through the skin of the back of your child with both the spinal cord and nerve roots involved." A myelomeningocele is the more severe form of spina bifida cystica, in which the spinal cord and nerve roots herniate into the sac through an opening in the spine, compromising the meninges and usually resulting in neurological impairment. A meningocele includes the meninges and spinal fluid only. A myelomeningocele usually contains the bowel and bladder innervation but involves many more nerves also. A myelomeningocele is not just a cyst that resolves within a year.

A nurse is teaching the parents of a boy with a neurogenic bladder about clean intermittent catheterization. Which response indicates a need for further teaching? A. "We must be careful to use latex-free catheters." B. "We need to soak the catheter in a vinegar and water solution daily." C. "My son may someday learn how to do this for himself." D. "The very first step is to apply water-based lubricant to the catheter."

D. "The very first step is to apply water-based lubricant to the catheter." It is very important to remind the parents that they must always wash hands very well with soap and water prior to catheterization to help prevent infection. The other statements are correct.

The student nurse is developing a care plan for a child who suffered a fractured tibia and will have a cast on his lower leg for approximately 6 weeks. Which nursing diagnosis would be the priority for this client? A. Deficient diversional activities related to a need for imposed activity restriction for 6 weeks B. Pain related to chronic inflammation of the lower leg C. Situational low self-esteem related to the use of a walker D. Impaired physical mobility related to a cast on the leg

D. Impaired physical mobility related to a cast on the leg Impaired physical mobility would be the priority need for this client. Basic comfort, food, fluid, and other basic needs are considered a higher priority than diversional activities and self-esteem. Pain would be the normally be the highest priority in this list, but this client would have acute inflammation rather than chronic inflammation.

The nurse is working with a group of caregivers of school-aged children discussing fractures. The nurse explains that if the fragments of fractured bone are separated, the fracture is said to be: A. Greenstick B. incomplete C. spiral D. complete

D. complete If the fragments of fractured bone are separated, the fracture is said to be complete. If fragments remain partially joined, the fracture is termed incomplete. Greenstick fractures are one kind of incomplete fracture, caused by incomplete ossification, common in children. Spiral fractures twist around the bone.

The nurse is conducting a physical examination of a 9-month-old infant with a suspected neuromuscular disorder. Which finding would warrant further evaluation? A. absence of tonic neck reflex B. absence of Moro reflex C. presence of symmetrical spontaneous movement D. presence of Moro reflex

D. presence of Moro reflex The persistence of a primitive reflex in a 9-month-old would warrant further evaluation. Symmetrical spontaneous movement and absence of the Moro and tonic neck reflexes are expected in a normally developing 9-month-old child.

The nurse caring for a client in a body cast knows that immobility can cause contractures, loss of muscle tone, or fixation of joints. Which nursing interdisciplinary intervention is recommended to help prevent these adverse conditions? A. Encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion. B. Check for a normal capillary refill of 3 to 5 seconds on a daily basis to ensure there in adequate arterial supply. C. Encourage child to stifle cough and take shallow breaths to prevent ineffective breathing patterns. D. Give the client large, frequent meals with decreased fiber and increased protein and Vitamin C.

A. Encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion. The nurse should turn the client and encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion. The client should be instructed to cough and breathe deeply to prevent respiratory complications. Normal capillary refill is 1 to 3 seconds. The client should be given small, frequent meals with increased fiber, protein, and vitamin C to prevent malnutrition.

A child is in traction and is at risk for impaired skin integrity. Which intervention is most effective? A. Inspect the child's skin for rashes, redness, irritation, or pressure injuries. B. Assess neurovascular status on the affected extremity once every shift. C. Gently massage the child's back to stimulate circulation D. Keep the child's skin distal to the traction clean and dry

A. Inspect the child's skin for rashes, redness, irritation, or pressure injuries. It is important to be vigilant in inspecting the child's skin for rashes, redness, and irritation to uncover areas where pressure injuries are likely to develop. Applying lotion, gentle massage, and keeping the skin dry and clean are part of the routine skincare regimen. However, performing these interventions without first performing a skin assessment can cause the nurse to miss important signs that can potentially result in more injury to the child. Neurovascular assessment should be performed frequently as prescribed by the health care provider or at least every 4 hours to evaluate skin integrity and venous circulation.

An adolescent with scoliosis is refusing to wear the prescribed body brace. Which instruction is best to progress the adolescent to the treatment goals? A. "It is important to prevent herniation of a spinal disk, which is painful." B. "It is important to wear the brace now to stabilize your spinal alignment, decreasing your symptoms." C. "It is important to prevent torticollis." D. "It is important to correct spinal curvature before it gets too bad, causing you problems."

B. "It is important to wear the brace now to stabilize your spinal alignment, decreasing your symptoms." It is important to have the adolescent understand the treatment and how the treatment will benefit him or her. Body bracing helps to hold the spine in alignment and prevent further curvature, decreasing the symptoms. The brace will not correct the problem. Adolescents have a hard time being compliant with the brace due to body image disturbance and peer reaction. The brace can also cause discomfort and be hot to wear. Torticollis is tightened neck muscles causing the head to tilt downward. A herniated disc is related to the disc space between the vertebrae. It has no affect on the curvature of the spine.

The nurse is observing a 3-year-old boy who is sitting and playing in the waiting area of his pediatrician's office. The nurse calls the boy and his mother back for the boy's appointment. The boy rolls onto his stomach and pushes himself to his knees. Then he presses his hands against his ankles, knees, and thighs, walking up the front of his body, to stand. Which condition should the nurse suspect in this client? A. Congenital myotonic dystrophy B. Duchenne muscular dystrophy C. Juvenile arthritis D. Facioscapulohumeral muscular dystrophy

B. Duchenne muscular dystrophy By age 3, children with Duchenne muscular dystrophy can rise from the floor only by rolling onto their stomachs and then pushing themselves to their knees. To stand, they press their hands against their ankles, knees, and thighs (they "walk up their front"); this is a Gower sign. Symptoms of facioscapulohumeral muscular dystrophy begin after the child is 10 years old, and the primary symptom is facial weakness. The child becomes unable to wrinkle the forehead and cannot whistle. Congenital myotonic dystrophy begins in utero and typically leads to death before age 1 year because of inability to sustain respiratory function. The symptoms of juvenile arthritis are primarily stiff and painful joints.

A nurse who is discussing Duchenne muscular dystrophy characterizes it correctly using which descriptors? A. Duchenne muscular dystrophy is diagnosed in boys who develop gait changes during the late school-age years. B. Duchenne muscular dystrophy causes progressive muscular weakness that ends in death. C. Duchenne muscular dystrophy is a progressive disease of muscles and nerves that affects males and females equally. D. Duchenne muscular dystrophy is a non-progressive disorder that severely affects muscle function through spinal cord atrophy.

B. Duchenne muscular dystrophy causes progressive muscular weakness that ends in death. Duchenne muscular dystrophy is the most common of several muscular dystrophies and is a progressive, fatal disorder. It involves mainly skeletal muscles, but other muscles are affected over time. Onset occurs in early childhood. The disorder is X-linked recessive. An enzyme is lacking that is necessary for the maintenance of muscle cells. No structural abnormalities of the spinal cord or peripheral nerves are noted.

The nurse is caring for an 11-year-old presenting with tenderness in the shoulder. He is the pitcher for his baseball team and reports shoulder pain with active internal rotation but is able to continue past the pain with full range of motion. Based on these reported symptoms, the nurse is aware that the disorder is most likely to be: A. Sever disease (calcaneal apophysitis). B. epiphysiolysis of the proximal humerus. C. epiphysiolysis of the distal radius. D. Osgood-Schlatter disease.

B. epiphysiolysis of the proximal humerus. Epiphysiolysis of the proximal humerus is an overuse disorder that occurs with rigorous upper extremity activity such as pitching and causes tenderness in the shoulder. Osgood-Schlatter disease causes knee pain and painful swelling or prominence of the anterior portion of the tibial tubercle. Sever disease (calcaneal apophysitis) causes pain over the posterior aspect of the calcaneus. Epiphysiolysis of the distal radius is an overuse disorder that causes wrist pain. It is common in gymnasts.

The nurse is teaching the parents of a female child with a myelomeningocele how to perform clean intermittent catheterization. The nurse determines that the teaching was effective when the parents return demonstrate the procedure and state: A. "Before inserting the catheter, we need to wipe her labia with normal saline from back to front." B. "We need to apply some petroleum jelly to her labia and the catheter before we attempt to insert it." C. "When the urine stops flowing, we should press on the lower belly to ensure the bladder is empty." D. "We need to insert the catheter about 6 inches so that we make sure the catheter is in the bladder."

C. "When the urine stops flowing, we should press on the lower belly to ensure the bladder is empty." When the urine stops flowing, the parents should press on the lower abdomen or have the child lean forward to tense the abdominals to ensure that no more urine is in the bladder. For a female, the catheter is inserted about 2 to 3 inches. For a male, the catheter is inserted about 4 to 6 inches. Before the catheter is inserted, the labia is cleaned with a washcloth or disposable wipe from front to back. A generous amount of water-soluble lubricant, not petroleum jelly, is applied to the catheter. There is no need to apply the lubricant to the labia.

The nurse is caring for a 10-year-old boy who plays on two soccer teams. He practices four days a week and his team travels to tournaments once a month. He has been diagnosed with a stress fracture in one of his vertebrae. Which instruction is most important to emphasize to the boy and his parents? A. "You will need to see a physical therapist for stretching and strengthening exercises." B. "Ice will help reduce the inflammation." C. "You and your coaches need to understand that you cannot play soccer for at least six weeks." D. "NSAIDs can help with pain control and inflammation."

C. "You and your coaches need to understand that you cannot play soccer for at least six weeks." A child with an overuse injury needs to avoid the causative activity for six to eight weeks. The other suggestions are also important, but the nurse must emphasize to the boy and his parents that they must tell the coaches "no soccer for six weeks." In some situations, it is helpful to supply a written directive from the nurse or physician to help the parent avoid undue pressure from coaches.