Peds - Musculoskeletal

B, C, D

A nurse is caring for a child who is in skeletal traction. Which of the following actions should the nurse take? Select all that apply. a. Remove the weights to reposition the client. b. Assess the child's position frequently. c. Assess pin sites every 4 hours. d. Ensure the weights are hanging freely. e. Ensure the rope's knot is in contact with the pulley.

D

A nurse is caring for a child who is suspected of having Legg-Calve-Perthes disease. The nurse should prepare the child for which of the following diagnostic procedures? a. bone biopsy b. genetic testing c. CT scans d. radiographs

A, E

A nurse is caring for a school-age child who has juvenile idiopathic arthritis. Which of the following home care instructions should the nurse include in the teaching? Select all that apply. a. provide extra time for completion of ADLs b. use cold compresses for joint pain c. take ibuprofen on an empty stomach d. remain home during periods of exacerbation e. perform ROM exercises

B, D

A nurse is caring for an infant and notices an audible click in their left hip. Which of the following diagnostic test should the nurse expect the provider to perform? Select all that apply. a. barlow test b. Babinski sign c. manipulation of the foot and ankle d. ortolani test e. ponseti method

D

A nurse is caring for an infant who has a myelomeningocele. Which of the following actions should the nurse include in the preoperative plan of care? a. assist the caregiver with cuddling the infant b. assess the infant's temperature rectally c. place the infant in a supine position d. apply a sterile, moist dressing on the sac

C -- Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Increased blood pressure may be an indication of autonomic dysreflexia. It is not necessary to minimize environmental stimuli for this type of injury. Spinal cord injury is not an infectious process. Immunoglobulin is not indicated. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover.

A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. What nursing intervention is a priority for this child? a. Minimizing environmental stimuli b. Administering immunoglobulin c. Monitoring and maintaining systemic blood pressure d. Discussing long-term care issues with the family

D

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

B -- During the first few hours after a cast is applied, the chief concern is that the extremity may continue to swell to the extent that the cast becomes a tourniquet, shutting off circulation and producing neurovascular complications (compartment syndrome). One measure to reduce the likelihood of this problem is to elevate the body part and thereby increase venous return. The health care provider does not need to be notified because edema is expected and warm moist packs will not decrease the edema. The child should move the toes, but that will not help reduce the edema.

A child has just returned from surgery for repair of a fractured femur. The child has a long-leg cast on. The toes on the leg with the cast are edematous, but they have color, sensitivity, and movement. What action should the nurse take? a. Call the health care provider to report the edema. b. Elevate the foot and leg on pillows. c. Apply a warm moist pack to the foot. d. Encourage movement of toes.

B -- Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks.

A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to know when the antibiotic protocol will end. The nurse responds that antibiotic therapy will probably last for: a. 2 weeks. b. 6 weeks. c. 2 months. d. 3 months.

C -- NSAIDs are the first-line drugs used in JIA. Potential side effects include gastrointestinal (GI), renal, and hepatic side effects. The child is at risk for GI bleeding and elevated blood pressure. The heart rate is not affected by this drug class. NSAIDs should be given with meals to minimize gastrointestinal problems. The anti-inflammatory response usually takes 3 weeks before effectiveness can be evaluated.

A child with juvenile idiopathic arthritis (JIA) is started on a nonsteroidal anti-inflammatory drug (NSAID). What nursing consideration should be included? a. Monitor heart rate. b. Administer NSAIDs between meals. c. Check for abdominal pain and bloody stools. d. Expect inflammation to be gone in 3 or 4 days.

B -- A latex-free environment is the goal. This includes eliminating the use of latex gloves and other medical devices containing latex. Allergy testing would provide information about whether the allergy has developed. It will not reduce the chances of developing the allergy. Although powder-free latex gloves are less allergenic, latex should not be used. Limiting the use of latex products is one component of providing a latex-free environment, but latex products should not be used.

A goal for children with spina bifida is to reduce the chance of allergy development. What is a priority nursing intervention? a. Recommend allergy testing. b. Provide a latex-free environment. c. Use only powder-free latex gloves. d. Limit use of latex products as much as possible.

B, C, D, E

A nurse is assessing a child who has Legg-Calve-Perthes disease. Which of the following findings should the nurse expect? Select all that apply. a. longer affected leg b. hip stiffness c. back pain d. limited ROM e. limp with walking

A, B, C, E

A nurse is caring for a child who has a fracture. Which of the following are manifestations of a fracture? Select all that apply. a. crepitus b. edema c. pain d. fever e. ecchymosis

A, B

A nurse is caring for a child who has cerebral palsy. Which of the following medications should the nurse expect to administer to treat painful muscle spasms? Select all that apply. a. baclofen b. diazepam c. oxybutynin d. methotrexate e. prednisone

C, D

A nurse is caring for a child who has muscular dystrophy. For which of the following findings should the nurse assess? (Select all that apply.) a. Purposeless, involuntary, abnormal movements b. Spinal defect and saclike protrusion c. Muscular weakness in lower extremities d. Unsteady, wide-based or waddling gait e. Upward slant to the eyes

D -- Apply moleskin to the edges of the cast to prevent the cast from rubbing on the client's skin. A cool fan can be used to facilitate drying of a plaster cast. The child should be turned every 2 hours to expose all areas of the cast to facilitate drying. A client who has a spica cast is non-weight-bearing until the cast is removed.

A nurse is caring for a child who is in a plaster spica cast. Which of the following actions should the nurse take? a. use a heat lamp to facilitate drying b. avoid turning the child until the cast is dry c. assist the client with crutch walking after the cast is dry d. apply moleskin to the edges of the cast

C

A school nurse is conducting a staff in-service to other school nurses on idiopathic scoliosis. During which period of child development does idiopathic scoliosis become most noticeable? a. Newborn period b. When child starts to walk c. Preadolescent growth spurt d. Adolescence

A

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 position of comfort. d. obtain parental permission for administration of acetaminophen or aspirin.

A

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. Which action should the nurse take 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.

C -- Marked distortion of the head of the femur may lead to an imperfect joint or to degenerative arthritis of the hip later in life.

In planning teaching to parents of a child with Legg-Calve-Perthes disease about the long-term effects of this disease, the nurse would include that: a. there are no long-term effects. b. the disease is self-limited and requires no long-term treatment. c. degenerative arthritis may develop later in life. d. there is risk of osteogenic sarcoma in adulthood.

B -- The spinal sac is protected from damage until surgery is performed. Early surgical closure is recommended to prevent local trauma and infection. Monitoring vital signs and watching for signs that might indicate developing hydrocephalus are important interventions, but preventing trauma to the sac is a priority. The sac is kept moist until surgical intervention is done.

The most important nursing intervention when caring for an infant with myelomeningocele in the preoperative stage is which? a. Take vital signs every hour. b. Place the infant on the side to decrease pressure on the spinal sac. c. Watch for signs that might indicate developing hydrocephalus. d. Apply a heat lamp to facilitate drying and toughening of the sac.

B -- Buck's traction is a type of skin traction that relies on the child's weight as counterbalance. The child must be kept with head elevated no more than 20 degrees, pulled up in bed, and the feet should not touch the bed surface or the foot of the bed.

The nurse caring for a child in Buck's skin traction will keep the: a. child in high-Fowler's position. b. child pulled up in bed. c. child's heel on the bed surface. d. child's feet against the foot of the bed.

C -- Frequent falling and clumsiness are clinical manifestations of Duchenne's muscular dystrophy.

The nurse caring for a child with Duchenne's muscular dystrophy notes a characteristic manifestation, which is that the child: a. ambulates by holding onto furniture. b. exhibits atrophy of the calf muscles. c. falls frequently and is clumsy. d. has delayed fine-motor development.

A, C, D, E Clinical features of Duchenne muscular dystrophy include calf muscle hypertrophy; progressive muscular weakness; wasting and contractures; loss of independent ambulation by 9 to 12 years of age; and slowly progressive, generalized weakness during adolescence. The onset is early, not late, usually between 3 and 5 years of age.

The nurse is preparing to admit a 10-year-old child with Duchenne muscular dystrophy. What clinical features of Duchenne muscular dystrophy should the nurse recognize? (Select all that apply.) a. Calf muscle hypertrophy b. Late onset, usually between 6 and 8 years of age c. Progressive muscular weakness, wasting, and contractures d. Loss of independent ambulation by 9 to 12 years of age e. Slowly progressive, generalized weakness during adolescence

A -- Heat is not a treatment for soft tissue injuries. The principles of managing soft tissue injuries are rest, ice, compression, and elevation.

The nurse is providing instructions about how to treat a sprained ankle. The nurse will recognize the need for additional teaching when the mother states: a. "Apply warm compresses to the ankle for the first 24 hours." b. "Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off." c. "Wrap the ankle in an Ace bandage for support." d. "Keep the leg elevated when sitting."

C -- 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. Bisphosphonate and physical therapy are beneficial for OI. Lightweight braces will be used when the child starts to ambulate.

The nurse is teaching infant care to parents with an infant who has been diagnosed with osteogenesis imperfecta (OI). What should the nurse include in the teaching session? a. "Bisphosphonate therapy is not beneficial for OI." b. "Physical therapy should be avoided as it may cause damage to bones." c. "Lift the infant by the buttocks, not the ankles, when changing diapers." d. "The infant should meet expected gross motor development without assistive devices."

B -- The common approach to clubfoot management and treatment is the Ponseti method. Serial casting is begun shortly after birth. Weekly gentle manipulation and stretching of the foot along with placement of serial long-leg casts allow for gradual repositioning of the foot. The extremity or extremities are casted until maximum correction is achieved, usually within 6 to 10 weeks. If parents state that this is the only cast the infant will need, they need further teaching.

The nurse knows that parents need further teaching with regard to the treatment of congenital clubfoot when they state what? a. "We'll keep the cast dry." b. "We're happy this is the only cast our baby will need." c. "We'll watch for any swelling of the foot while the cast is on." d. "We're getting a special car seat to accommodate the cast."

A

The nurse should monitor for which effect on the cardiovascular system when a child is immobilized? a. Venous stasis b. Increased vasopressor mechanism c. Normal distribution of blood volume d. Increased efficiency of orthostatic neurovascular reflexes

B -- Delayed gross motor development is a universal manifestation of CP. The child shows a delay in all motor accomplishments, and the discrepancy between motor ability and expected achievement tends to increase with successive developmental milestones as growth advances. The infant who does not lift his head when on the tummy is showing a gross motor delay, as that is seen at 0 to 3 months. The other statements are within normal growth and development expectations.

The nurse should suspect a child has cerebral palsy (CP) if the parent says what? a. "My 6-month-old baby is rolling from back to prone now." b. "My 4-month-old doesn't lift his head when on his tummy." c. "My 8-month-old can sit without support." d. "My 10-month-old is not walking."

B -- Osteomyelitis is an infection of the bone. Inflammation produces an exudate that collects under the marrow and cortex of the bone. The vessels are compressed and thrombosis occurs, producing ischemia and pain.

The parent of a child with osteomyelitis asks why his child is in so much pain. The nurse's response will be based on the understanding that the pain of osteomyelitis is caused by: a. the pressure of inelastic bone. b. purulent drainage in the bone marrow. c. the cast applied on the extremity. d. circulatory congestion of the skin.

B -- Parents and children are taught positions to assume while sitting and recumbent that reduce spasticity. The American Academy of Pediatrics has stated that patterning should not be used for neurologically disabled children. Patterning attempts to alter abnormal tone and posture and elicit desired movements through positional manipulation or other means of modifying or augmenting sensory output. Stretching should be done after appropriate analgesic medication has been given and is effective. Topical analgesia is not effective for the muscle spasms of spastic CP.

The parents of a child with spastic cerebral palsy (CP) state that their child seems to have significant pain. In addition to systemic pharmacologic management, the nurse includes which teaching? a. Patterning b. Positions to reduce spasticity c. Stretching exercises after meals d. Topical analgesics for muscle spasms

D -- The goals of therapy include early recognition and promotion of an optimum developmental course to enable affected children to attain their potential within the limits of their dysfunction. The disorder is permanent, and therapy is chiefly symptomatic and preventive. It is not possible at this time to reverse the degenerative processes. CP is not contagious

What is a major goal of therapy for children with cerebral palsy (CP)? a. Cure the underlying defect causing the disorder. b. Reverse the degenerative processes that have occurred. c. Prevent the spread to individuals in close contact with the child. d. Recognize the disorder early and promote optimum development.

C -- With a combination of dietary modification, regular toilet habits, and prevention of constipation and impaction, some degree of fecal continence can usually be achieved. Incontinence can be minimized with the development of a regular bowel training program. A surgical intervention can assist with continence. Enemas and laxatives are part of a bowel training program. Colostomies are not indicated in children with myelomeningocele

What most accurately describes bowel function in children born with a myelomeningocele? a. Incontinence cannot be prevented. b. Enemas and laxatives are contraindicated. c. Some degree of fecal continence can usually be achieved. d. Colostomy is usually required by the time the child reaches adolescence.

C -- DMD is characterized by a waddling gait and lordosis. Gower sign is a characteristic way of rising from a squatting or sitting position on the floor. DMD is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. Onset occurs usually between ages 3 and 5 years. DMD has a progressive and relentless loss of muscle function until death by respiratory or cardiac failure.

What statement best describes Duchenne (pseudohypertrophic) muscular dystrophy (DMD)? a. It has an autosomal dominant inheritance pattern. b. Onset occurs in later childhood and adolescence. c. It is characterized by presence of Gower sign, a waddling gait, and lordosis. d. Disease stabilizes during adolescence, allowing for life expectancy to approximately age 40 years.

B -- Toe walking after 3 years of age may indicate a muscle problem.

What would the nurse consider an abnormal finding on a musculoskeletal assessment of a 4-year-old child? a. Has inward-turned knees while standing. b. Walks on the toes. c. Appears to have flat feet. d. Swings his arms when walking.

C -- The skin exposed to frequent friction may break down.

When caring for a child in Buck's extension, the nurse would include: a. positioning the child with hips flexed 90 degrees at all times. b. keeping the weights in contact with the floor. c. checking for skin irritation from traction equipment. d. releasing the weights on a schedule.

D -- Neurovascular checks include assessment of pain, pulse, sensation, color, capillary refill, and movement. Pupils are assessed with a neurological check.

Which assessment performed by a nursing student performing a neurovascular check alerts the instructor that further education is necessary? a. Pulses b. Capillary refill c. Movement d. Pupils

B -- Application of moist heat, with a compress or by tub bath upon awakening in the morning, will help to lessen stiffness.

Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis? a. Wearing splints at night to prevent extension contractures b. Applying moist heat packs upon awakening c. Taking a warm tub bath the evening before d. Sleeping with two pillows under the head

A -- As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all occurred at the same time. The nurse must consider whether the bruises match the caretaker's explanation of what happened.

Which observation is most likely to cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs? a. Red, green, and yellow bruises on his body. b. Bruises are dispersed on his head, arms, and legs. c. A broken arm last year, and the child being described as accident-prone. d. The mother is very anxious for her son to get medical attention.

D

Which should 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 -- Callus forms more rapidly in the child than the adult.

Why does a child's fracture heal more rapidly than the adult's? a. A child's bones are less porous than adult bone. b. A child's bones are covered by a thicker periosteum. c. A child's bones are not affected by bone overgrowth. d. A child's bones have faster callus formation.

D -- Surgical correction involves additional risks of anesthesia, infection, and possibly blood transfusion. The recovery period is only 3 to 4 months rather than the 2 to 4 years of conservative therapies. The use of non-weight-bearing appliances and surgical intervention does not require prolonged bed rest. Conservative therapy is indicated for 2 to 4 years. The child is encouraged to attend school and engage in activities that can be adapted to therapeutic appliances.

Parents are considering treatment options for their 5-year-old child with Legg-Calvé-Perthes disease. Both surgical and conservative therapies are appropriate. They are able to verbalize the differences between the therapies when they make what statement? a."All therapies require extended periods of bed rest." b."Conservative therapy will be required until puberty." c."Our child cannot attend school during the treatment phase." d."If conservative measures are unsuccessful, surgical reconstruction may be necessary."

C -- Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic CP. Athetosis and dystonic movements are part of the classification of dyskinetic or athetoid CP. Tremors and lack of active movement may indicate other neurologic disorders. A wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic CP.

Spastic cerebral palsy (CP) is characterized by which clinical manifestations? a. Athetosis, dystonic movements b. Tremors, lack of active movement c. Hypertonicity; poor control of posture, balance, and coordinated motion d. Wide-based gait; poor performance of rapid, repetitive movements

B, C, D, E Whether single or multiple joints are involved, stiffness, swelling, and loss of motion develop in the affected joints in JIA. The swelling results from soft tissue edema, joint effusion, and synovial thickening. The affected joints may be warm and tender to the touch, but it is not uncommon for pain not to be reported. The limited motion early in the disease is a result of muscle spasm and joint inflammation; later it is caused by ankylosis or soft tissue contracture. Morning stiffness of the joint(s) is characteristic and present on arising in the morning or after inactivity. Erythema is not typical, and a warm, painful, red joint is always suspect for infection.

The nurse is caring for a 14-year-old child with juvenile idiopathic arthritis (JIA). What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Erythema over joints b. Soft tissue contractures c. Swelling in multiple joints d. Morning stiffness of the joints e. Loss of motion in the affected joints

D

The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complication should the nurse monitor related to the child's immobilization status? a. Metabolic rate increases b. Increased joint mobility leading to contractures c. Bone calcium increases, releasing excess calcium into the body (hypercalcemia) d. Venous stasis leading to thrombi or emboli formation

C -- Incorporating play into the therapeutic program for a child with CP often requires great ingenuity and inventiveness from those involved in the child's care. Objects and toys are chosen for the child's developmental stage to provide needed sensory input using a variety of shapes, forms, and textures. Nurses can help parents integrate therapy into play activities in natural ways.

The nurse is caring for a 4-year-old child with cerebral palsy (CP). The child, developmentally, is at an infant stage. Appropriate developmental stimulation for this child should be what? a. Playing "pat-a-cake" with the child b. None so the child does not become overstimulated c. Putting a colorful mobile with music on the bed d. Giving the child a coloring book and crayons

B

The nurse is caring for a preschool child immobilized by a spica cast. Which effect on metabolism should the nurse monitor on this child related to the immobilized status? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased production of stress hormones

C

The nurse is caring for a school-age child diagnosed with juvenile idiopathic arthritis (JIA). Which intervention should be a priority? a. Apply ice packs to relieve stiffness and pain. b. Administer acetaminophen to reduce inflammation. c. Teach the child and family correct administration of medications. d. Encourage range-of-motion exercises during periods of inflammation.

B -- Teaching the parent to use an ice pack to relieve the itching is an important aspect when planning discharge for a child with a cast. The affected limb should not be allowed to hang in a dependent position for more than 30 minutes. The affected arm should be kept elevated as much as possible. If there is swelling or redness of the fingers, the parent should notify the health care provider.

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

A -- To prevent skin breakdown with an infant who has developmental dysplasia of the hip and is in a Pavlik harness, the parent should gently massage the skin under the straps once a day to stimulate circulation. The parent should not apply lotions or powder because this could irritate the skin. The parent should not remove the harness, except during a bath, and should place the diaper under the straps.

The nurse is teaching the parents of a 1-month-old infant with developmental dysplasia of the hip about preventing skin breakdown under the Pavlik harness. What statement by the parent would indicate a correct understanding of the teaching? a. "I should gently massage the skin under the straps once a day to stimulate circulation." b. "I will apply a lotion for sensitive skin under the straps after my baby has been given a bath to prevent skin irritation." c. "I should remove the harness several times a day to prevent contractures." d. "I will place the diaper over the harness, preferably using a superabsorbent disposable diaper that is relatively thin."

C -- During the acute phase, any movement of the affected limb causes discomfort to the child. Careful positioning with the affected limb supported is necessary. Weight bearing is not permitted until healing is well under way to avoid pathologic fractures. Intravenous antibiotics are used initially. Food is not necessary with parenteral therapy. Active range of motion would be painful for the child.

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

D -- For a child who is immobilized, circulatory stasis and DVT development are prevented by instructing patients to change positions frequently, dorsiflex their feet and rotate the ankles, sit in a bedside chair periodically, or ambulate several times daily. Elevating the legs or placing a foot cradle on the bed will not prevent DVTs. A pillow under the knee would impair circulation, not improve it.

What should the nurse plan for an immobilized child in cervical traction to prevent deep vein thrombosis (DVT)? a. Elevate the child's legs. b. Place a foot cradle on the bed. c. Place a pillow under the child's knees. d. Assist the child to dorsiflex the feet and rotate the ankles.