Chapter 21: Caring for the Child With a Musculoskeletal Condition

13. A nurse is caring for an 8-year-old child hospitalized 2 days after open reduction and internal fixation (ORIF) of a femur fracture sustained in a motor vehicle crash. The child is now in a long-leg cast. Which assessment finding prompts the nurse to notify the health-care provider? A. A foul odor coming from the cast B. Child eating only 20% of meals C. Old dried drainage marked on the cast D. Request for pain medicine every 4 hours

A A. A foul odor coming from the cast may indicate an infection at the surgical site or the fracture site. The nurse should notify the health-care provider. B. Loss of appetite may be from several causes: fatigue, stress, side effect of medications, dislike of hospital food, loss of industry (child is in Erikson's stage of industry vs. inferiority), trying to regain some control, pain, or fear of pain. The nurse would need to assess this situation further to determine its cause before notifying the health-care provider. C. Old drainage would not be worrisome; if the drainage continues to increase, then the nurse should notify the health-care provider. D. At 2 days since surgery, wanting pain medication every 4 hours is not unreasonable.

12. A child is 3 hours postoperative, having had an open reduction and internal fixation (ORIF) of a type IV tibial fracture, which is now also casted. Which action by the nurse takes priority? A. Assess neurovascular status every hour. B. Change IV pain medication to oral pills. C. Provide an ice bag for 30 minutes every hour. D. Teach parents about activity restrictions.

A A. After surgery and/or casting, it is vital to assess neurovascular status, which is usually done with postoperative vital signs. Excessive swelling can disrupt circulation to the extremity, so the nurse assesses the child's neurovascular status frequently. B. When the child is tolerating oral foods and fluids, the nurse can switch to pain pills from IV narcotics. C. Applying ice is a good intervention but not for more than 15 minutes at a time. D. Teaching is important but not as important as preventing injury from complications.

17. Which laboratory finding would indicate to the nurse that there is a potential problem with the musculoskeletal system of a client? A. ESR 20 mm/hr. B. C-reactive protein 2.0 mg/dL C. Calcium 10 mg D. WBCs of 11,000/mm3

A A. An elevated sed rate (ESR), although nonspecific, can indicate a potential problem in the musculoskeletal system and requires further evaluation. B. This C-reactive protein value is within normal limits. C. This calcium value is within normal limits. D. This white blood cell count is within normal limits.

9. A child who has been limping for several weeks is brought to the clinic and undergoes radiological studies. The results show osteonecrosis. Which information does the nurse plan to teach the parents about their child's condition? A. Non-weight-bearing status and mobility limitations B. Overcorrection with serial casting for 2-3 years C. Surgical correction with the Z-plasty technique D. Wearing and caring for a Browne splint

A A. Osteonecrosis is a cardinal sign of Legg-Calvé-Perthes disease. This disorder is frequently treated with non-weight-bearing status and bracing or casting. B. Overcorrection with serial casting for 2-3 years is a treatment modality used to treat clubfoot. C. Surgical correction with the Z-plasty technique is a treatment modality used to treat clubfoot. D. Wearing and caring for a Browne splint is a treatment modality used to treat clubfoot.

6. A parent calls the clinic to report that his child's cast seems to be looser than it was yesterday. Which instruction is most appropriate for the nurse to provide to the parent? A. "Bring your child in so we can evaluate the cast." B. "You can try wetting it and wrapping it tighter." C. "Pad the top of the cast with a small towel so it fits." D. "This is not unusual; just keep your next appointment."

A A. Parents should be instructed to take their child to a health-care provider if a cast appears loose, damaged, or soft. B. The cast should be kept clean and dry. C. The parent should not be instructed to make modifications to the cast. D. A loose cast should be inspected and should not be put off until the next appointment.

15. A child is going home with a distractor in place after surgery to repair syndactyly. Which discharge teaching is most important? A. Clean around the pin sites twice a day with soap and water. B. Don't pull the pins; they will gradually fall out on their own. C. Perform range-of-motion exercises to the affected fingers daily. D. Turn the screw with the Allen wrench twice a day for a week.

A A. The distractor uses pins placed in the bone fragments that extend through the skin. The parents need to care for the pins using soap and water to clean around the exit sites. B. The pins need to be removed surgically; they will not fall out on their own. C. Because the bones are pinned, range of motion is not possible. D. The Allen wrench is used to turn the screw on the distractor twice a week.

11. A nurse is caring for a child who had an open reduction and internal fixation (ORIF) of a femur fracture 12 hours ago. The nurse finds the child pale and short of breath. What action by the nurse takes priority? A. Assess oxygen saturation while a coworker calls the physician. B. Assess and treat the child for pain or anxiety as needed. C. Raise the head of the bed to a 45-degree angle and reassess. D. Review the child's postoperative hemoglobin and hematocrit.

A A. This child appears to be experiencing a complication of fracture, which may include shock, fat embolism, deep vein thrombosis, pulmonary embolism, and infection. Shortness of breath should alert the nurse to a respiratory complication as a first priority. The nurse should have a coworker call the physician while obtaining other assessment data, including oxygen saturation, vital signs, and a respiratory assessment. B. The child may have pain or anxiety, but these are not the priority. C. Raising the head of the bed may or may not be helpful, but the nurse first needs to assess oxygen saturation. D. Although it is possible that the child's postoperative hemoglobin and hematocrit are low enough that the child is experiencing shock, the priority steps in assessing and intervening are airway, breathing, and circulation (ABCs). Breathing comes before circulation, so this action is not the priority.

20. A 10-year-old child has had a sunken chest since birth but has recently been noted to have activity intolerance when playing. Which diagnostic testing does the nurse teach the child and parents about? Select all that apply. A! "Chest x-ray." B! "Chromosome analysis." C! "ECG and echocardiogram." D! "Pulmonary function studies." E! "Ultrasound of the chest."

A,B,C,D A. This is correct. This child has signs and symptoms of pectus excavatum, which manifests with a sunken chest. If the cardiac or respiratory systems are involved, the child will show exercise intolerance (complaints of chest pain). A chest x-ray is a common diagnostic measure for this disorder. B. This is correct. This child has signs and symptoms of pectus excavatum, which manifests with a sunken chest. Chromosomal analysis is a common diagnostic measure for this disorder. C. This is correct. This child has signs and symptoms of pectus excavatum, which manifests with a sunken chest. If the cardiac or respiratory systems are involved,the child will show exercise intolerance (changes on ECG). ECG and/or echocar- diogram are common diagnostic measures for this disorder. D. This is correct. This child has signs and symptoms of pectus excavatum, which manifests with a sunken chest. If the cardiac or respiratory systems are involved, the child will show exercise intolerance (shortness of breath with activity). Pul- monary function studies are a common diagnostic measure for this disorder. E. This is incorrect. An ultrasound of the chest is not a diagnostic procedure for pec- tus excavatum.

18. A patient diagnosed with osteogenesis imperfecta (OI) is being evaluated for treatment. What orders does the nurse anticipate that the health-care provider will include? Select all that apply. A! "Pamidronate (Aredia) therapy." B! "Ongoing referral to an orthopedist." C! "Endoscopy procedure." D! "Course of antibiotic therapy." E! "Referral to a neurologist."

A,B,E A. This is correct. Medical treatment of OI includes bisphosphonate therapy, which helps to prevent further bone resorption. B. This is correct. Medical treatment of OI includes a multidisciplinary approach, of which an orthopedist is included. C. This is incorrect. There is no clinical indication for an endoscopic procedure. D. This is incorrect. There is no clinical indication for a course of antibiotic therapy. E. This is correct. Medical treatment of OI includes a multidisciplinary approach, of which a neurologist is included.

21. The nurse is providing care to a pediatric patient who suffered an ankle sprain. Which interventions are appropriate to include in the patient's plan of care? Select all that apply. A! "Apply an Ace wrap to apply pressure and reduce swelling of the joint." B! "Apply heat to the extremity for the first 38 hours at 15-minute intervals." C! "Elevate and move the affected joint to reduce swelling and stiffness." D! "Immediately perform range of motion exercises on the extremity." E! "Place ice on the injury for 15 minutes at a time for the first 1 to 2 days."

A,C,E A. This is correct. After a sprain, it is important to use the RICE acronym: Rest, Ice, Compression, and Elevation. Compression with an Ace wrap, or some other method to apply pressure to the affected joint, will help reduce swelling of the joint. B. This is incorrect. The application of heat is not part of the RICE acronym for sprains. C. This is correct. After a sprain, it is important to use the RICE acronym: Rest, Ice, Compression, and Elevation. Elevating the affected joint reduces swelling and early motion helps maintain full range of motion. D. This is incorrect. A sprain requires resting the injured extremity; performing range of motion exercises would cause further damage. E. This is correct. After a sprain, it is important to use the RICE acronym: Rest, Ice, Compression, and Elevation. Applying ice for the first 48 hours, keeping ice packs,in place for 15-minute intervals, will decrease swelling.

19. A nurse is assessing a pediatric patient fall risk. Comparing the prior Pediatric Fall Risk Tool assessment in the prior shift, the score was 7 and now the score is 10. What priority action should the nurse take? Select all that apply. A! "Make sure that the bed is in the lowest locked position." B! "Restrict fluids." C! "Keep the room dimly lit." D! "Place the call light in reach." E! "Assist out of bed for transfers."

A,D,E A. This is correct. Making sure the bed is in the lowest position with the wheels locked is a basic safety measure to prevent falls. B. This is incorrect. There is no clinical indication to restrict fluids as it relates to an increased risk for falls. C. This is incorrect. Keeping the room dimly lit may increase the likelihood of falls for this patient. D. This is correct. Placing the call light within reach is a basic safety measure to pre- vent falls. E. This is correct. A higher score on the Pediatric Fall Risk Tool indicates an in- creased risk for falls. A score of 7 is considered to be at low risk, but a score of 8 or higher indicates a high risk for falls. Since the patient is now at high risk, high-risk management strategies are appropriate, such as assisting the patient out of the bed for transfers.

10. A 10-year-old child is in the emergency department with a type IV femur fracture. Which intervention takes priority? A. Assessing the child for signs of maltreatment B. Ensuring that signed consent for surgery is on the chart C. Explaining the process of closed reduction with sedation D. Preparing the child for prolonged immobility in traction

B A. Fractures in a 10-year-old are not as commonly caused by child abuse as by bicycle crashes or sporting injuries, so unless other signs of maltreatment are noticed, this would not be a priority. B. A type IV fracture must be reduced surgically. The nurse must ensure that signed consent is on the chart. C. Because the child is not having a closed reduction, explanation of this process is not needed. D. The child will not be immobilized in traction for a prolonged period.

3 A new nurse is caring for a child after spinal fusion to correct scoliosis. Which action by the new nurse causes the experienced nurse to intervene? A. Assesses neurological status and vital signs every hour B. Instructs patient to turn by pulling on side rails C. Monitors chest tube for air leakage and drainage D. Promotes use of the incentive spirometer each hour

B A. It is appropriate for the nurse to assess neurological status and vital signs every hour. B. After spinal fusion, the patient must be logrolled to turn. Logrolling involves two nurses turning the patient as one single unit so that the spine is maintained in a straight line. The patient should not be instructed to pull on the side rails to turn. C. It is appropriate for the nurse to monitor the chest tube for air leakage and drainage. D. It is appropriate for the nurse to promote use of the incentive spirometer each hour.

4. A nurse working in an inpatient pediatric unit cares for many children with musculoskeletal impairments. Which outcome takes priority for these children? A. Adapting to changing activity restrictions B. Continuing their growth and development C. Resuming ambulation as soon as possible D. Staying current with schoolwork with tutors

B A. Some children may need to adapt to changing activity restrictions, but the priority outcome is maintaining normal growth and development. B. Growth and development are dependent upon being able to interact with the environment. Any child with a musculoskeletal disorder is at risk for impaired growth and development. A priority outcome for any of these children is to maintain normal growth and development. C. For some children, ambulation will be delayed or not possible. D. Staying current with education is important but does not take priority over maintaining normal growth and development.

7. A parent calls the nursing call center stating that his child, who has a cast after surgical treatment of a clubfoot, is very fussy even after acetaminophen (Tylenol) administration and that the child's toes seem cool. What advice does the nurse give the parent? A. "Elevate the affected extremity and apply ice for 20 minutes." B. "Make four cuts to the top of the cast, each about 1 inch long." C. "Take your child to the nearest emergency department now." D. "Try giving your child a dose of ibuprofen (Pediaprofen) instead."

C A. If circulation is compromised, elevation and ice will make the problem worse. B. The parent should not be instructed to modify the cast. C. Parents always need to observe for complications of casting, including neurovascular compromise. A child who is excessively fussy and whose toes are cool should be seen by a health-care provider to assess circulation and possibly modify or change the cast. The parent should be told to take the child to the nearest emergency department. D. Although ibuprofen may manage the child's pain better than acetaminophen, the priority instruction is to send the parent to the emergency department.

1. The nurse is providing care to a pediatric patient admitted for a work-up of bone deformity. The latest laboratory values indicate calcium at 6.6 mg/dL and phosphorus at 2.1 mg/dL. Which condition does the nurse correlate with these values? A. Muscular dystrophy B. Osgood-Schlatter disease C. Rickets D. Scoliosis

C A. Muscular dystrophy is a neuromuscular disorder that is not indicated by low calcium and phosphorus levels. B. Osgood-Schlatter disease is characterized by knee pain. It is a genetic condition related to overuse and has no correlation to calcium and phosphorus levels. C. Normal calcium is 8.5-11 mg/dL, and normal phosphorus is 3-4.5 mg/dL. Low values for both indicate rickets. D. Scoliosis is a spinal deformity diagnosed by radiography, not by laboratory values.

16. A child is being treated for osteomyelitis. Which priority treatment plan should the nurse anticipate that the health-care provider will order? A. NSAIDs for pain relief B. Around-the-clock dosing of Tylenol C. Long-term antibiotic therapy D. Steroid dose pack

C A. While NSAIDs may be ordered for pain relief, the priority is treating the disease. B. While medication may be ordered for pain relief, treating the disease is the priority. Further, around-the-clock dosing of Tylenol would not be indicated. C. Many bacteria can cause osteomyelitis, but the most common bacteria is Staphylo- coccus aureus. Bacteria multiply in the middle of the bone, and the infection spreads to the ends of the bones. Osteomyelitis requires long-term antibiotic thera- py. D. Steroid dose packs are not indicated for osteomyelitis.

8. A mother brings her daughter to the clinic after noticing the child's new swimsuit fits baggily on one side of her bottom and the child's right thigh looks quite odd compared with the other one. Which assessment question would provide the nurse the most important information? A. "Do her joints dislocate easily?" B. "Does she fatigue easily?" C. "Has your child been limping?" D. "When did you see her in a swimsuit last?"

C A. While joint dysfunction is a symptom of Legg-Calvé-Perthes disease, it is not specific to this disease process and thus not the priority. B. Fatigue is not a symptom of Legg-Calvé-Perthes disease. The child may be resting because the pain decreases with rest. C. The mother seems to have noticed thigh and buttock muscle wasting, which are signs of Legg-Calvé-Perthes disease. Asking about a limp would be the most important question, as it is specific to this disease process. D. The nurse should assess for Legg-Calvé-Perthes disease. Asking when the child was last seen in the swimsuit does not provide information that would help with this.

14. A 4-year-old child is recovering from a modified Nuss procedure. Which is the priority intervention by the nurse? A. Ambulating the child as soon as allowed B. Encouraging food and fluids postoperatively C. Monitoring vital signs and wound drainage D. Playing with the child using pinwheels or bubbles

D A. Ambulating the child as soon as allowed is an important postoperative nursing intervention, but actions to prevent pneumonia take priority. B. Encouraging food and fluids an important postoperative nursing intervention, but actions to prevent pneumonia take priority. C. Monitoring vital signs and wound drainage is an important postoperative nursing intervention, but actions to prevent pneumonia take priority. D. The modified Nuss procedure is an open chest reconstruction for severe cases of pectus excavatum. Preventing pneumonia is a critical nursing action. Because this child is too young to use an incentive spirometer, "playing" with them using bubbles, pinwheels, or paper triangles the child can blow across the table accomplishes pulmonary hygiene.

5. A woman who wishes to become pregnant again consults with the nurse about preventing her child from being born with clubfoot. She has two other children, both treated for this disorder. Which information does the nurse provide about preventing clubfoot? A. Avoid secondhand cigarette smoke while pregnant B. Sleep on your left side as much as possible. C. Getting enough folic acid early in pregnancy is advisable. D. The disorder is genetic, so no prevention is available.

D A. Secondhand smoke exposure is not related to clubfoot. B. Sleeping on the left side promotes circulation but has no effect on clubfoot. C. Folic acid is important for preventing neural tube disorders but has no effect on clubfoot. D. Recent research shows that clubfoot is genetic, so no prevention is possible.

2. A pediatric nurse is caring for a 1-year-old child who is in a spica cast. The nurse teaches the parents that modifications need to be made for this child. Which modification does the nurse teach? A. Using a baby bath with shallow water to clean the child B. Using a car seat with sturdy sides to transport the child C. Using a sitting position on the floor to feed the child D. Using a wagon instead of a stroller to move the child

D A. The parents will need to modify the bath by giving the child a sponge bath. B. Toddler car seats that do not have sides are a good modification for a child in a spica cast. C. Placing the child in the prone position on the floor can make feeding the child easier. D. Mobilizing a child in a wagon is a good modification for a stroller while the child is in the spica cast.