Chapter 36: Musculoskeletal Problems

The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching? 1. "I will inspect the skin under the brace for redness or breakdown." 2. "I will encourage my child to do their exercises to maintain strength." 3. "I understand that my child needs to wear this brace for 12 hours a day." 4. "I understand that this brace is not a cure for scoliosis; it only slows the progression of the curvature."

3 Rationale: The brace needs to be worn from 16 to 23 hours a day. Braces are not curative; they slow the progression of the curvature. The skin under the brace needs to be inspected for any redness or breakdown. The child would continue to perform prescribed exercise to help maintain and strengthen the spinal and abdominal muscles. Test-Taking Strategy: Focus on the subject, the treatment plan for scoliosis. Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement. Recall that the brace needs to be worn from 16 to 23 hours a day. The other options are correct.

The nurse assists to create a nursing care plan for the child with an arm cast and would include which interventions in the plan? Select all that apply. 1. Instruct parents to keep the cast clean and dry. 2. Monitor the extremity for circulatory impairment. 3. Instruct the child not to stick objects down the cast. 4. Ensure that rough cast materials are cut off to keep the edges smooth. 5. Notify the registered nurse (RN) immediately if circulatory impairment occurs.

1, 2, 3, 5 Rationale: Cutting the cast is not appropriate; cast material can drop into the cast and cause skin irritation and skin breaks. The edges can be covered with waterproof adhesive tape to ensure a smooth cast edge. Instruct the parents and the child to keep the cast clean and dry, and not to stick objects down the cast. Monitoring for circulatory impairment is important and immediately reporting signs of impairment to the RN is necessary. Test-Taking Strategy: Focus on the subject, cast care. Read each option carefully thinking about the principles related to case care and the complications. Recall that maintaining skin integrity is a priority concern to answer correctly.

The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching? 1. "I need to have my child wear a soft fabric under the brace." 2. "I will apply lotion under the brace to prevent skin breakdown." 3. "I need to encourage my child to perform the prescribed exercises." 4. "I need to avoid applying powder under the brace, because it will cake."

2 Rationale: The use of either lotions or powders needs to be avoided because they can become sticky or cake under the brace, thus causing irritation. Options 1, 3, and 4 are appropriate statements regarding the care of a child with a brace. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling that lotions and powders need to be avoided because of the irritation they can cause will direct you to the correct option.

A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse would perform which emergency actions in the care of the child? Select all that apply. 1. Elevate the right arm. 2. Apply warm packs to the right arm. 3. Check the neurovascular status of the right extremity. 4. Check the range of motion (ROM) of the right arm and shoulder. 5. Determine the level of pain using a pediatric pain assessment tool.

1, 3, 5 Rationale: Emergency nursing actions to take for a child sustaining an extremity fracture include elevating the injured extremity, checking the extent of the injury including pain level, immobilizing the affected extremity, applying cold packs to the injured area, and monitoring the neurovascular status of the extremity. Test-Taking Strategy: Focus on the subject, emergency actions to take when a child sustains an extremity fracture. Recall that heat will increase circulation to the extremity causing further swelling and increasing the pain; this will assist in eliminating option 2. Next, eliminate option 4 because range of motion can cause further injury; determining the extent of the injury is necessary before any movement is done.

The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child? 1. Keeping the weights hanging freely 2. Ensuring that the ropes are in the pulleys 3. Placing the bed linens on the traction ropes 4. Ensuring that the weights are out of the child's reach

3 Rationale: Bed linens would not be placed on the traction ropes because of the risk of disrupting the traction apparatus. Options 1, 2, and 4 are appropriate measures when caring for a child who is in skeletal traction. Test-Taking Strategy: Focus on the subject, the action that the nurse avoids. This tells you that you need to select an option that is an incorrect intervention. Use knowledge regarding the care of the child in traction to direct you to the correct option.

The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action would the nurse take? 1. Elevate the extremity. 2. Document the findings. 3. Notify the registered nurse (RN). 4. Ambulate the child with crutches.

3 Rationale: Reduced sensation to touch or complaints of numbness or tingling at a site distal to the fracture may indicate poor tissue perfusion. This finding needs to be reported to the registered nurse or PHCP. Options 1, 2, and 4 are inappropriate and would delay the required and immediate interventions. Test-Taking Strategy: Focus on the subject, the action that the nurse would take. Note the data in the question and recall the signs of circulatory compromise. Noting the child's complaint will assist with directing you to the correct option.

The nurse is assisting a primary health care provider (PHCP) during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data would the nurse expect to note during the examination? 1. Full range of motion (ROM) of the legs 2. Marked asymmetry on the affected side 3. The unstable femoral head pops out of the acetabulum. 4. The dislocated femoral head pops back into the acetabulum.

4 Rationale: With the Ortolani maneuver, the examiner reduces the dislocated femoral head back into the acetabulum. A positive Ortolani maneuver is a palpable clunk as the femoral head moves over the acetabular ring. Options 1 and 2 are data collection techniques for the identification of the clinical manifestations of hip dysplasia, but they do not describe the Ortolani maneuver. When performing the Barlow maneuver, the examiner pushes the unstable femoral head out of the acetabulum. Test-Taking Strategy: Focus on the subject, the expected finding when performing the Ortolani maneuver. Eliminate options 1 and 2 first, because they are data collection techniques. From the remaining options, it is necessary to know the action/purpose of the Ortolani maneuver.

The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse would make which response to the mother? 1. "Avoid all exercise during painful periods." 2. "The ROM exercises must be performed every day." 3. "Have the child perform simple isometric exercises during this time." 4. "Administer additional pain medication before performing the ROM exercises."

3 Rationale: During painful episodes, hot or cold packs, splinting, and positioning the affected joint in a neutral position help to reduce the pain. Although resting the extremity is appropriate, it is important to begin simple isometric or tensing exercises as soon as the child is able. These exercises do not involve joint movement. Test-Taking Strategy: Use general medication guidelines to assist in eliminating option 4. Additional medication would not be given. Eliminate options 1 and 2 because of the closed-ended words, all and must, in these options.

The nurse provides information to the parent of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the parent indicates the need for further teaching regarding this disorder? 1. "I understand treatment needs to be started as soon as possible." 2. "I realize my child will require follow-up care until fully grown." 3. "I need to bring my child back to the clinic in 2 months for a new cast." 4. "I need to come to the clinic every week with my child for the casting."

3 Rationale: Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved within 3 to 6 months, surgery is usually indicated. Because clubfoot can recur, all children with the condition require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome. Test-Taking Strategy: Focus on the subject, the treatment plan for clubfoot. Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement. This will assist you with eliminating options 1 and 2. Recalling that serial manipulations and casting are required weekly will direct you to the correct option.

The mother of a child with Marfan syndrome asks the nurse what can be done to help her child. Which are the best responses by the nurse? Select all that apply. 1. "You will need to keep your child indoors and avoid sports." 2. "You will need to consider surgery in the future if recommended." 3. "You will need to make regular pediatric appointments for your child." 4. "You will need to make regular eye examination appointments for your child." 5. "You will need to be sure your child takes prescribed cardiac medication(s) to decrease stress on the aorta."

2, 3, 4, 5, 6 Rationale: Parents of the child with Marfan syndrome need to be instructed to monitor for vision problems and get regular eye examinations, and avoid participation in contact sports; however, it is not necessary for the child to stay indoors. The nurse needs to monitor the curvature of the spine as the child grows. Antibiotics need to be taken before any dental procedure to prevent endocarditis. Cardiac medications need to be taken to decrease stress on the aorta, and surgical replacement of the aortic root and valve may be necessary. Making regular pediatric appointments is important for monitoring the child. Test-Taking Strategy: Note the strategic word, best. This indicates that all the answers may be correct, but you will need to select the ones that are better than the others. Focus on the subject, Marfan syndrome. Think about the interventions that are taken to decrease stress on the aorta and to prevent endocarditis. This will assist you with answering the question.