Chapter 50: The Child with a Musculoskeletal Alteration

A priority nursing intervention when caring for a child in a Pavlik harness is a. Skin care b. Bowel function c. Feeding patterns d. Respiratory function

a. Skin care (The child in a Pavlik harness needs special attention to skin care because the infant's skin is sensitive and the harness may cause irritation.)

A nurse is preparing to administer naproxen to a toddler weighing 29 pounds. The pharmacy delivers a bottle containing 125 mg/5 mL. Based on knowledge of the safe dose, how much liquid does the nurse prepare to administer? Display your answer using a whole number. ______ mL

66 mL [First find the child's weight in kilograms. 29 pounds = 13.1818 kilograms. Next, take the dose (10 mg/kg) and multiply by 13.1818 = 131.81. Now, divide in half as this dose is given in two divided doses daily = 65.905 mL. Finally round to the nearest whole number = 66 mL.]

A child has a cast applied to the left forearm. Which interventions should the nurse include in the home care instructions for the parents? (Select all that apply.) a. Keep small toys away from the cast. b. Use a padded ruler to scratch the skin under the cast if it itches. c. Assess the cast daily for unusual odors. d. Elevate the extremity on pillows for the first 24 to 48 hours. e. Numbness and tingling in the extremity are expected.

A. Keep small toys away from the cast. C. Assess the cast daily for unusual odors. D. Elevate the extremity on pillows for the first 24 to 48 hours. (Small toys should be kept away from the cast because they can become lodged inside the cast. The cast should be inspected daily for any unusual odors, which can indicate infection. The extremity should be elevated for the first 24 to 48 hours to decrease edema. Nothing should be placed inside the cast. If numbness or tingling is experienced, the physician should be notified.)

Which interventions should the nurse implement to prevent complications of immobility for a child in skeletal traction? Select all that apply. a. Reposition the child every 2 hours. b. Avoid use of an egg-crate or sheepskin mattress. c. Limit fluid intake. d. Administer stool softeners as prescribed. e. Encourage coughing and deep breathing.

A. Reposition the child every 2 hours. D. Administer stool softeners as prescribed. E. Encourage coughing and deep breathing. (Complications of immobility can affect the skin, the gastrointestinal system, and the respiratory system. The child should be repositioned every 2 hours to prevent skin breakdown. Stool softeners should be administered to avoid constipation, and the child should cough and deep breathe to maintain respiratory function. Egg-crate or sheepskin mattresses can be useful in preventing skin breakdown, and fluids should be increased to prevent constipation, not decreased.)

What is the most appropriate intervention for an adolescent with a mild scoliosis? a. Long-term monitoring b. Surgical intervention c. Bracing d. No follow-up

a. Long-term monitoring (The child with mild scoliosis requires long-term follow-up to determine whether the curve will progress or remain stable.)

What actions should the nurse perform while caring for a school-age child who sprained his ankle playing football? Select all that apply. a. Turn the child every 1 to 2 hours. b. Assist with range-of-motion exercises every 2 hours. c. Apply ice to the affected ankle. d. Wrap the ankle with an Ace bandage. e. Elevate the affected extremity.

C. Apply ice to the affected ankle. D. Wrap the ankle with an Ace bandage. E. Elevate the affected extremity. (The child with a soft tissue injury in the first 6 to 12 hours is treated by controlling the swelling and reducing muscle damage. The acronym RICE summarizes the care needed: rest, ice, compression, and elevation. During the acute phase of the injury, the child is not moved frequently, and range-of-motion exercises would not be done. The child with a soft tissue injury in the first 6 to 12 hours is treated by controlling the swelling and reducing muscle damage.)

A frequent parental concern is children's leg length inequality. Asymptomatic leg length inequality is relatively common in children. Is this statement true or false?

True (Causes may be congenital or acquired. Treatment ranges from no intervention to extensive reconstruction or prosthetic fitting.)

Discharge planning for the child with juvenile arthritis includes the need for a. Routine ophthalmologic examinations to assess for visual problems b. A low-calorie diet to decrease or control weight in the less mobile child c. Avoiding the use of aspirin to decrease gastric irritation d. Immobilizing the painful joints, which is the result of the inflammatory process

a. Routine ophthalmologic examinations to assess for visual problems (The systemic effects of juvenile arthritis can result in visual problems, making routine eye examinations important.)

Which statement by the mother of an adolescent being discharged after spinal fusion for severe scoliosis indicates the need for further teaching? a. "I am glad we chose surgery. Now it is all over and done." b. "I'll see you in a month; we'll be back fairly regularly." c. "I have to pick up some more T-shirts on the way home." d. "Those exercises the physical therapist showed us were not too hard."

a. "I am glad we chose surgery. Now it is all over and done." (Spinal fusion requires long-term follow-up to assess the stability of the spinal correction.)

A child with osteomyelitis asks the nurse, "What is a 'sed' rate?" What is the best response for the nurse? a. "It tells us how you are responding to the treatment." b. "It tells us what type of antibiotic you need." c. "It tells us whether we need to immobilize your extremity." d. "It tells us how your nerves and muscles are doing."

a. "It tells us how you are responding to the treatment." 9The erythrocyte sedimentation rate (ESR) indicates the presence of inflammation and infectious process and is one of the best indicators of the child's response to treatment. Although the ESR indirectly identifies whether an antibiotic is needed, the organism involved dictates the type of antibiotic and the length of treatment. The ESR does not direct whether the extremity will be immobilized. An ESR rate will not evaluate neuromuscular status.)

A nurse is assessing cranial nerve VII. How does the nurse perform this assessment? a. Ask the child to smile or "show your teeth." b. Have the child shrug shoulders against resistance. c. Tell the child to squeeze your hands hard. d. Instruct the child to stick out the tongue.

a. Ask the child to smile or "show your teeth." (Cranial nerve VII (facial nerve) is assessed by having the child smile. Shrugging the shoulders against resistance is testing cranial nerve XI (spinal accessory nerve). Squeezing the hands assesses grip strength. The ability to stick out the tongue shows that cranial nerve XII (hypoglossal) is intact.)

What is the major concern guiding treatment for the child with Legg-Calvé-Perthes disease? a. Avoid permanent deformity. b. Minimize pain. c. Maintain normal activities. d. Encourage new hobbies.

a. Avoid permanent deformity. (The major concern related to Legg-Calvé-Perthes disease is to prevent an arthritic process resulting from the flattening of the femoral head of the femur when it protrudes outside the acetabulum.)

When assessing the child with osteogenesis imperfecta, the nurse should expect to observe a. Discolored teeth b. Below-normal intelligence c. Increased muscle tone d. Above-average stature

a. Discolored teeth (Children with osteogenesis imperfecta have incomplete development of bones, teeth, ligaments, and sclerae. Teeth are discolored because of abnormal enamel.)

In caring for a child with a compound fracture, the nurse should carefully assess for a. Infection b. Osteoarthritis c. Epiphyseal disruption d. Periosteum thickening

a. Infection (Because the skin has been broken, the child is at risk for organisms to enter the wound.)

The nurse knows that treatment of Osgood-Schlatter disease includes a. Limitation of knee bending or kneeling b. Increasing range of motion (ROM) of the knee c. Encouraging flexion of the hip d. Limitation of adduction of the hip

a. Limitation of knee bending or kneeling (Limitation of knee bending or kneeling provides pain control and allows the knees to heal.)

A mother whose 7-year-old child has been placed in a cast for a fractured right arm reports that he will not stop crying even after taking acetaminophen with codeine. He also will not straighten the fingers on his right arm. The nurse tells the mother to a. Take him to the emergency department. b. Put ice on the injury. c. Avoid letting him get so tired. d. Wait another hour; if he is still crying, call back.

a. Take him to the emergency department. (Unrelieved pain and the child's inability to extend his fingers are signs of compartment syndrome, which requires immediate attention. Placing ice on the extremity is an inappropriate action for the symptoms. Telling the mother not to let her child get tired is an inappropriate response to a concern. A child who has signs and symptoms of compartment syndrome should be seen immediately. Waiting an hour could compromise the recovery of the child.)

A nurse is teaching parents the difference between pediatric fractures and adult fractures. Which observation is true about pediatric fractures? a. They seldom are complete breaks. b. They are often compound fractures. c. They are often at the epiphyseal plate. d. They are often the result of decreased mobility of the bones

a. They seldom are complete breaks. (Pediatric fractures seldom are complete breaks. Rather, children's bones tend to bend or buckle.)

A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material? a. Wash the area with warm water and soap. b. Vigorously scrub leg. c. Apply powder to absorb material. d. Carefully pick material off leg.

a. Wash the area with warm water and soap. (Washing with soap and warm water will remove the desquamated skin and secretions. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child.)

Which interaction is part of the discharge plan for a school-age child with osteomyelitis who is receiving home antibiotic therapy? a. Instructions for a low-calorie diet b. Arrange for tutoring and school work c. Instructions for a high-fat, low-protein diet d. Instructions for the parent to return the child to team sports immediately

b. Arrange for tutoring and school work (Promoting optimal growth and development in the school-age child is important. It is important to continue school work and arrange for tutoring if indicated. The child with osteomyelitis is on a high-calorie, high-protein diet. A high-fiber diet may or may not be indicated. The bone must heal before the child returns to school.)

During a well-child visit, the nurse identifies that an 18-month-old infant is bowlegged. She is aware that this assessment is a. Common in children with nutritional deficiencies b. Common in infants and toddlers c. A serious condition needing further evaluation d. An indication of neurologic impairment

b. Common in infants and toddlers (Bowlegs are common in infants and toddlers.)

During a well-child visit, the nurse identifies that an 18-month-old infant is bowlegged. What action by the nurse is most appropriate? a. Assess the infant's diet history. b. Document the finding in the chart. c. Facilitate a referral to an orthopedist. d. Perform further assessment of the musculoskeletal system.

b. Document the finding in the chart. (Bowlegs are common in infants and toddlers. The nurse only needs to document the findings. No other actions are required.)

When assessing a child for an upper extremity fracture, the nurse should know that these fractures most often result from a. Automobile accidents b. Falls c. Physical abuse d. Sports injuries

b. Falls (The major cause of children's fractures is falls. Because of the protection reflexes, the outstretched arm often receives the full force of the fall.)

Juvenile arthritis should be suspected in a child who exhibits a. Frequent fractures b. Joint swelling and pain lasting longer than 6 weeks c. Increased joint mobility d. Lurching and abnormal gait, limited abduction

b. Joint swelling and pain lasting longer than 6 weeks (Intermittent joint pain lasting longer than 6 weeks is indicative of juvenile arthritis.)

A boy who has fractured his forearm is unable to extend his fingers. The nurse knows that this a. Is normal following this type of injury b. May indicate compartmental syndrome c. May indicate fat embolism d. May indicate damage to the epiphyseal plate

b. May indicate compartmental syndrome (Swelling causes pressure to rise within the immobilizing device leading to compartmental syndrome. Signs include severe pain, often unrelieved by analgesics, and neurovascular impairment. It is not uncommon in the forearm, so the inability to extend the fingers may indicate compartmental syndrome.)

During painful episodes of juvenile arthritis, a plan of care should include what nursing intervention? a. A weight-control diet to decrease stress on the joints b. Proper positioning of the affected joints to prevent musculoskeletal complications c. Complete bed rest to decrease stress to joints d. High-resistance exercises to maintain muscular tone in the affected joints

b. Proper positioning of the affected joints to prevent musculoskeletal complications (Proper positioning is important to support and protect affected joints. Isometric exercises and passive range-of-motion exercises will prevent contractures and deformities.)

Which factor should the nurse include when teaching a parent about the care of a newborn in a Pavlik harness for hip dysplasia? a. The harness may be removed with every diaper change. b. The harness is used to maintain the infant's hips in flexion and abduction and external rotation. c. The harness is only the first step of treatment. d. The harness is worn for 2 weeks.

b. The harness is used to maintain the infant's hips in flexion and abduction and external rotation. (The harness is used to maintain the infant's hips in flexion and external rotation to allow the hips (femoral head and acetabulum) to mold and grow normally.)

When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess the family's safety practices. Fractures in infants usually result from falls. c. Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.

c. Assess for child abuse. Fractures in infants are often nonaccidental. (Fractures in infants warrant further investigation to rule out child abuse. Fractures in children younger than 1 year are unusual because of the cartilaginous quality of the skeleton; a large amount of force is necessary to fracture their bones. Safety practices are important to assess as well, but the priority is checking for child abuse. Genetic factors are a rare cause of fractures.)

Which statement is accurate concerning a child's musculoskeletal system and how it may be different from an adult's? a. Growth occurs in children as a result of an increase in the number of muscle fibers. b. Infants are at greater risk for fractures because their epiphyseal plates are not fused. c. Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. d. Their bones have less blood flow.

c. Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. (Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. A child's growth occurs because of an increase in size rather than an increase in the number of the muscle fibers. Fractures in children younger than 1 year are unusual because a large amount of force is necessary to fracture their bones. A child's bones have greater blood flow than an adult's bones.)

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should explain that a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk.

c. Frequent, serial casting is tried first. (Serial casting is begun shortly after birth before discharge from the nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy.)

When providing education for the parents of a child with Duchenne muscular dystrophy, the nurse plans to include a. Testing all female children for the disease b. Testing the father for the presence of the trait on the Y chromosome c. Genetic counseling for all female children d. Testing the parents to determine the carrier

c. Genetic counseling for all female children (Duchenne muscular dystrophy is a recessive sex-linked disease carried on the X chromosome, so only males are affected with the disease.)

A 4-year-old child with a long leg cast complains of "fire" in his cast. The nurse should a. Notify the physician on his next rounds. b. Note the complaint in the nurse's notes. c. Notify the physician immediately. d. Report the complaint to the next nurse on duty.

c. Notify the physician immediately. (A burning sensation under the cast is an indication of tissue ischemia. It may be an early indication of serious neurovascular compromise, such as compartment syndrome, that requires immediate attention. The child's symptom requires immediate attention. Notifying the physician on the next rounds is inappropriate. Charting the complaint in the nurse's notes is an appropriate action but not the priority. The priority action is to contact the provider. Communication across shifts is important to the continuing assessment of the child; however, this symptom requires immediate evaluation, and the provider should be contacted.)

A 6-year-old patient who has been placed in skeletal traction has pain, edema, and fever. The nurse should suspect a. Meningitis b. Crepitus c. Osteomyelitis d. Osteochondrosis

c. Osteomyelitis (The most serious complication of skeletal traction is osteomyelitis. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, or unusual odor. An elevated temperature may accompany the symptoms.)

Which factor is important to include in the teaching plan for parents of a child with Legg-Calvé-Perthes disease? a. It is an acute illness lasting 1 to 2 weeks. b. It affects primarily adolescents. c. There is a disturbance in the blood supply to the femoral epiphysis. d. It is caused by a virus.

c. There is a disturbance in the blood supply to the femoral epiphysis. (Legg-Calvé-Perthes disease is a self-limiting disease that affects the blood supply to the femoral epiphysis. The most serious problem associated is the risk of permanent deformity.)

A 6-year-old patient who has been placed in skeletal traction has pain, edema, and fever. The nurse should assess which of the following? a. Neurologic status b. Range of motion of all extremities c. Warmth at site of pain d. Blood pressure

c. Warmth at site of pain (The most serious complication of skeletal traction is osteomyelitis. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, or unusual odor. An elevated temperature may accompany the symptoms. Assessing neurologic status is not required. Range of motion may or may not be affected with osteomyelitis, but this child is in skeletal traction so range of motion will be limited. Blood pressure is assessed with other vital signs.)

Patient and parent education for the child who has a synthetic cast should include a. Applying a heating pad to the cast if the child has swelling in the affected extremity b. Wrapping the outer surface of the cast with an Ace bandage c. Splitting the cast if the child complains of numbness or pain d. Covering the cast with plastic and waterproof tape to keep it dry while bathing or showering

d. Covering the cast with plastic and waterproof tape to keep it dry while bathing or showering (Damp skin is more susceptible to breakdown. Cast should be kept clean and dry.)

Which term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? a. Scoliosis b. Ankylosis c. Lordosis d. Kyphosis

d. Kyphosis (Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine.)

The nurse is assessing a 14-year-old who plays football and complains of knee pain when running and climbing stairs during football practice. The nurse should anticipate which action for this condition? a. Bedrest with range-of-motion exercises b. Prolonged IV antibiotics c. Electromyography d. NSAIDs or knee immobilizer

d. NSAIDs or knee immobilizer (This child most likely has Osgood-Schlatter disease, a self-limiting disorder that resolves with skeletal maturity. NSAIDs and possible knee immobilizers are the treatment. Bedrest with range of motion in indicated for Legg-Calvé-Perthes disease. IV antibiotics are used in osteomyelitis. Electromyography is used to diagnose muscular dystrophy.)

During a 14-year-old's physical examination, the nurse identifies that he plays soccer and football and is complaining of knee pain when he rises from a squatting position, and difficulty with weight bearing. The nurse should suspect a. Legg-Calvé-Perthes disease b. Osteomyelitis c. Duchenne muscular dystrophy d. Osgood-Schlatter disease

d. Osgood-Schlatter disease

A nurse knows that which exercise is best for a child with juvenile arthritis? a. Jogging b. Tennis c. Gymnastics d. Swimming

d. Swimming (The warmth of the water -- especially if the pool is heated -- coupled with mild resistance, makes swimming the perfect medium for strengthening and range-of-motion exercises while protecting the joints. Jogging, tennis, and gymnastics jar the hip, knee, and ankle joints and can cause joint damage.

When a child with a musculoskeletal injury on the foot is assessed, what is most indicative of a fracture? a. Increased swelling after the injury is iced b. The presence of localized tenderness distal to the site c. The presence of an elevated temperature for 24 hours d. The inability of the child to bear weight

d. The inability of the child to bear weight. (An inability to bear weight on the affected extremity is indicative of a more serious injury. With a fracture, general manifestations include pain or tenderness at the site, immobility or decreased range of motion, deformity of the extremity, edema, and inability to bear weight. Although edema is often present with a fracture, it would be unusual for swelling to increase after application of ice, and this would not be most indicative of a fracture. Swelling after icing does not identify the degree of the injury. Localized tenderness along with limited joint mobility may indicate serious injury, but inability to bear weight on the extremity is a more reliable sign. Tenderness is not a usual complaint distal to the affected site. Elevated temperature is associated with infection but not a fracture.)

Which nursing intervention is appropriate to assess for neurovascular competency in a child who fell off the monkey bars at school and hurt his arm? a. The degree of motion and ability to position the extremity b. The length, diameter, and shape of the extremity c. The amount of swelling noted in the extremity and pain intensity d. The skin color, temperature, movement, sensation, and capillary refill of the extremity

d. The skin color, temperature, movement, sensation, and capillary refill of the extremity (A neurovascular evaluation includes assessing skin color and temperature, ability to move the affected extremity, degree of sensation experienced, and speed of capillary refill in the extremity. The degree of motion in the affected extremity and ability to position the extremity are incomplete assessments of neurovascular competency. The length, diameter, and shape of the extremity are not assessment criteria in a neurovascular evaluation. Although the amount of swelling is an important factor in assessing an extremity, it is not a criterion for a neurovascular assessment.)

Tissue ischemia and nerve damage are serious complications that may result from immobilization in a cast or from traction. The five Ps of vascular impairment can be used as a guide when assessing for neurovascular problems. List the five Ps.

pain, pallor, pulselessness, paresthesia, paralysis (Prompt referral to a physician and intervention is crucial if neurovascular impairment is to be prevented.)