Peds - Ch. 44: Mobility/Neuromuscular or Musculoskeletal Disorder

A nurse is performing a physical examination of a child with a suspected fracture. Which assessment technique would the nurse assume would not be used?

Auscultation The physical examination specific to fractures includes inspection, observation, and palpation. The nurse may assume that auscultation is not used; however, auscultation of the child's lungs may reveal adventitious sounds that are often present when respiratory muscle function is impaired.

A nurse is caring for a newborn client who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?

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 conducting a physical examination of a 9-month-old infant with a suspected neuromuscular disorder. Which finding would warrant further evaluation?

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.

An adolescent with scoliosis is refusing to wear the prescribed body brace. Which instruction is best to progress the adolescent to the treatment goals?

"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 has been teaching the parents of a child diagnosed with osteogenesis imperfecta about the use of bisphosphonates for this condition. What statement by a parent indicates a need for further education?

"This medication will cure my child of this disorder." Bisphosphonates are used in the palliative, not curative, treatment of osteogenesis imperfecta. The medication increases bone mineral density, therefore reducing the risk of the child developing fractures. The medication does not actually prevent fractures from happening.

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.

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

The nurse is teaching a group of peers regarding different types of fractures seen in children. Which statement best describes a complete fracture?

A fracture in which the bone breaks into two pieces A fracture in which the bone breaks into two pieces is called a complete fracture. A fracture in which the bone bends without breaking is called a plastic or bowing deformity. A fracture in which the bone buckles rather than breaks is called a buckle fracture. An incomplete fracture of the bone is called a greenstick fracture.

In understanding the development of the musculoskeletal system, the nurse recognizes that what is implanted in a gel-like substance during fetal life?

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 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:

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 10-year-old boy with a suspected neuromuscular disorder. Which finding is a sign of Duchenne muscular dystrophy?

Gowers sign A sign of Duchenne muscular dystrophy (DMD) is Gowers sign, or the inability of the child to rise from the floor in the standard fashion because of weakness. Signs of hydrocephalus are not typically associated with DMD. Kyphosis and scoliosis occur more frequently than lordosis. A child with DMD has an enlarged appearance to their calf muscles due to pseudohypertrophy of the calves.

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?

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 caring for a child who had a cast on his lower leg placed two hours ago. When assessing the child's foot, the nurse notes that the toes are cool and the child reports extreme pain. What is the best action by the nurse?

Notify the health care provider of the findings immediately. Cool fingers or toes, extreme pain, and impaired movement are symptoms of compartment syndrome. Compartment syndrome can severely decrease blood flow to the area causing damage and necrosis to the surrounding area. If compartment syndrome occurs, the cast needs to be released immediately; therefore, the health care provider must be notified of these assessment findings immediately. Administration of pain medication, positioning, and ice are interventions that may be prescribed after a cast is placed, but they are not the first treatment for compartment syndrome.

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?

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.

The nurse is caring for a 3-year-old boy with a fracture of the humerus. His chart indicates "fracture is partially through the physis extending into the metaphysis." The nurse identifies this as which Salter-Harris classification?

Type II According to the Salter-Harris classification, a type II fracture is partially through the physis extending into the metaphysis. A type I fracture is through the physis, widening it. A type IV fracture is through the metaphysis, physis, and epiphysis. A type V fracture is a crushing injury to the physis.

A group of students is reviewing information about the skeletal development in children. The students demonstrate understanding of the information when they identify that ossification is complete by what age?

adolescence Ossification and conversion of cartilage to bone continue throughout childhood and are complete at adolescence.

The nurse caring for a client diagnosed with muscular dystrophy would expect which laboratory values to be most abnormal?

creatine kinase Serum creatine kinase levels are elevated early in the disorder, when significant muscle wasting is actively occurring. Bilirubin is a by-product of liver function. Potassium and sodium levels can change due to various factors and aren't indicators of muscular dystrophy.

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:

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 caring for a client with suspected muscular dystrophy would prepare her client for which diagnostic test?

muscle biopsy Muscle biopsy provides definitive diagnosis of muscular dystrophy demonstrating the absence of dystrophin. X-ray is best for identifying an osseous deformity. Ambulation assessment alone wouldn't confirm diagnosis of this client's disorder. EEG wouldn't be appropriate in this case.

A nurse is reviewing the medical record of a child who has sustained a fracture. Documentation reveals a bowing deformity. The nurse interprets this fracture as:

significant bending without actual breaking. A plastic or bowing deformity is one in which there is significant bending of the bone without breaking. A buckle fracture is one in which the bone buckles rather than breaks. This is usually due to a compression injury. An incomplete fracture of the bone is a greenstick fracture. A complete fracture is one in which the bone breaks into two pieces.

The nurse is speaking with the parents of a child who has a cast. The parents state that the child reports itching in the area of the cast. What is the best response by the nurse?

"Blowing cool air with a fan or hair dryer may relieve the feeling." Itching is a common report, but just stating this does not address the entire situation. The suggestion of blowing cool air is the best answer. Clients should never put anything in a cast to scratch. Lotion may be applied to the skin above or below a cast but should never be poured into a cast.

The caregiver of a 2-year-old who has a polyurethane resin cast on her arm calls the clinic to report that her child is crying and says that the cast has sand in it. The caregiver states that she has had casts herself and knows how badly they can itch. She says she always used a hanger to scratch but is worried that it will be too sharp for the child. Which statement would be appropriate for the nurse to make to this caregiver?

"Nothing should be put into the cast. You can blow cool air into it with a hair dryer." Children and caregivers should be cautioned not to put anything inside the cast, no matter how much the casted area itches. Small toys and sticks or stick-like objects should be kept out of reach until the cast has been removed. Ice packs applied over the cast may help decrease the itching. Blowing cool air through a cast with a hair dryer set on a cool temperature or using a fan may help to relieve discomfort under a cast.

The caregiver of a child who has had a cast applied to the leg observes the nurse putting adhesive tape strips around the edge of the cast. The caregiver asks the nurse why she is doing this. The best response by the nurse would be:

"These make a smooth edge on the cast so the skin is better protected." If the cast has no protective edge, it should be petaled with adhesive tape strips. These help keep the skin protected from the rough edge of the cast. If the cast is near the genital area, plastic should be taped around the edge to prevent wetting and soiling of the cast; petaling the cast does not provide protection to keep the cast dry.

An infant has been born and diagnosed with a meningocele. Which action will the nurse incorporate into each contact with this infant?

inspection of the cystic sac on the child's back for leakage Leakage from the cystic area indicates loss of cerebrospinal fluid (CSF) and risk of infection of the central nervous system. Prompt intervention is needed, probably surgical. Listening for bowel sounds confirms intestinal peristalsis but is not necessary with each infant contact. A shrill cry may indicate increased intracranial pressure (ICP). This is important to note yet is not as pressing as being aware of leakage. The baby would be positioned prone, not supine, to protect the sac.

The nurse will teach parents of children with myelomeningocele to maintain an environment free of what element?

latex A latex-free environment is important because research shows that up to 73% of children with repeated surgeries for spina bifida are sensitive to latex. Those with known sensitivity must be managed in a latex-free environment in the health care setting and in the home, in the school, and beyond. Children at risk for latex sensitivity should wear medical alert identification. The other options may present risks to individual children but are not a threat to those with spina bifida as a group.

The nurse is providing preoperative care for a newborn with myelomeningocele. Which action is the central nursing priority?

prevent rupture or leaking of cerebrospinal fluid The central nursing priority is to prevent rupture or leaking of cerebrospinal fluid. Keeping the infant in a prone position will help prevent pressure on the lesion. Keeping the lesion free from fecal matter or urine is important as well, but the priority is to prevent rupture or leakage. The nurse should consider the lesion first when maintaining the infant's body temperature.

Through which mechanism is Duchenne muscular dystrophy acquired?

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

The nurse is caring for a group of children on the pediatric unit. The nurse should collect further data and explore the possibility of child abuse (child mistreatment) in which situation?

A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate. Spiral fractures, which twist around the bone, are frequently associated with child abuse (child mistreatment) and are caused by a wrenching force. When a broken bone penetrates the skin, the fracture is called compound, or open. A simple, or closed, fracture is a single break in the bone without penetration of the skin. In a greenstick fracture, the bone bends and often just partially breaks.

The nurse is assessing a child with spina bifida occulta. During the assessment, the parents say, "It's going to be so difficult taking care of our child. He'll never be able to walk." The nurse identifies which nursing diagnosis as the priority?

Deficient knowledge related to diagnosis and condition The parents' statement indicates a lack of understanding about the condition. Spina bifida is a term that is often used to refer to all neural tube disorders that affect the spinal cord. This can be confusing and a cause of concern for parents. There are well-defined degrees of spinal cord involvement, and it is important for health care professionals to use the correct terminology. Spina bifida occulta is a defect of the vertebral bodies without protrusion of the spinal cord or meninges. This defect is not visible externally and in most cases has no adverse affects. In most cases, spina bifida occulta is benign and asymptomatic and produces no neurologic signs; it may be considered a normal variant. Mobility typically is not impaired with spina bifida occulta. The child is at no greater risk for injury as any other child. The parents demonstrate a lack of knowledge, not problems with coping.

In caring for a child in traction, which intervention is the highest priority for the nurse?

The nurse should monitor for decreased circulation every 4 hours. Any child in traction must be carefully monitored to detect any signs of decreased circulation or neurovascular complications. Cleaning pin sites is appropriate for a child in skeletal traction to reduce the risk of infection. Providing age-appropriate activities and monitoring intake and output are important interventions for any ill child but would not be the highest priority interventions for the child in traction.

The nurse is caring for a child who has just had a plaster cast applied to the arm. The nurse is correct in performing which action with this child?

Handling the cast with open palms when moving the arm. A wet plaster cast should be handled only with open palms because fingertips can cause indentations and result in pressure points. There is no reason the arm should be restrained or the arm moved to aid in the drying process.

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?

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.

Which of these strategies would be the first choice in attempting to maximize function in a child with muscular dystrophy?

long leg braces Long leg braces are functional assistive devices that provide increased independence and increased use of upper and lower body strength. Wheelchairs, both motorized and manual, provide less independence and less use of upper and lower body strength. Walkers are functional assistive devices that provide less independence than braces.

A 12-year-old female client has been diagnosed with scoliosis with a curvature of 30 degrees. What type of treatment would the nurse anticipate being started on this client?

Bracing For spinal curvatures of 25 to 40 degrees, the usual treatment is bracing. Curvatures greater than 40 degrees may be treated with traction or spinal instrumentation and fusion. Exercise may be implemented for very mild curvatures to strengthen the back muscles.

The nurse is caring for an infant with myelomeningocele prior to having repair surgery. What nursing intervention(s) is necessary to include in this infant's plan of care? Select all that apply.

-positioning of paralyzed legs to prevent contractures -protecting knees and elbows from skin breakdown -keeping the skin clean and dry A myelomeningocele is a spinal cord defect. The sac protrudes through the skin. The spinal cord ends at the level of the defect causing no motor or sensory function below that point. The infant must remain in a prone position to keep from causing damage to the sac until repair can be done. This also means no diapers. Skin integrity and positioning are essential. This infant could have breakdown on the knees and elbows and even the side of the head. The infant needs to be cleaned regularly and kept dry. Different types of mattresses can be used to reduce pressure on bony prominences. The paralyzed lower extremities need to be repositioned regularly to prevent contractures. A high-calorie, concentrated formula is not necessary. Regular-calorie formula is adequate. A pacifier for nonnutritive sucking is a good idea and may be a comfort to the infant, but it is not essential.

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?

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.

A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's best response?

"The cause is unknown and there are many environmental factors that may contribute to it." There is no one known cause of spina bifida, but scientists believe that it's linked to hereditary and environmental factors. Neural tube defects, including spina bifida, have been strongly linked to low dietary intake of folic acid. Maternal age doesn't have an impact on spina bifida. An amniocentesis is performed to help diagnose spina bifida in utero but doesn't cause the disorder. Maternal alcohol intake during pregnancy has been linked to intellectual disability, craniofacial defects, and cardiac abnormalities, but not spina bifida.

A child is born with clubfoot (congenital talipes equinovarus). The child later receives a cast on the affected leg to correct the problem. Which measure should the nurse mention to the mother to ensure good circulation in the affected leg?

Check the infant's toes for coldness or blueness. Review with parents how to check the infant's toes for coldness or blueness and how to blanch a toenail bed and watch it turn pink to assess for good circulation. The other answers are other interventions pertaining to caring for a child with clubfoot but are not associated specifically with ensuring good circulation.

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:

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 parent calls the clinic nurse to say the child has shin splints after playing soccer. What instructions should the nurse provide this parent?

"Applying ice to the area will reduce the pain and swelling." Shin splints are a form of an overuse syndrome. These syndromes occur when there is repeated force applied to connective tissue, causing it to break down. The first line of treatment for these injuries is RICE (rest, ice, compression, elevation). Cold should be applied for 20 to 30 minutes and then removed for 60 minutes. This process is repeated until the area is numb. Cold causes vasoconstriction to reduce the pain and swelling. As part of RICE, the legs should be elevated, but there is no timeline for how long this should occur. Warm baths would cause vasodilation, further increasing the pain and swelling.

The nurse is caring for a newborn with facial nerve palsy from birth trauma. The mother is very upset and concerned about the child's prognosis. Which response by the nurse would be most appropriate?

"In most cases treatment is not necessary, only observation." The nurse should reassure the mother by reminding her that in most cases treatment is not necessary, only observation. Asking about signs of improvement might alarm the mother because in some cases it can take many months for the palsy to resolve. Asking whether this was a result of pressure from forceps does not address the mother's concerns about the child's prognosis. The mother may not understand or know why the condition occurred. Telling the mother that this is the most common facial nerve palsy does not address the mother's concerns about the child's prognosis.