Chapter 12: Orthopedic Disorders (Success)

Which condition is the harness used for in the following figure?

It is used for DDH. The Pavlik harness is used to treat DDH in neonates. TEST-TAKING HINT: Being able to answer previous questions correctly can some- times help with later questions.

Where should the top of the crutch bar be in relation to the axilla?

The crutch bar should not put pressure on nerves in the axilla. TEST-TAKING HINT: The axillae do not rest on the crutch bar.

A spinal curve of less than________________ not require treatment for scoliosis. degrees that is nonprogressive does

20. A 20-degree spinal curve that is non- progressive will not disfigure or interfere with normal functioning, so it is not treated with bracing or surgery. TEST-TAKING HINT: The test taker must know about treatment for scoliosis.

Which would the nurse teach a patient when NSAIDs are prescribed for treating juvenile idiopathic arthritis (JIA)? 1. Take with food. 2. Take on an empty stomach. 3. Blood levels are required for drug dosages. 4. Good oral hygiene is needed.

1 1 NSAIDs can cause gastric bleeding with long-term use; food helps to reduce the exposure of the drug on the stomach lining. 2 NSAIDs can cause gastric bleeding with long-term use; food helps to reduce the exposure of the drug on the stomach lining. 3 NSAIDs do not require a blood level because they are available over the counter. 4 NSAIDs do not interfere with the oral cavity; however, other medications used for JRA cause oral ulcers. TEST-TAKING HINT: The test taker must know what NSAIDs are and that they are available over the counter.

Which nursing diagnosis is most important for a child with Ewing sarcoma who will be undergoing chemotherapy? 1. Risk for fluid volume deficit. 2. Potential for chronic pain. 3. Risk for skin impairment. 4. Ineffective airway clearance.

1 1. Chemotherapy can cause nausea, vomiting, and possibly diarrhea, which contribute to fluid volume deficit. 2. Chemotherapy itself does not cause chronic pain. 3. Radiation therapy has the potential for skin impairment. 4. This is not an acute problem with chemotherapy. TEST-TAKING HINT: This is a general question asking for basic side effects of chemotherapy.

The nurse is teaching an adolescent about Ewing sarcoma and indicates which as a common site? 1. Shaft. 2. Growth plate. 3. Ball of the femur. 4. Bone marrow.

1 1. Ewing sarcoma is a bone tumor that affects the shafts of long bones. 2. Pediatric bone sarcomas do not affect the growth plate. 3. This is a specific location of a specific bone. Ewing sarcoma can affect multiple bones. 4. The bone marrow is a site for hematolog- ical cancers. TEST-TAKING HINT: It is important to be familiar with the physiology of bones to understand how bone sarcomas affect them. Ewing sarcoma is a rare cancer that affects a different part of the bone relative to osteosarcoma.

A child is going to receive radiation for Ewing sarcoma. Which of the following is the best nursing intervention to prevent skin breakdown during therapy? 1. Advise the child to wear loose-fitting clothes to minimize irritation. 2. Advise the child to use emollients to prevent dry skin. 3. Apply cold packs nightly to reduce the warmth caused by the treatments. 4. Apply hydrocortisone to soothe itching from dry skin.

1 1. Loose clothing helps reduce irritation on the sensitive irradiated skin. 2. Emollients are contraindicated during radiation because they can reflect the rays. 3. Irradiated skin is very sensitive to extreme temperatures; a cold pack could cause pain. 4. Hydrocortisone is not helpful for the radiation-induced itching; it is for atopic itching. TEST-TAKING HINT: The test taker must know what is most helpful for relieving irritation as a result of what radiation does to the skin. The question asks for what to do during therapy.

The nurse is teaching the parent of a child diagnosed with systemic lupus erythe- matosus (SLE). The nurse evaluates the teaching as effective when the parent states: 1. "The cause is unknown." 2. "There is no genetic involvement." 3. "Drugs are not a trigger for the illness." 4. "Antibodies improve disease outcome."

1 1. SLE is a complex disease; there are many triggers, but how the disease develops is not known. 2. There is some correlation with family history. 3. There are multiple triggers for SLE, including prescription drugs. 4. Antibodies have nothing to do with SLE outcome. TEST-TAKING HINT: Not all diseases have a known cause.

Which is the definition of talipes virus? 1. An inversion or bending inward of the foot. 2. An eversion or bending outward of the foot. 3. A high arch of the foot. 4. A low arch (flatfoot) of the foot.

1 1. Talipes varus is an inversion of the foot. 2. Talipes valgus is an eversion of the foot. 3. Pes cavus is a high arch of the foot. 4. Pes planus is flatfoot. TEST-TAKING HINT: The test taker must know the definition of terms.

The nurse is teaching about congenital clubfoot in infants. The nurse evaluates the teaching as successful when the parent states that clubfoot is best treated when? 1. Immediately after diagnosis. 2. At age 4 to 6 months. 3. Prior to walking (age 9 to 12 months). 4. After walking is established (age 15 to 18 months).

1 1. The best outcomes for clubfoot are seen if casting begins as soon as the diagnosis is made. 2. Although casting helps if started in the newborn period, the delay of even 4 to 6 months postpones the positive outcome. 3. Infants of 9 months are already pulling up to stand and taking steps. Clubfoot puts weight on surfaces of feet that are not meant for weightbearing. 4. Clubfoot does not allow for normal gait, and the delay will decrease the likelihood of a successful outcome. TEST-TAKING HINT: The general principle of early treatment of orthopedic problems should lead to the correct answer.

A nurse is caring for a 5-year-old who has a fracture of the tibia involving the growth plate. When providing information to the parents, the nurse should indicate that: 1. This is a serious injury that could cause long-term growth issues. 2. The fracture usually heals within 6 weeks without further complications. 3. The child will never be able to play contact sports. 4. Fractures involving the growth plate require pain medication.

1 1.. Fractures of the growth plate are serious, as they can disrupt the growth process. 2. Long-term follow-up is usually needed to evaluate limb discrepancies and potential joint abnormalities. 3. The ability to participate in contact sports depends on many potential complications. 4. The amount of pain medication needed in all fractures is determined by the patient. TEST-TAKING HINT: The test taker must know what determines how much pain medication is needed.

The nurse on the pediatric floor is receiving a child with the possible diagnosis of septic arthritis of the elbow. Which would the nurse expect on assessment? Select all that apply. 1. Resistance to bending the elbow. 2. Nausea and vomiting. 3. Fever. 4. Bruising of the elbow. 5. Swelling of the elbow. 6. A history of nursemaid's elbow as a toddler.

1, 2, 3, 5. 1. Infection of the elbow joint can cause pain that leads to protecting the joint and resisting movement. 2. Infection of the elbow may cause generalized nausea and vomiting. 3. Infection of the elbow frequently causes fever. 4. There is no bruising with septic arthritis. 5. Septic arthritis can cause swelling of the joint. 6. There is no increased risk with a history of nursemaid elbow. TEST-TAKING HINT: The test taker can rule out answer 6, as risk of infection is not related to past injury.

Which would the nurse assess in a child diagnosed with osteomyelitis? Select all that apply. 1. Unwillingness to move affected extremity. 2. Severe pain. 3. Fever. 4. Previous closed fracture of an extremity. 5. Redness and swelling at the site.

1, 2, 3, 5. 1. Pain in an extremity leads to resistance to movement. 2. Pain is frequently severe in osteomyelitis. 3. Fever is present in the acute phase of the illness. 4. Osteomyelitis can sometimes be seen after a direct inoculation of an open fracture. There is no increased risk after a closed fracture. 5. Redness and swelling occur because of the infection. TEST-TAKING HINT: The test taker can rule out answer 4 if it is understood that a closed fracture does not increase the risk of bone infection.

Which should the nurse include in the teaching plan for a child who had surgery to correct bilateral clubfeet and had the casts removed? Select all that apply. 1. "Your child will need to wear a brace on the feet 23 hours a day for at least 2 months." 2. "Your child should see an orthopedic surgeon regularly until the age of 18 years." 3. "Your child will not be able to participate in sports that require a lot of running." 4. "Your child may have a recurrence of clubfoot in a year or more." 5. "Most children treated for clubfeet develop feet that appear and function normally." 6. "Most children treated for clubfeet require surgery at puberty.

1, 2, 4, 5. 1. After the final casting, bracing is required for 23 to 24 hours per day for 2 months. This decreases the likelihood of a recurrence. 2. Because clubfoot can recur, it is impor- tant to have regular follow-up with the orthopedic surgeon until age 18 years. 3. After treatment, most children are able to participate in any sport. 4. Even with proper bracing, there may be a recurrence. 5. Most children treated for clubfeet develop normally appearing and functioning feet. 6. Most children do not require surgery at puberty. TEST-TAKING HINT: If the test taker is aware that clubfoot can recur, providing instruction that includes long-term follow-up care will help in selecting answers.

A 13-year-old just returned from surgery for scoliosis. Which nursing intervention(s) is/are appropriate in the first 24 hours? Select all that apply. 1. Assess for pain. 2. Logroll to change positions. 3. Get the teen to the bathroom 12 to 24 hours after surgery. 4. Check neurological status. 5. Monitor blood pressure

1, 2, 4, 5. 1. General post-operative nursing inter- ventions include assessing for pain. 2. Specific to scoliosis surgery, logrolling is the means of changing positions. 3. Patients may not be upright less than 24 hours post-operatively. 4. It is essential to check neurological status in a patient who just had scolio- sis surgery. 5. General post-operative nursing inter- ventions include assessing vital signs. TEST-TAKING HINT: The test taker can use general post-operative care principles to lead to several correct answers.

Nursing care of a child with a fractured extremity in whom there is suspected compartment syndrome includes which of the following? Select all that apply. 1. Assess pain. 2. Assess pulses. 3. Elevate extremity above the level of the heart. 4. Monitor capillary refill. 5. Provide pain medication as needed.

1, 2, 4, 5. 1. In a recent fracture, the nurse should assess pain and provide treatment. 2. Pain, pallor, and weak or absent pulses are all signs of compartment syndrome. 3. Elevating the extremity is important to decrease edema prior to the onset of compartment syndrome. However, once compartment syndrome is suspected, the extremity should be kept at the level of the heart to facilitate arterial and venous flow. 4. Weak or absent pulse is a sign of com- partment syndrome, so monitoring capillary refill is important in assessment. 5. Pain, pallor, and weak or absent pulses are signs of compartment syndrome. Pain should be treated. TEST-TAKING HINT: The test taker can eliminate answer 3 because it is impor- tant to keep the affected extremity at heart level to help arterial and venous blood flow.

A 14-year-old with osteogenesis imperfecta (OI) is confined to a wheelchair. Which nursing interventions will promote normal development? Select all that apply. 1. Encourage participation in groups with teens who have disabilities or chronic illness. 2. Encourage decorating the wheelchair with stickers. 3. Encourage transfer of primary care to an adult provider at age 18 years. 4. Allow the teen to view the radiographs. 5. Help the teen set realistic goals for the future. 6. Discourage discussion of sexuality, as the child is not likely to date.

1, 2, 4, 5. 1. This patient is trying to become more independent and trying to fit in with the peer group. Encouraging socializing with peers who face similar challenges alleviates feelings of isolation. 2. Decorating the wheelchair encourages the patient to assume independence in self-care. 3. It is not necessarily appropriate to trans- fer health care at age 18 years. If the teen is with a provider who has known the pa- tient and family most of the teen's life, it might be best to remain with that provider for several more years. 4. Allowing the patient to view radiographs encourages the patient to assume self-care. 5. Helping the patient set realistic goals for the future encourages independence. 6. It is appropriate for the nurse to discuss sexuality with this patient. Being confined to a wheelchair does not preclude dating or becoming intimate. TEST-TAKING HINT: The test taker can use normal growth and development to help choose correct answers.

A 6-year-old involved in a bicycle crash has a spleen injury and a right tibia/fibula fracture that has been casted. Which is/are an early sign(s) of compartment syndrome in this child? Select all that apply. 1. Edema. 2. Numbness. 3. Severe pain. 4. Weak pulse. 5. Anular rash.

1, 2, 4. 1. Edema, numbness or tingling, and pain are early signs of compartment syndrome. 2. Edema, numbness or tingling, and pain are early signs of compartment syndrome. 3. Edema, numbness or tingling, and pain are early signs of compartment syndrome. 4. A weak pulse is a late sign of compartment syndrome. 5. There is no rash with early compartment syndrome. TEST-TAKING HINT: The test taker can eliminate answers 3 and 5 because severe

One nursing diagnosis for juvenile idiopathic arthritis (JIA) is impaired physical mobility. Select all that apply. 1. Give pain medication prior to ambulation. 2. Assist with range-of-motion activities. 3. Encourage the child to eat a high-fat diet. 4. Provide oxygen as necessary. 5. Use nonpharmacological methods, such as heat.

1, 2, 5 1. Providing pain medication prior to ambulation helps decrease pain during ambulation. 2. Children with JIA need to do range-of-motion exercises to prevent joint stiffness. 3. A high-fat diet is not helpful for mobility. 4. Oxygen is usually not necessary with the diagnosis of JIA. 5. Using nonpharmacological methods such as heat helps with flexibility and pain. TEST-TAKING HINT: By understanding the disease process of JIA, the test taker will know what interventions are needed to help alleviate pain and disability.

Select all that apply to the care of a child with a retroperitoneal rhabdomyosarcoma. 1. Acute pain. 2. Risk for impaired urinary elimination. 3. Impaired gas exchange. 4. Self-care deficit. 5. Risk for constipation.

1, 2, 5. 1. Pain occurs due to pressure on the organs in the lower abdomen. 2. A retroperitoneal tumor affects the organs of the lower abdomen, includ- ing the bowel and bladder. 3. A retroperitoneal tumor affects the organs of the lower abdomen, including the bowel and bladder. This tumor does not affect the lungs. 4. There is no indication the child cannot administer self-help. 5. Because this tumor is in the lower abdomen, it puts pressure on the bowel causing constipation. TEST-TAKING HINT: The test taker must understand the areas of the body. Having an idea of the organs involved will indi- cate possible problems that can arise when a tumor is in those locations.

The nurse caring for a child with osteomyelitis assesses poor appetite. Which inter- vention(s) is/are most appropriate for this child? Select all that apply. 1. Offer high-calorie liquids. 2. Offer favorite foods. 3. Do not worry about intake, as appetite loss is expected. 4. Suggest intravenous removal to encourage oral intake. 5. Decrease pain medication that might cause nausea. 6. Offer frequent small meals.

1, 2, 6. 1. High-calorie liquids are sometimes received better when the child has a poor appetite. 2. Offering favorite foods can sometimes tempt the child to eat, even with a poor appetite. 3. Although decreased appetite is expected, it is something that needs nursing inter- vention in order to promote healing. 4. An intravenous line is necessary for antibiotics, so it cannot be removed to encourage oral intake. 5. Although some pain medications cause nausea, their use is important. If patients are in pain, they are not likely to want to eat. 6. Small, frequent meals might increase daily caloric intake. TEST-TAKING HINT: Using routine nursing interventions for decreased appetite can lead to the correct answers.

A child with Ewing sarcoma is receiving chemotherapy and is experiencing severe nausea. The nurse has to administer Ativan at 0.04 mg/kg, and the child weighs 65 lb. What dose should the nurse administer?

1.2 mg. Change pounds to kilograms (2.2 lb = 1 kg: 65/2.2 = 29.5 kg). Then multiply kilograms by the dose of 0.04 mg/kg: 29.5 × 0.04 = 1.18 mg or round to 1.2 mg. TEST-TAKING HINT: Divide 65 lb by 2.2 to determine kilograms.

Which instruction(s) should the nurse give the parents of an adolescent with slipped capital femoral epiphysis (SCFE)? Select all that apply. 1. Continue upper body exercises to limit loss of muscle strength. 2. Do not turn the teen in bed when complaining of pain. 3. Provide homework, computer games, and other activities to decrease boredom. 4. Do most activities of daily living for the teen. 5. Expect expressions of anger and hostility. 6. Continue setting limits on behavior.

1, 3, 5, 6. 1. Immobilization can lead to a decrease in muscle strength. Upper body exer- cises should be continued soon after surgery. 2. Although turning the patient in bed after surgery may be painful, it is essential that parents and the patient know that it is necessary to prevent skin ulcerations and promote healing. 3. It is important for this patient to con- tinue as many normal activities as pos- sible. This should include schoolwork and leisure activities. 4. To promote independence that is essential for a teenager, this patient should be encouraged to continue activities of daily living. 5. Some expressions of anger and hostil- ity are normal, as this adolescent is losing some independence with this immobility. 6. Continuation of setting limits on behavior is important to keep as much normalcy as possible. TEST-TAKING HINT: The test taker needs to understand the developmental need for independence in this age group.

After the birth of an infant with clubfoot, the nursery nurse should do which when instructing the parents? Select all that apply. 1. Speak in simple language about the defect. 2. Avoid the parents unless providing direct care so they can grieve privately. 3. Keep the infant's feet covered at all times. 4. Present the infant as precious; emphasize the well-formed parts of the body. 5. Tell the parent that defects could be much worse. 6. Be prepared to answer questions multiple time

1, 4, 6. 1. The parents will likely be shocked immediately after the birth of the child. To facilitate their understanding, the nurse should speak in simple terms. 2. Avoiding the parents is not therapeutic. 3. The baby should be shown to the parents as are all newborns, without hiding the clubfoot. 4. The baby should be shown to the par- ents as are all newborns, emphasizing the well-formed parts of the body. 5. Negating the parents' grieving is not therapeutic. 6. Information may need to be repeated as the family begins to absorb the information. TEST-TAKING HINT: The test taker can draw on therapeutic communication skills to choose correct answers.

Which factor(s) is/are associated with slipped capital femoral epiphysis (SCFE)? Select all that apply. 1. Obesity. 2. Female gender. 3. African descent. 4. Age of 5 to 10 years. 5. Pubertal hormonal changes. 6. Endocrine disorders.

1, 5, 6. 1. Obesity increases the risk of SCFE by stressing the epiphyseal plate. 2. SCFE is more common in males. 3. SCFE is more common in whites. 4. SCFE is most common from the ages of 10 to 16 years. 5. SCFE is most common during pubertal hormonal changes. 6. SCFE is associated with endocrine disorders. TEST-TAKING HINT: If the test taker knows that SCFE is most common during rapid growth, answer 4 can be eliminated, and answer 5 can be chosen.

The nurse tells the parent that other conditions can be associated with congenital clubfoot. Select all that apply. 1. Myelomeningocele. 2. Cerebral palsy. 3. Diastrophic dwarfism. 4. Breech position in utero. 5. Prematurity. 6. Fetal alcohol syndrome.

1,2,3 1. There is an association between myelomeningocele and congenital clubfoot. 2. There is an association between some forms of cerebral palsy and congenital clubfoot. 3. There is an association between diastrophic dwarfism and congenital clubfoot. 4. Breech position is not associated with congenital clubfoot. It is associated with DDH. 5. There is no association between prematu- rity and congenital clubfoot. 6. Fetal alcohol syndrome is not associated with clubfoot. TEST-TAKING HINT: The test taker could look at other congenital deformities to gain a clue to an association to clubfoot.

Which can occur in untreated developmental dysplasia of the hip (DDH)? Select all that apply. 1. Duck gait. 2. Pain. 3. Osteoarthritis in adulthood. 4. Osteoporosis in adulthood. 5. Increased flexibility of the hip joint in adulthood.

1,2,3 1, 2, 3. 1. Due to abnormal hip joint function, the patient's gait is stiff and waddling. 2. Due to abnormal femoral head place- ment, the patient may experience pain and decreased flexibility in adulthood. 3. Due to abnormal femoral head placement, the patient may experience osteoarthritis in the hip joint in adulthood. 4. There is no increased risk for osteoporosis. 5. There is no increased flexibility of the hip joint in adulthood. TEST-TAKING HINT: If the test taker knows that untreated DDH leads to decreased smooth movement of hip joint, answer 5 can be eliminated.

When planning a rehabilitative approach for a child with osteogenesis imperfecta (OI), the nurse should prevent which of the following? Select all that apply. 1. Positional contractures and deformities. 2. Bone infection. 3. Muscle weakness. 4. Osteoporosis. 5. Misalignment of lower extremity joints

1,3,4,5. 1. A long-term goal in caring for a child with OI is to prevent contractors and deformities. 2. There is no increased risk for bone infec- tion in OI. 3. A long-term goal in caring for a child with OI is to prevent muscle weakness. 4. A long-term goal in caring for a child with OI is to prevent osteoporosis. 5. A long-term goal in caring for a child with OI is to prevent misalignment of lower extremity joints. TEST-TAKING HINT: The test taker should think about general nursing considerations for children with fractures and choose answers 1, 3, 4, and 5.

Which would the nurse expect to assess on a 3-week-old infant with developmental dysplasia of the hip (DDH)? 1. Excessive hip abduction. 2. Femoral lengthening of an affected leg. 3. Asymmetry of gluteal and thigh folds. 4. Pain when lying prone.

1. 1. In DDH, a newborn can have excessive hip adduction. 2. In DDH, an appearance of femoral short- ening is frequently present on the affected side. 3. In DDH, asymmetrical thigh and gluteal folds are frequently present. 4. Infants do not experience pain from this condition. TEST-TAKING HINT: If the test taker knows that DDH decreases smooth movement of the femoral head, then answers 1 and 2 can be eliminated because they indicate increased movement of the femur.

The nurse should be suspicious of which condition in the following figure?

DDH. The asymmetry of the thigh folds suggests DDH.

It is recommended that a child with metastatic rhabdomyosarcoma undergo a bone marrow transplant. Education regarding life-threatening side effects should include: 1. Diarrhea. 2. Fever. 3. Skin breakdown. 4. Tumor shrinkage.

2 1 Diarrhea can be a side effect of chemotherapy, but it is not usually life threatening. 2 Fever indicates infection that can be life threatening after a bone marrow transplant. 3 Skin breakdown is usually not life threat- ening. 4 Skin shrinkage is expected with treatment, but it is not life threatening. TEST-TAKING HINT: The test taker must understand what a bone marrow transplant involves and how bone marrow suppres- sion can have life-threatening effects.

The parent of a child diagnosed with osteomyelitis asks how the child acquired the illness. Which is the nurse's best response? 1. "Direct inoculation of the bone from stepping barefoot on a sharp stick." 2. "An infection from a scratched mosquito bite carried the infection through the bloodstream to the bone." 3. "The blood supply to the bone was disrupted because of the child's diabetes." 4. "An infection of the upper respiratory tract."

2 1. Although osteomyelitis can occur from direct inoculation, inoculation is not the most common cause. 2. Infection through the bloodstream is the most likely cause of osteomyelitis in a child. 3. Although osteomyelitis can occur because of blood supply disruption, that is more likely to occur in older adults. Diabetes does increase the risk of osteomyelitis, but diabetes is more common in older adults. 4. A viral upper respiratory infection is not the most likely cause. TEST-TAKING HINT: The age of the patient is important in choosing the most likely cause of the disease.

A child with Ewing sarcoma is undergoing a limb salvage procedure. Which statement indicates the parents understand the procedure? 1. "Our child will have a bone graft to save the limb." 2. "Our child will need follow-up lengthening procedures." 3. "Our child will need shorter shirt sleeves." 4. "Our child will not need chemotherapy."

2 1. Bone grafts are not part of limb salvage. 2. Limb salvage requires the lengthening procedures to encourage the bone to continue to grow so the child will not have a short limb. 3. This does not indicate understanding by the parents. 4. Having a limb salvage does not mean the child will never require chemotherapy as part of the treatment. TEST-TAKING HINT: A limb salvage means the limb is saved, but that is not the end of treatment for the child

A child with osteosarcoma is going to receive chemotherapy before surgery. Which statement by the parents indicates they understand the side effect of neutropenia? 1. "My child will be more at risk for diarrhea." 2. "My child will be more at risk for infection." 3. "My child's hair will fall out." 4. "My child will need to drink more."

2 1. Diarrhea is a side effect of chemotherapy, not neutropenia. 2. Neutropenia makes a child more at risk for infection, because the immune system is compromised due to the chemotherapy. 3. Alopecia is a side effect of chemotherapy. 4. Dehydration is a potential side effect of chemotherapy. TEST-TAKING HINT: Neutropenia consists of neutro- (meaning "neutrophils," a subset of the white blood cells) and -penia (meaning "low or decreased").

Why are chemotherapeutic agents such as methotrexate and cyclophosphamide sometimes used to treat juvenile idiopathic arthritis (JIA)? 1. Effective against cancer-like JIA. 2. Affect the immune system. 3. Are similar to NSAIDs. 4. Are absorbed into the synovial fluid.

2 1. JIA is not a type of cancer. 2. These drugs affect the immune system to reduce its ability to attack itself, as in the case of JIA. 3. These medications are not the same as NSAIDs. 4. They are not absorbed into the synovial fluid to treat JIA; they suppress the immune system. TEST-TAKING HINT: There are some drugs that are used for other reasons outside of their usual use, such as chemotherapeutic agents. Many drugs have multiple uses.

Which is most important when teaching a parent about preventing osteomyelitis? 1. Parents can stop worrying about bone infection once their child reaches school age. 2. Parents need to clean open wounds thoroughly with soap and water. 3. Children will always get a fever if they have osteomyelitis. 4. Children should wear long pants when playing outside because their legs might get scratched.

2 1. Osteomyelitis can occur in children older than school age. 2. Because bacteria from an open wound can lead to osteomyelitis, thorough cleaning with soap and water is the best prevention. 3. Children with osteomyelitis do not always have a fever. 4. It is not necessary to require children to wear long pants whenever playing out- side. TEST-TAKING HINT: The test taker can eliminate answers 1 and 3 because they do not address prevention

Which should the nurse stress to the parents of an infant in a Pavlik harness for treat- ment of developmental dysplasia of the hip (DDH)? 1. Put socks on over the foot pieces of the harness to help stabilize the harness. 2. Use lotions or powder on the skin to prevent rubbing of straps. 3. Remove harness during diaper changes for ease of cleaning diaper area. 4. Check under the straps at least two to three times daily for red areas.

2 1. Socks should be put on under the straps to prevent rubbing of the skin. The harness is stable if fitted correctly. 2. Lotions and powders tend to cake and irritate under the straps. Their use is not recommended. 3. The harness is not to be removed except in specific conditions and after instruction on removal and refitting. Diapering is easily done with the harness in place. 4. Checking under straps frequently is suggested to prevent skin breakdown. TEST-TAKING HINT: The test taker can eliminate answer 1 because the question is about skin breakdown, not harness fit.

Which is an important nursing intervention to teach about photosensitivity to the parents of a child with systemic lupus erythematosus (SLE)? 1. Regular clothing is appropriate for sun exposure. 2. Sunscreen application is necessary for protection. 3. Teenage patients cannot participate in outdoor sports. 4. Uncovered fluorescent lights offer no danger.

2 1. Sun-protective clothing is important, including hats. 2. Sunscreen helps reduce accelerated burning due to sensitivity. 3. Participating in sports is important for normalcy and should be encouraged. 4. Protection from uncovered fluorescent lights is as important as protection from ultraviolet A and B light. TEST-TAKING HINT: In general, sunscreen is important for every question regarding sun exposure and photosensitivity.

A 9-year-old is in a spica cast and complains of pain 1 hour after receiving intravenous opioid analgesia. What should the nurse do first? 1. Give more pain medication. 2. Perform a neuromuscular assessment. 3. Call the surgeon for orders. 4. Tell the child to wait another hour for the medication to work.

2 1. The nurse needs to assess the child prior to giving more pain medication. 2. The nurse looks for the source of the pain by performing a neuromuscular assessment. 3. If the neuromuscular assessment is nor- mal, the nurse might need to call the surgeon for further orders. 4. The child should have relief from pain after about 20 to 30 minutes of receiving the intra- venous medication, so waiting is not correct. TEST-TAKING HINT: The surgeon should be called only after an assessment of the patient is done. The test taker can rule out answer 3.

A child is admitted to the pediatric unit with the diagnosis of systemic lupus erythe- matosus (SLE). On assessment, the nurse expects the child to have: 1. Leukemia. 2. Malar rash. 3. Weight gain. 4. Heart failure.

2 1. This is not a clinical manifestation. 2. The "butterfly," or malar, rash is the most common manifestation of SLE. 3. Weight loss, not weight gain, is a symptom of SLE. 4. Heart failure is not a common manifesta- tion, but it can occur after long-term disease that affects the heart muscle. TEST-TAKING HINT: By understanding the pathophysiology of SLE, the test taker will be able to find the correct answer.

Which classification of osteogenesis imperfecta (OI) is lethal in utero and in infancy? 1. Type I. 2. Type II. 3. Type III. 4. Type IV.

2 1. Type I is the most common form. It is characterized by little deformity, variable fractures, blue sclera, hearing loss common in the 20s, and a normal life span. 2. Type II is lethal in utero and in infancy because of multiple fractures and deformities and underdeveloped lungs. 3. Type III is characterized by fractures, deformities, and short stature. Patients rarely live to age 30 years. 4. Type IV is similar to type I but not associated with blue sclera. TEST-TAKING HINT: The test taker might be tempted to choose type IV, thinking that the higher number (IV) is the most severe form of OI.

When counseling the parents of a child with osteogenesis imperfecta (OI), the nurse should include which of the following? Select all that apply. 1. Discourage future children because the condition is inherited. 2. Provide education about the child's physical limitations. 3. Give the parents a letter signed by the primary care provider explaining OI. 4. Provide information on contacting the Osteogenesis Imperfecta Foundation. 5. Encourage the parents to treat the child like their other children. 6. Encourage use of calcium to decrease risk of fractures.

2, 3, 4. 1. Genetic counseling should be provided as part of long-term care so that the parents can make an informed decision about future children. 2. The nurse should provide education about the child's physical limitations so that physical therapy and appropriate activity can be encouraged. 3. OI is frequently confused with child abuse. Carrying a letter stating that the child has OI and what that condition looks like can ease the stressors of an emergency department visit. 4. The Osteogenesis Imperfecta Foundation is an organization that can provide infor- mation and support for a family with a child with the condition. 5. Children with OI must be treated with careful handling and cannot be allowed to participate in all activities that unaffected siblings are allowed. 6. There is no support for the use of additional calcium to decrease fractures. TEST-TAKING HINT: The test taker can elim- inate answer 1 because it is based on the nurse's values, not necessarily those of the parents.

When a child is suspected of having osteomyelitis, the nurse can prepare the family to expect which of the following? Select all that apply. 1. Pain medication is contraindicated so that symptoms are not masked. 2. Blood cultures will be obtained. 3. Pus will be aspirated from the subperiosteum. 4. An intravenous line with antibiotics will be started 5. Surgery will be necessary.

2, 3, 4. 1. Medication will be given regularly to help with the pain. 2. Blood cultures will be obtained. 3. Pus will be aspirated from the subperiosteum. 4. Antibiotics will be given via an intravenous line. 5. Surgery is indicated only when medication fails. TEST-TAKING HINT: The test taker should prioritize nursing interventions and know that safety needs are paramount. 1, 2, 4, 5. 1. After the final casting, bracing is required for 23 to 24 hours per day for 2 months. This decreases the likelihood of a recurrence. 2. Because clubfoot can recur, it is impor- tant to have regular follow-up with the orthopedic surgeon until age 18 years. 3. After treatment, most children are able to participate in any sport. 4. Even with proper bracing, there may be a recurrence. 5. Most children treated for clubfeet develop normally appearing and functioning feet. 6. Most children do not require surgery at puberty. TEST-TAKING HINT: If the test taker is aware that clubfoot can recur, providing instruction that includes long-term follow-up care will help in selecting answers. C, D. The nurse needs to assess areas under the cast for drainage through the cast and assess neurocirculatory status of the feet. TEST-TAKING HINT: The test taker should know to check for neurocirculatory status and wound drainage. 2, 3, 4. 1. Medication will be given regularly to help with the pain. 2. Blood cultures will be obtained. 3. Pus will be aspirated from the subperiosteum. 4. Antibiotics will be given via an intravenous line. 5. Surgery is indicated only when medication fails. TEST-TAKING HINT: If the test taker is unsure of specific care for osteomyelitis, standard nursing care for infection can lead to correct choices.

Because estrogen is a possible trigger for a systemic lupus erythematosus (SLE) flare, advice for a teenager who may become sexually active includes which of the following? Select all that apply. 1. Use Ortho Tri-Cyclen. 2. Use Depo-Provera. 3. Practice abstinence. 4. Use condoms. 5. Use Ortho Evra

2, 3, 4. 1. Ortho Tri-Cyclen contains estrogen; therefore, it is contraindicated. 2. Depo-Provera is progesterone, the only contraceptive that is approved for use in sexually active women with SLE. 3. Abstinence is always recommended to prevent pregnancy. 4. Condoms are always recommended. 5. Ortho Evra ("the patch") contains estrogen and is therefore not recommended. TEST-TAKING HINT: The test taker must be familiar with the types of contraceptives and with which contain combination hor- mones versus progesterone only

A 10-year-old with osteomyelitis has been on intravenous antibiotics for 48 hours. The child is allergic to amoxicillin. Vital signs are T 101.8°F (38.8°C), BP 100/60, P 96, R 24. Which is the primary reason for surgical treatment? 1. Young age. 2. Drug allergies. 3. Nonresponse to intravenous antibiotics. 4. Physician preference

3 1. All children with osteomyelitis are treated initially with intravenous antibiotics, re- gardless of age. 2. Although drug allergies are a concern, antibiotic choices can be made to accommodate patients with specific drug allergies. 3. If a patient does not respond to an appropriate antibiotic within 48 hours, surgery may be indicated. 4. Although there is some difference of opinion about the use of surgery in the treatment of osteomyelitis, the standard initial treatment is intravenous antibiotics. TEST-TAKING HINT: Answer 4 should be eliminated because patient treatment should be based on evidence-based practice.

Which would the nurse teach an adolescent is a complication of corticosteroids used in the treatment of juvenile idiopathic arthritis (JIA)? 1. Fat loss. 2. Adrenal stimulation. 3. Immune suppression. 4. Hypoglycemia.

3 1. Long-term corticosteroid use causes fat deposits, especially in the back, face, and trunk. 2 With the use of corticosteroids, there is adrenal suppression because the exoge- nous steroid causes the body to lower production of its own steroids. 3 Steroids cause immune suppression, which is the reason behind its use in JIA; it reduces the body's attack on itself. 4 Steroids cause hyperglycemia. TEST-TAKING HINT: The test taker must understand how immune system diseases work in order to know how treatments will be helpful. Consider how steroids work and their complications. Each an- swer listed, except the correct answer, is the opposite of the true side effects.

The nurse evaluates teaching as successful when the parent explains that an excisional biopsy is done for which reason? 1. To find metastatic disease. 2. To remove all metastatic disease. 3. To confirm the type of metastatic disease. 4. To treat metastatic disease.

3 1. Metastatic disease is confirmed by a com- bination of tests. 2. A biopsy removes only a small piece of the tumor. 3. A biopsy confirms the histology of the tumor. 4. Chemotherapy, radiation, and surgery are required for treatment. TEST-TAKING HINT: A biopsy is used to get the basic information of any solid cancer. Additional tests and procedures are part of treatment and more extensive diagnosis.

The nurse expects the blood culture report of an 8-year-old with septic arthritis to grow which causative organism? 1. Streptococcus pneumoniae. 2. Escherichia coli. 3. Staphylococcus aureus. 4. Neisseria gonorrhoeae

3 1. S. pneumoniae is more common in chil- dren younger than age 5 years, but it is not the most common organism. 2. E. coli is more common in neonates, but it is also not the most common cause. 3. S. aureus is a common organism found on the skin and is frequently the cause of septic arthritis. 4. N. gonorrhoeae should be considered in sexually active patients, but it is not the most common organism TEST-TAKING HINT: The age of the child is important in choosing the correct answer.

The nurse is explaining rhabdomyosarcoma cancer to an adolescent. From which of the following muscles does the cancer arise? 1. Skeletal. 2. Cardiac. 3. Striated. 4. Connective

3 1. Striated muscle is in many organs and sites of the body, thus leading to the mul- tiple sites of the disease. 2. Striated muscle is in many organs and sites of the body, thus leading to the multiple sites of the disease. 3. Striated muscle is in many organs and sites of the body, thus leading to the multiple sites of the disease. 4. There is no such muscle. TEST-TAKING HINT: The test taker must understand the basic locations for each muscle listed.

The parent of a 3-week-old states that the infant was recasted this morning for clubfoot and has been crying for the past hour. Which intervention should the nurse suggest the parent do first? 1. Give pain medication. 2. Reposition the infant in the crib. 3. Check the neurocirculatory status of the foot. 4. Use a cool blow-dryer to blow into the cast to control itching.

3 1. The cause of the crying needs to be determined prior to administering pain medication. 2. Although this is a good choice, it is not the first intervention. 3. Checking the neurocirculatory status of the foot is the highest priority. 4. Although this is a good choice for cast discomfort, it is not the first choice. TEST-TAKING HINT: The test taker should prioritize nursing interventions and know that safety needs are paramount.

A child is diagnosed with stage IV rhabdomyosarcoma, and the parent asks what that means. The nurse provides which of the following explanations? 1. The tumor is limited to the organ site. 2. There is regional disease from the organ involved. 3. There is distant metastatic disease. 4. The disease is limited to the lymph nodes.

3 1. This is stage I disease. 2. This is stage II disease. 3. Stage IV disease means there is distant metastatic disease. 4. Lymph node involvement is not used as part of staging for rhabdomyosarcoma. TEST-TAKING HINT: The test taker must be familiar with the basic staging of cancers.

Select the number of inches lateral to the heel where a crutch should be placed. 1to3. 2. 4to5. 3. 6to8. 4. 9 to 10.

3 1. This position does not provide the best protection for balance and stability. 2. This position does not provide the best protection for balance and stability. 3. This position provides the best protec- tion for balance and stability. 4. This position does not provide the best protection for balance and stability. TEST-TAKING HINT: Consider the stance that is best for balance when standing.

Which should be included in teaching a family about post-surgical care for slipped capital femoral epiphysis (SCFE)? Select all that apply. 1. The patient will receive help with weight-bearing ambulation 24 to 48 hours after surgery. 2. Monitoring of pain medication to prevent drug dependence. 3. Instruction on pin site care. 4. Offering low-calorie meals to encourage weight loss. 5. Correct use of crutches by the patient. 6. Outpatient physical therapy for 6 to 8 weeks.

3, 5 1. Ambulation is to be non-weight bearing with crutches until range of motion is painless. This is usually 4 to 8 weeks. 2. Pain medication is to be administered regularly during hospitalization to pro- vide comfort to the patient and encourage cooperation with daily activities and ambulation. Drug dependence for the post-operative patient is not a significant concern. 3. The parents will be assessing pin sites for infection and stability upon dis- charge. Instructions on care should be demonstrated for and then by the parents. 4. Although obesity is often a factor in SCFE, the patient requires adequate caloric intake for healing and recovery post-operatively. Obesity issues can be addressed after surgical recovery. 5. Instruction on crutch usage will be given prior to discharge. Crutch walk- ing will not be done during the early post-operative stage. 6. Outpatient physical therapy is not usually necessary. TEST-TAKING HINT: The test taker should be able to rule out answer 2 by under- standing the safe use of pain medication in the immediate post-operative period.

Which is most important to discuss with an adolescent who is going to have a leg amputation for osteosarcoma? 1. Pain. 2. Spirituality. 3. Body image. 4. Lack of coping.

3. 1. Pain is a common concern but adoles- cents are more concerned about their body image. 2. In general, adolescents are more concerned with their body image and not spirituality. 3. Body image is a developmental issue for adolescents and influences their acceptance of themselves and by peers. 4. Body image is more of a concern for adolescents and should be addressed first by the nurse. Lack of coping is not a priority at this time. TEST-TAKING HINT: The question asks for specific versus general anticipatory guid- ance issues

A 12-year-old diagnosed with scoliosis is to wear a brace for 23 hours a day. What is the most likely reason the child will not wear it for that long? 1. Pain from the brace. 2. Difficulty in putting the brace on. 3. Self-consciousness about appearance. 4. Not understanding what the brace is for.

3. 1. Putting on the brace is not painful. 2. Putting on the brace is not difficult. 3. Children this age are very conscious of their appearance and fitting in with their peers, so they might be very resistant to wearing a brace. 4. Although a child this age might not fully understand how the brace helps the con- dition, that would not be the most likely cause of noncompliance. TEST-TAKING HINT: The test taker must understand the development of children

When instructing a family about care of an orthosis, the nurse should emphasize which of the following? 1. Clean the brace with diluted bleach. 2. Dry the brace over a heater or in the sun. 3. Clean the brace weekly with mild soap and water. 4. Return the brace to the orthopedic surgeon for cleaning.

3. 1. The use of bleach can damage the brace. 2. Drying in direct sunlight or on a heater can warp the brace. 3. An orthosis should be cleaned weekly with mild soap and water. 4. The brace can be safely cleaned at home. TEST-TAKING HINT: The test taker can rule out answer 4, because equipment care would not be confined to a physician's office.

The nurse is teaching the parent of a child newly diagnosed with juvenile idiopathic arthritis (JIA). The nurse would evaluate the teaching as successful when the parent is able to say that the disorder is caused by the: 1. Breakdown of osteoclasts in the joint space causing bone loss. 2. Loss of cartilage in the joints. 3. Build-up of calcium crystals in joint spaces. 4. Immune-stimulated inflammatory response in the joint.

4 1 This is part of the normal breakdown and buildup of bone in the body. 2 This is part of the process for osteoarthritis. 3 This is the pathophysiology of calcium chondrosis. 4 IA is caused by an immune response by the body on the joint spaces. TEST-TAKING HINT: The test taker must understand JIA is an immune-modulated disorder and how the body attacks itself,

Which is an important nursing intervention to monitor in a child with systemic lupus erythematosus (SLE) and renal involvement? 1. Monitor weight. 2. Check for uric salts in urine. 3. Watch for hypotension. 4. Check for protein in urine.

4 1. For renal impairment due to SLE, moni- toring the child's weight is important but checking the urine is a priority. 2. Uric salts are a normal concentrate of urine. 3. Hypertension is a problem with renal involvement, not hypotension. 4. Protein in urine is a sign of renal impair- ment, even in nephrotic syndrome, in which the kidneys are losing protein. TEST-TAKING HINT: The test taker must understand what can happen to the body when organs, such as the kidneys, fail

Which should be obtained to make a diagnosis of slipped capital femoral epiphysis (SCFE)? 1. A history of hip trauma. 2. A physical examination of hip, thigh, and knees. 3. A complete blood count. 4. A radiographic examination of the hip.

4 1. In most cases of SCFE, there is no history of trauma to the hip. 2 Physical examination may reveal some restriction of rotation of the hip, but it is not diagnostic. 3. There is no change in blood laboratory values with SCFE. 4. Radiographic examina- tion is the only definitive tool for diagno- sis of SCFE. TEST-TAKING HINT: The most definitive tool in assessing a hip is radiographic examination.

Which is the nurse's best explanation to the parent of a toddler who asks what a greenstick fracture is? 1. It is a fracture located in the growth plate of the bone. 2. Because children's bones are not fully developed, any fracture in a young child is called a greenstick fracture. 3. It is a fracture in which a complete break occurs in the bone, and small pieces of bone are broken off. 4. It is a fracture that does not go all the way through the bone.

4 1. It is a fracture that does not go all the way through the bone. 2. It is a fracture that does not go all the way through the bone. 3. It is a fracture that does not go all the way through the bone. 4. It is a fracture that does not go all the way through the bone. TEST-TAKING HINT: The test taker must know the definition of a greenstick fracture.

When teaching parents about osteosarcoma, the nurse knows instruction has been successful when a parent says that this type of cancer is common in which age group? 1. Infancy. 2. Toddlers. 3. School-aged children. 4. Adolescents.

4 1. Osteosarcoma is a common cancer of adolescents. 2. Osteosarcoma is a common cancer of adolescents. 3. Osteosarcoma is a common cancer of adolescents. 4. Osteosarcoma is a common cancer of adolescents. TEST-TAKING HINT: The test taker must remember that pediatric cancers usually develop during times of peak growth. Adolescence is the greatest time of peak bone growth.

Which would be the best nursing intervention for a child with phantom pain after an amputation? 1. Tell the child that the pain does not exist. 2. Request a PCA pump from the physician for pain management. 3. Encourage the child to rub the stump. 4. Provide Elavil to help with pain.

4 1. This is not a helpful intervention. 2. PCA is not necessary for phantom pain. 3. Rubbing the stump is not helpful and possibly harmful to healing. 4. Elavil is a medication for nerve pain that is helpful in relieving phantom pain. TEST-TAKING HINT: Knowing that phantom pain is due to nerve pain from the lost limb enables elimination of answer 2.

Which parts of the body should the nurse assess on a child in a spica cast? List the relevant label(s) from the following figure.

C, D. The nurse needs to assess areas under the cast for drainage through the cast and assess neurocirculatory status of the feet. TEST-TAKING HINT: The test taker should know to check for neurocirculatory status and wound drainage.

Name the harness in the following figure.

Pavlik harness. The Pavlik harness is used to treat DDH diagnosed in the newborn period. TEST-TAKING HINT: The harness places the hip joints in abduction.

Use the following labels to name the places on the bone in the following figure. 1. Epiphysis. 2. Diaphysis. 3. Epiphyseal plate. 4. Medullary cavity. 5. Calcaneus bone. 6. Compact bone.

TEST-TAKING HINT: The test taker should look at each word and think about the parts of the bone. Separate the parts of the words, and think about what their stems mean to help with locations.