Musculoskeletal

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 technique should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub the leg. c. Carefully pick material off the leg. d. Apply powder to absorb the material.

ANS: A Simply soaking in the bathtub is usually sufficient for removal of the desquamated skin and sebaceous secretions. Several days may be required to eliminate the accumulation completely. 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.

What is a major goal for the therapeutic management of juvenile idiopathic arthritis (JIA)? a. Control pain and preserve joint function. b. Minimize use of joint and achieve cure. c. Prevent skin breakdown and relieve symptoms. d. Reduce joint discomfort and regain proper alignment.

ANS: A The goals of therapy are to control pain, preserve joint range of motion and function, minimize the effects of inflammation, and promote normal growth and development. There is no cure for JIA at this time. Skin breakdown is not an issue for most children with JIA. Symptom relief and reduction in discomfort are important. When the joints are damaged, it is often irreversible.

Immobilization causes what effect on metabolism? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased levels of stress hormones

ANS: B Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake. Immobilization leads to hypercalcemia and a negative nitrogen balance secondary to muscle atrophy. Decreased production of stress hormones occurs with decreased physical and emotional coping capacity.

What nursing intervention is most appropriate when caring for the child with osteomyelitis? a. Encourage frequent ambulation. b. Administer antibiotics with meals. c. Move and turn the child carefully and gently to minimize pain. d. Provide active range of motion exercises for the affected extremity.

ANS: C During the acute phase, any movement of the affected limb causes discomfort to the child. Careful positioning with the affected limb supported is necessary. Weight bearing is not permitted until healing is well under way to avoid pathologic fractures. Intravenous antibiotics are used initially. Food is not necessary with parenteral therapy. Active range of motion would be painful for the child.

A child with juvenile idiopathic arthritis (JIA) is started on a nonsteroidal antiinflammatory drug (NSAID). What nursing consideration should be included? a. Monitor heart rate. b. Administer NSAIDs between meals. c. Check for abdominal pain and bloody stools. d. Expect inflammation to be gone in 3 or 4 days.

ANS: C NSAIDs are the first-line drugs used in JIA. Potential side effects include gastrointestinal (GI), renal, and hepatic side effects. The child is at risk for GI bleeding and elevated blood pressure. The heart rate is not affected by this drug class. NSAIDs should be given with meals to minimize gastrointestinal problems. The antiinflammatory response usually takes 3 weeks before effectiveness can be evaluated.

What is the primary method of treating osteomyelitis? a. Joint replacement b. Bracing and casting c. Intravenous antibiotic therapy d. Long-term corticosteroid therapy

ANS: C Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus infection. The treatment of choice is antibiotics. Joint replacement, bracing and casting, and long-term corticosteroid therapy are not indicated for infectious processes.

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, what should the nurse explain? 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.

ANS: C 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. Serial casting is the preferred treatment. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.

What is an important nursing consideration when caring for a child with juvenile idiopathic arthritis (JIA)? a. Apply ice packs to relieve acute swelling and pain. b. Administer acetaminophen to reduce inflammation. c. Teach the child and family correct administration of medications. d. Encourage range of motion exercises during periods of inflammation.

ANS: C The management of JIA is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of a regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that nonsteroidal antiinflammatory drugs should not be given on an empty stomach and to be alert for signs of toxicity. Warm, moist heat is best for relieving stiffness and pain. Acetaminophen does not have antiinflammatory effects. Range of motion exercises should not be done during periods of inflammation.

A 14-year-old is admitted to the emergency department with a fracture of the right humerus epiphyseal plate through the joint surface. What information does the nurse know regarding this type of fracture? a. It will create difficulty because the child is left handed. b. It will heal slowly because this is the weakest part of the bone. c. This type of fracture requires different management to prevent bone growth complications. d. This type of fracture necessitates complete immobilization of the shoulder for 4 to 6 weeks.

ANS: C This type of fracture (Salter type III) can cause problems with growth in the affected limb. Early and complete assessment is essential to prevent angular deformities and longitudinal growth problems. The difficulty for the child does not depend on the location at the epiphyseal plate. Any fracture of the dominant arm presents obstacles for the individual. Healing is usually rapid in the epiphyseal plate area. Complete immobilization is not necessary. Often these injuries are surgically repaired with open reduction and internal fixation.

What measure is important in managing hypercalcemia in a child who is immobilized? a. Provide adequate hydration. b. Change position frequently. c. Encourage a diet high in calcium. d. Provide a diet high in calories for healing.

ANS: A Vigorous hydration is indicated to prevent problems with hypercalcemia. Suggested intake for an adolescent is 3000 to 4000 ml/day of fluids. Diuretics are used to promote the removal of calcium. Changing position is important for skin and respiratory concerns. Calcium in the diet is restricted when possible. A high-protein diet served as frequent snacks with favored foods is recommended. A high-calorie diet without adequate protein will not promote healing.

3. The nurse is assisting with application of a synthetic cast on a child with a fractured humerus. What are the advantages of a synthetic cast over a plaster of Paris cast? (Select all that apply.) a. Less bulky b. Drying time is faster c. Molds readily to body part d. Permits regular clothing to be worn e. Can be cleaned with small amount of soap and water

ANS: A, B, D, E The advantages of synthetic casts over plaster of Paris casts are that they are less bulky, dry faster, permit regular clothes to be worn, and can be cleaned. Plaster of Paris casts mold readily to a body part, but synthetic casts do not mold easily to body parts.

The nurse is caring for a child immobilized because of Russel traction. What interventions should the nurse implement to prevent renal calculi? (Select all that apply.) a. Monitor output. b. Encourage the patient to drink apple juice. c. Encourage milk intake. d. Ensure adequate fluids. e. Encourage the patient to drink cranberry juice.

ANS: A, D, E To prevent renal calculi in a child who is immobilized, a nurse should monitor output; ensure adequate fluids; and encourage cranberry juice, which acidifies urine. Apple juice and milk alkalize the urine, so they should not be encouraged.

A child has just returned from surgery for repair of a fractured femur. The child has a long-leg cast on. The toes on the leg with the cast are edematous, but they have color, sensitivity, and movement. What action should the nurse take? a. Call the health care provider to report the edema. b. Elevate the foot and leg on pillows. c. Apply a warm moist pack to the foot. d. Encourage movement of toes.

ANS: B During the first few hours after a cast is applied, the chief concern is that the extremity may continue to swell to the extent that the cast becomes a tourniquet, shutting off circulation and producing neurovascular complications (compartment syndrome). One measure to reduce the likelihood of this problem is to elevate the body part and thereby increase venous return. The health care provider does not need to be notified because edema is expected and warm moist packs will not decrease the edema. The child should move the toes, but that will not help reduce the edema.

What finding is characteristic of fractures in children? a. Fractures rarely occur at the growth plate site because it absorbs shock well. b. Rapidity of healing is inversely related to the child's age. c. Pliable bones of growing children are less porous than those of adults. d. The periosteum of a child's bone is thinner, is weaker, and has less osteogenic potential compared to that of an adult.

ANS: B Healing is more rapid in children. The younger the child, the more rapid the healing process. Nonunion of bone fragments is uncommon except in severe injuries. The epiphyseal plate is the weakest point of long bones and a frequent site of injury during trauma. Children's bones are more pliable and porous than those of adults. This allows them to bend, buckle, and break. The greater porosity increases the flexibility of the bone and dissipates and absorbs a significant amount of the force on impact. The adult periosteum is thinner, is weaker, and has less osteogenic potential than that of a child.

A child with a hip spica cast is being prepared for discharge. Recognizing that caring for a child at home is complex, the nurse should include what instructions for the parents' discharge teaching? a. Turn every 8 hours. b. Specially designed car restraints are necessary. c. Diapers should be avoided to reduce soiling of the cast. d. Use an abduction bar between the legs to aid in turning.

ANS: B Standard seat belts and car seats may not be readily adapted for use by children in some casts. Specially designed car seats and restraints meet safety requirements. The child must have position changes much more frequently than every 8 hours. During feeding and play activities, the child should be moved for both physiologic and psychosocial benefit. Diapers and other strategies are necessary to maintain cleanliness. The abduction bar is never used as an aid for turning. Putting pressure on the bar may damage the integrity of the cast.

The nurse is teaching the parent of a 4-year-old child with a cast on the arm about care at home. What statement by the parent indicates a correct understanding of the teaching? a. "I should have the affected limb hang in a dependent position." b. "I will use an ice pack to relieve the itching." c. "I should avoid keeping the injured arm elevated." d. "I will expect the fingers to be swollen for the next 3 days."

ANS: B Teaching the parent to use an ice pack to relieve the itching is an important aspect when planning discharge for a child with a cast. The affected limb should not be allowed to hang in a dependent position for more than 30 minutes. The affected arm should be kept elevated as much as possible. If there is swelling or redness of the fingers, the parent should notify the health care provider.

A 4-year-old child is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses the skin of his right foot and sees that it is pale with an absence of pulse. What should the nurse do first? a. Reposition the child and notify the practitioner. b. Notify the practitioner of the changes noted. c. Give the child medication to relieve the pain. d. Chart the observations and check the extremity again in 15 minutes.

ANS: B The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. This is an emergency condition. Pain medication should be given after the practitioner is notified. The findings should be documented with ongoing assessment.

A 3-year-old child has a femoral shaft fracture. The nurse recognizes that the approximate healing time for this child is how long? a. 2 weeks b. 4 weeks c. 6 weeks d. 8 weeks

ANS: B The approximate healing times for a femoral shaft fracture are as follows: neonatal period, 2 to 3 weeks; early childhood, 4 weeks; later childhood, 6 to 8 weeks; and adolescence, 8 to 12 weeks.

The nurse knows that parents need further teaching with regard to the treatment of congenital clubfoot when they state what? a. "We'll keep the cast dry." b. "We're happy this is the only cast our baby will need." c. "We'll watch for any swelling of the foot while the cast is on." d. "We're getting a special car seat to accommodate the cast."

ANS: B The common approach to clubfoot management and treatment is the Ponseti method. Serial casting is begun shortly after birth. Weekly gentle manipulation and stretching of the foot along with placement of serial long-leg casts allow for gradual repositioning of the foot. The extremity or extremities are casted until maximum correction is achieved, usually within 6 to 10 weeks. If parents state that this is the only cast the infant will need, they need further teaching.

A 7-year-old child has just had a cast applied for a fractured arm with the wrist and elbow immobilized. What information should be included in the home care instructions? a. No restrictions of activity are indicated. b. Elevate casted arm when both upright and resting. c. The shoulder should be kept as immobile as possible to avoid pain. d. Swelling of the fingers is to be expected. Notify a health professional if it persists more than 48 hours.

ANS: B The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. The child should not engage in strenuous activity for the first few days. Rest with elevation of the extremity is encouraged. Joints above and below the cast on the affected extremity should be moved. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours.

What is an appropriate nursing intervention when caring for a child in traction? a. Removing adhesive traction straps daily to prevent skin breakdown b. Assessing for tightness, weakness, or contractures in uninvolved joints and muscles c. Providing active range of motion exercises to affected extremity three times a day d. Keeping child prone to maintain good alignment

ANS: B Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released or replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement is expected with children. Each time the child moves, the nurse should check to ensure that proper alignment is maintained.

A child has had a short-arm synthetic cast applied. What should the nurse teach to the child and parents about cast care? (Select all that apply.) a. Relieve itching with heat. b. Elevate the arm when resting. c. Observe the fingers for any evidence of discoloration. d. Do not allow the child to put anything inside the cast. e. Examine the skin at the cast edges for any breakdown.

ANS: B, C, D, E Cast care involves elevating the arm, observing the fingers for evidence of discoloration, not allowing the child to put anything inside the cast, and examining the skin at the edges of the cast for any breakdown. Ice, not heat, should be applied to relieve itching.

The nurse is caring for a 14-year-old child with juvenile idiopathic arthritis (JIA). What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Erythema over joints b. Soft tissue contractures c. Swelling in multiple joints d. Morning stiffness of the joints e. Loss of motion in the affected joints

ANS: B, C, D, E Whether single or multiple joints are involved, stiffness, swelling, and loss of motion develop in the affected joints in JIA. The swelling results from soft tissue edema, joint effusion, and synovial thickening. The affected joints may be warm and tender to the touch, but it is not uncommon for pain not to be reported. The limited motion early in the disease is a result of muscle spasm and joint inflammation; later it is caused by ankylosis or soft tissue contracture. Morning stiffness of the joint(s) is characteristic and present on arising in the morning or after inactivity. Erythema is not typical, and a warm, painful, red joint is always suspect for infection.

The nurse uses the five Ps to assess ischemia in a child with a fracture. What finding is considered a late and ominous sign? a. Petaling b. Posturing c. Paresthesia d. Positioning

ANS: C Paresthesia distal to the injury or cast is an ominous sign that requires immediate notification of the practitioner. Permanent muscle and tissue damage can occur within 6 hours. The other signs of ischemia that need to be reported are pain, pallor, pulselessness, and paralysis. Petaling is a method of placing protective or smooth edges on a cast. Posturing is not a sign of peripheral ischemia. Finding a position of comfort can be difficult with a fracture. It would not be an ominous sign unless pain was increasing or uncontrollable.

The nurse is teaching a child with a cast about cast removal. What should the nurse teach the child about cast removal? a. "The cast cutter will be a quiet machine." b. "You will feel cold as the cast is removed." c. "You will feel a tickly sensation as the cast is removed." d. "The cast cutter cuts through the cast like a circular saw."

ANS: C Cutting the cast to remove it or to relieve tightness is frequently a frightening experience for children. They fear the sound of the cast cutter and are terrified that their flesh, as well as the cast, will be cut. Because it works by vibration, a cast cutter cuts only the hard surface of the cast. The oscillating blade vibrates back and forth very rapidly and will not cut when placed lightly on the skin. Children have described it as producing a "tickly" sensation.

he nurse is caring for a hospitalized adolescent whose femur was fractured 18 hours ago. The adolescent suddenly develops chest pain and dyspnea. The nurse should suspect what complication? a. Sepsis b. Osteomyelitis c. Pulmonary embolism d. Acute respiratory tract infection

ANS: C Fat emboli are of greatest concern in individuals with fractures of the long bones. Fat droplets from the marrow are transferred to the general circulation, where they are transported to the lung or brain. This type of embolism usually occurs within the second 12 hours after the injury. Sepsis would manifest with fever and lethargy. Osteomyelitis usually is seen with pain at the site of infection and fever. A child with an acute respiratory tract infection would have nasal congestion, not chest pain.

What is a physiologic effect of immobilization on children? a. Metabolic rate increases. b. Venous return improves because the child is in the supine position. c. Circulatory stasis can lead to thrombus and embolus formation. d. Bone calcium increases, releasing excess calcium into the body (hypercalcemia).

ANS: C The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with immobilization. With the loss of muscle contraction, there is a decreased venous return to the heart. Calcium leaves the bone during immobilization, leading to bone demineralization and increasing the calcium ion concentration in the blood.

What should the nurse plan for an immobilized child in cervical traction to prevent deep vein thrombosis (DVT)? a. Elevate the child's legs. b. Place a foot cradle on the bed. c. Place a pillow under the child's knees. d. Assist the child to dorsiflex the feet and rotate the ankles.

ANS: D For a child who is immobilized, circulatory stasis and DVT development are prevented by instructing patients to change positions frequently, dorsiflex their feet and rotate the ankles, sit in a bedside chair periodically, or ambulate several times daily. Elevating the legs or placing a foot cradle on the bed will not prevent DVTs. A pillow under the knee would impair circulation, not improve it.

The nurse is caring for an immobilized preschool child. What intervention is helpful during this period of immobilization? a. Encourage wearing pajamas. b. Let the child have few behavioral limitations. c. Keep the child away from other immobilized children if possible. d. Take the child for a "walk" by wagon outside the room.

ANS: D Transporting the child outside of the room by stretcher, wheelchair, or wagon increases environmental stimuli and provides social contact. Street clothes are preferred for hospitalized children. This decreases the sense of illness and disability. The child needs appropriate limits for both adherence to the medical regimen and developmental concerns. It is not necessary to keep the child away from other immobilized children.

Parents bring a 7-year-old child to the clinic for evaluation of an injured wrist after a bicycle accident. The parents and child are upset, and the child will not allow an examination of the injured arm. What priority nursing intervention should occur at this time? a. Send the child to radiology so radiography can be performed. b. Initiate an intravenous line and administer morphine for the pain. c. Calmly ask the child to point to where the pain is worst and to wiggle fingers. d. Have the parents hold the child so that the nurse can examine the arm thoroughly.

nitially, assessment is the priority. Because the child is alert but upset, the nurse should work to gain the child's trust. Initial data are gained by observing the child's ability to move the fingers and to point to the pain. Other important observations at this time are pallor and paresthesia. The child needs to be sent for radiography, but initial assessment data need to be obtained. Sending the child for radiography will increase the child's anxiety, making the examination difficult. It is inappropriate to ask parents to restrain their child. These parents are upset about the injury. If restraint is indicated, the nurse should obtain assistance from other personnel.