Peds Ch 29

An adolescent client who is diagnosed with Duchenne muscular dystrophy is seen in the clinic for a routine health visit. Which nursing diagnosis is the priority for this client? 1. Risk for Impaired Mobility Related to Hypertrophy of Muscles 2. Risk for Infection Related to Altered Immune System 3. Risk for Impaired Skin Integrity Related to Paresthesia 4. Risk for Altered Comfort Related to Effects of the Illness

Answer: 1 Explanation: 1. Nursing care for muscular dystrophy (MD) focuses on promoting independence and mobility for this progressive, incapacitating disease. Risk for Infection, Risk for Impaired Skin Integrity, and Risk for Altered Comfort are not as high a priority as Risk for Impaired Mobility.

The nurse in the newborn nursery is performing the admission assessment on a neonate. Which assessment finding indicates the neonate may have congenital hip dysplasia? 1. Asymmetry of the gluteal and thigh fat folds 2. Trendelenburg sign 3. Telescoping of the affected limb 4. Lordosis

Answer: 1 Explanation: 1. A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat folds. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with congenital hip dysplasia. Lordosis does not occur with hip dysplasia.

The school nurse is providing care to a school-age client who experienced a sprain of the right ankle on the playground. Which intervention is appropriate for the nurse to implement for this client? 1. Apply ice to the extremity 2. Apply a warm, moist pack to the extremity 3. Perform passive range of motion to the extremity 4. Lower the extremity to below the level of the heart

Answer: 1 Explanation: 1. For the first 24 hours of a sprain, rest, ice, compression, and elevation should be used. Therefore, the nurse should apply ice to the extremity.

The nurse completes parent education related to treatment for a pediatric client with congenital clubfoot. Which statement by the parents indicates the need for further education? 1. "We're happy this is the only cast our baby will need." 2. "We'll watch for any swelling of the feet while the casts are on." 3. "We'll keep the casts dry." 4. "We're getting a special car seat to accommodate the casts."

Answer: 1 Explanation: 1. Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to 2 weeks. Parents should be watching for swelling while the casts are on, keeping the casts dry, and using a car seat to accommodate the casts.

An adolescent client must wear a brace for the correction of scoliosis. Which nursing diagnosis is most appropriate for this client? 1. Risk for Impaired Skin Integrity 2. Risk for Altered Growth and Development 3. Risk for Impaired Mobility 4. Risk for Impaired Gas Exchange

Answer: 1 Explanation: 1. The skin should be monitored for breakdown in any area the brace may rub. The other diagnoses would not be a priority and should be corrected by the wearing of the brace.

The nurse has completed discharge teaching for the family of a child diagnosed with Legg-Calve-Perthes disease. Which statement by the family indicates the need for further education? 1. "We're glad this will only take about 6 weeks to correct." 2. "We understand swimming is a good sport for Legg-Calve-Perthes." 3. "We know to watch for areas on the skin the brace may rub." 4. "We understand that abduction of the affected leg is important."

Answer: 1 Explanation: 1. The treatment generally takes approximately 2 years. Swimming is a good activity to increase mobility. A brace may be worn, so skin irritation should be monitored. The leg should be kept in the abducted position.

The nurse is providing care to a toddler client who is diagnosed with osteogenesis imperfecta. Which nursing intervention is appropriate for this client? 1. Support of the trunk and extremities when moving 2. Traction care 3. Cast care 4. Postop spinal surgery care

Answer: 1 Explanation: 1. With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved. Traction, casts, and spinal surgery are not routinely done for osteogenesis.

A school health nurse is screening school-age students for scoliosis. Which assessment findings indicate the need for further evaluation for scoliosis? Select all that apply. 1. Uneven shoulders and hips 2. A one-sided rib hump 3. Prominent scapula 4. Lordosis 5. Pain

Answer: 1, 2, 3 Explanation: 1. The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Lordosis and pain are not present with scoliosis.

The parents of a child with Duchenne muscular dystrophy are in the clinic after diagnosis and ask the nurse if the family should have genetic testing completed. Who should the nurse suggest to have genetic testing? Select all that apply. 1. Female cousins 2. Aunts 3. Sisters 4. Brothers 5. Uncles and male cousins

Answer: 1, 2, 3 Explanation: 1. This is an X-linked disorder so all females in the family should be tested.

An infant returns from surgery for correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The toes on both feet are edematous, but there is color, sensitivity, and movement to them. Which action by the nurse is the most appropriate? 1. Call the healthcare provider to report the edema. 2. Elevate the legs on pillows. 3. Apply a warm, moist pack to the feet. 4. Encourage movement of toes.

Answer: 2 Explanation: 1. The legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. Some amount of swelling can be expected, so it would not be appropriate to notify the healthcare provider, especially if the color, sensitivity, and movement remain normal to the toes. Ice should be applied, not heat. An infant would not be able to follow directions to move toes, and in this case it would not be as effective as elevating the legs on pillows.

The nurse is caring for a pediatric client in Bryant skin traction. Which nursing intervention is most appropriate for this client? 1. Remove the adhesive traction straps daily to prevent skin breakdown. 2. Check the traction frequently to ensure that proper alignment is maintained. 3. Place the child in a prone position to maintain good alignment. 4. Move the child as infrequently as possible to maintain traction.

Answer: 2 Explanation: 1. The traction apparatus should be checked frequently to ensure that proper alignment is maintained. The adhesive straps should not be removed. The child should be placed in a supine position, and frequent repositioning is necessary to prevent complications of immobility.

The nurse is caring for the newborn with bilateral clubfoot. What nursing diagnoses would the nurse address? Select all that apply. 1. Activity intolerance 2. Impaired physical mobility 3. Risk for impaired skin integrity 4. Ineffective breathing pattern 5. Impaired parenting

Answer: 2, 3, 5 Explanation: 1. Nursing diagnoses that may apply to the newborn with bilateral clubfoot are impaired physical mobility, risk for impaired skin integrity, impaired parenting, and ineffective health maintenance.

A nurse is assessing a child after an open reduction of a fractured femur. Which assessment findings would indicate that the child is experiencing compartment syndrome? Select all that apply. 1. Pink, warm extremity 2. Pain not relieved by pain medication 3. Dorsalis pedis pulse present 4. Prolonged capillary-refill time with paresthesia 5. Skin appears tense.

Answer: 2, 4, 5 Explanation: 1. The major serious complication post-fracture reduction is compartment syndrome. A prolonged capillary-refill time with loss of paresthesia, pain not relieved by medication, and skin that appears tense are signs of compartment syndrome. Pink, warm extremity; pain relieved by medication; and a present dorsalis pedis pulse would all be normal findings post-fracture reduction.

A nurse notes blue sclera during a newborn assessment. Which item will the newborn require further assessment for based on this finding? 1. Marfan syndrome 2. Achondroplasia 3. Osteogenesis imperfecta 4. Muscular dystrophy

Answer: 3 Explanation: 1. Clinical manifestations of osteogenesis imperfecta include blue sclera. This is not present in Marfan syndrome, achondroplasia, or muscular dystrophy.

The nurse is teaching family members how to care for their infant in a Pavlik harness to treat congenital developmental dysplasia of the hip. Which statement will the nurse include in the teaching session? 1. "Apply lotion or powder to minimize skin irritation." 2. "Put clothing over the harness for maximum effectiveness of the device." 3. "Check at least 2 or 3 times a day for red areas under the straps." 4. "Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper."

Answer: 3 Explanation: 1. The brace should be checked 2 or 3 times for red areas under the straps. Lotion or powder can contribute to skin breakdown. A light layer of clothing should be under the brace, not over. The diaper should also be under the brace.

A school-age client is admitted to the hospital with osteomyelitis. Which statement regarding the treatment of osteomyelitis is most appropriate for the nurse to share with the parents? 1. "Cultures should be done immediately after the first dose of antibiotic infuses." 2. "Antibiotics are ineffective against this virus." 3. "Methicillin is the antibiotic of choice." 4. "Antibiotic therapy should continue for 3 to 6 weeks."

Answer: 4 Explanation: 1. Medical management of osteomyelitis begins with intravenous administration of a broad-spectrum antibiotic. Antibiotic therapy should continue for 3 to 6 weeks. Cultures are always done before an antibiotic is started. Methicillin is not the drug of choice.

A child returns from spinal-fusion surgery. Which item is the priority assessment for this child? 1. Increased intracranial pressure 2. Seizure activity 3. Impaired pupillary response during neurological checks 4. Impaired color, sensitivity, and movement to lower extremities

Answer: 4 Explanation: 1. When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. The other signs are neurological impairment and are not high risk with spinal surgery.