Ch 22
The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis? A) Risk for impaired skin integrity due to cast and location B) Deficient knowledge related to cast care C) Risk for delayed development related to immobility D) Self-care deficit related to immobility
Ans: A Although deficient knowledge, risk for delayed development, and self-care deficit may be applicable, the child is at increased risk for skin breakdown due to the size of the cast and its location. In addition, the cast has an opening, which allows for elimination. Soiling of cast edges or leakage of urine or stool can lead to skin breakdown.
A child with Duchenne muscular dystrophy is to receive prednisone as part of his treatment plan. After teaching the child's parents about this drug, which statement by the parents indicates the need for additional teaching? A) "We should give this drug before he eats anything." B) "We need to watch carefully for possible infection." C) "The drug should not be stopped suddenly." D) "He might gain some weight with this drug."
Ans: A Corticosteroids such as prednisone can cause gastric upset, so the medication should be given with food to reduce this risk. The drug may mask the signs of infection, so the parents need to monitor the child closely for any changes. Treatment with this drug should not be stopped abruptly due to the risk for acute adrenal insufficiency. Common side effects of this drug include weight gain, osteoporosis, and mood changes.
The nurse is assessing the neuromusculoskeletal system of a newborn. What is an abnormal assessment finding? A) Sluggish deep tendon reflexes B) Full range of motion in extremities C) Absence of hypotonia D) Lack of purposeful muscular control
Ans: A Deep tendon reflexes are present at birth and are initially brisk in the newborn and progress to average over the first few months. Sluggish deep tendon reflexes indicate an abnormality. The newborn is capable of spontaneous movement but lacks purposeful control. Full range of motion is present at birth. Healthy infants and children demonstrate normal muscle tone; hypertonia or hypotonia is an abnormal finding.
When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely? A) Skeletal traction B) Physical therapy C) Orthotics D) Occupational therapy
Ans: A Skeletal traction would be the least likely treatment for a child with cerebral palsy. Physical therapy, orthotics and braces, and occupational therapy are all common treatments used for cerebral palsy.
The nurse is providing postoperative care for a 14-month-old girl who has undergone a myelomeningocele repair. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. Which response by the nurse would be most appropriate? A) "I will help you become comfortable in caring for your daughter." B) "You must learn how to care for your daughter at home." C) "You will need to learn to collaborate with all the caregivers." D) "There is a lot to learn, and you need a positive attitude."
Ans: A The nurse needs to empower families to become the experts on their child's needs and conditions via education and participation in care. The most positive approach is to let the mother know the nurse will support her and help her become an expert on her daughter's care. Telling the mother that she must learn how to care for her daughter or that she must have a positive attitude is not helpful. Telling her that she needs to collaborate with the caregivers is true, but does not address her fears.
The nurse is caring for a 14-month-old boy with rickets who was recently adopted from overseas. His condition was likely a result of a diet very low in milk products. The nurse is providing teaching regarding treatment. Which response by the parents indicates a need for further teaching? A) "We must give him calcium and phosphorus with food every morning." B) "He must take vitamin D as prescribed and spend some time in the sunlight." C) "He must take calcium at breakfast and phosphorus at bedtime." D) "We should encourage him to have fish, dairy, and liver if he will eat it."
Ans: A The nurse should emphasize that the calcium and phosphorus supplements should be administered at alternate times to promote proper absorption of both of these supplements. Taking vitamin D, spending time in the sun, and encouraging intake of fish, dairy, and liver are appropriate responses.
The nurse is conducting a physical examination of a child with suspected developmental dysplasia of the hip. Which finding would help confirm this diagnosis? A) Abduction occurs to 75 degrees and adduction to within 30 degrees (with stable pelvis). B) A distinct "clunk" is heard with Barlow and Ortolani maneuvers. C) A high-pitched "click" is heard with hip flexion or extension. D) The thigh and gluteal folds are symmetric.
Ans: B A distinct "clunk" while performing Barlow and Ortolani maneuvers is caused as the femoral head dislocates or reduces back in to the acetabulum. A higher-pitched "click" may occur with flexion or extension of the hip. This is a benign, adventitious sound that should not be confused with a true "clunk" when assessing for developmental dysplasia of the hip. Abduction to 75 degrees, adduction within 30 degrees, and symmetric thigh and gluteal folds are normal findings.
When teaching a group of students about the skeletal development in children, what information would the instructor include? A) The growth plate is made up of the epiphysis. B) A young child's bones commonly bend instead of break with an injury. C) The infant's skeleton has undergone complete ossification by birth. D) Children's bones have a thin periosteum and limited blood supply.
Ans: B A young child's bones are more flexible and more porous with a lower mineral count than adults. Thus, bones will often bend rather than break when an injury occurs. The growth plate is composed of the epiphysis and physis. The infant's skeleton is not fully ossified at birth. Children's bones have a thick periosteum and an abundant blood supply.
The nurse is conducting a physical examination of a child with a brachial plexus injury. Which finding would lead the nurse to be highly suspicious of Erb palsy? A) The child is unable to close one of his eyes. B) The involved extremity is adducted, prone, and internally rotated. C) Asymmetry of the face occurs when the child is crying. D) The mouth is drawn to the noninvolved side.
Ans: B Erb palsy is an upper brachial plexus injury and the involved extremity usually presents as adducted, prone, and internally rotated. Inability to close one eye, facial asymmetry, or drawing of the mouth to the noninvolved side are associated with facial nerve palsy as a result of cranial nerve injuries.
A nurse is caring for a 14-year-old girl following myelography. What is the priority nursing action? A) Monitoring for a decrease in spasticity B) Observing for signs of meningeal irritation C) Assessing motor function D) Observing for mental confusion or hallucinations
Ans: B Following myelography, the nurse should carefully observe for signs of meningeal irritation because of what is involved in this procedure. Monitoring for a decrease in muscle spasticity, assessing motor function, and observing for mental confusion or hallucinations is appropriate following an intrathecal test dose of baclofen.
What information would the nurse include in the preoperative plan of care for an infant with myelomeningocele? A) Positioning supine with a pillow under the buttocks B) Covering the sac with saline-soaked nonadhesive gauze C) Wrapping the infant snugly in a blanket D) Applying a diaper to prevent fecal soiling of the sac
Ans: B For the infant with a myelomeningocele, saline-soaked nonadhesive gauze or antibiotic-soaked gauze is used to keep the sac moist. The infant is positioned prone, with a folded towel under the abdomen, so that the urine and feces flow away from the sac. A warmer or isolette is used to keep the infant warm. Blankets are avoided because they could place excess pressure on the sac. Diapering may be contraindicated to avoid placing pressure on the sac.
A nurse is preparing a presentation for a parent group about musculoskeletal injuries. When describing a child's risk for this type of injury, the nurse integrates knowledge that bone growth occurs primarily in which area? A) Growth plate B) Epiphysis C) Physis D) Metaphysis
Ans: B Growth of the bones occurs primarily in the epiphyseal region. This area is vulnerable and structurally weak. Traumatic force applied to the epiphysis during injury may result in fracture in that area of the bone. The growth plate refers to the combination of the epiphysis, the end of a long bone, and the physis, a cartilaginous area between the epiphysis and the metaphysis.
A newborn is diagnosed with metatarsus adductus. The parents ask the nurse how this occurred. Which response by the nurse would be most appropriate? A) "This condition is due to a genetic defect in the bones." B) "It's most likely from how the baby was positioned in utero." C) "They really don't know what causes this condition." D) "There is probably an underlying deformity of the baby's hip."
Ans: B Metatarsus adductus is a medial deviation of the forefoot that occurs as a result of in utero positioning. Osteogenesis imperfecta is a genetic bone disorder. The underlying cause of congenital clubfoot is not known. Developmental dysplasia of the hip involves a deformity of the newborn's hip.
The nurse is teaching a group of students about myelinization in a child. Which statement by the students indicates that the teaching was successful? A) Myelinization is completed by 4 years of age. B) The process occurs in a head-to-toe fashion. C) The speed of nerve impulses slows as myelinization occurs. D) Nerve impulses become less specific in focus with myelinization.
Ans: B Myelinization occurs in a cephalocaudal, proximodistal manner and is completed by 2 years of age. As myelinization proceeds, nerve impulses become faster and more accurate.
The nurse is assessing a child with a possible fracture. What would the nurse identify as the most reliable indicator? A) Lack of spontaneous movement B) Point tenderness C) Bruising D) Inability to bear weight
Ans: B Point tenderness is one of the most reliable indicators of a fracture in a child. Neglect of an extremity, inability to bear weight, bruising, erythema, and pain may be present, but these findings can also suggest other conditions.
A 10-year-old girl is brought to the emergency department by her father after tripping over a rock while running in the yard. She tells the nurse, "I think I twisted my ankle." When assessing the child, what would the nurse most likely assess? A) Bruising B) Edema C) Limited range of motion D) Absent pulse
Ans: B The girl is describing a sprain, which is frequently accompanied by edema. Bruising may or may not be present. The nurse should not attempt to perform passive range of motion on the affected body part. A pulse should be present; if one is not, neurovascular compromise is present.
The nurse is assessing a newborn who was delivered after a prolonged labor due to an abnormal presentation. The newborn sustained a cranial nerve injury. The nurse would most likely expect to assess deficits related to which cranial nerve? A) Optic B) Facial C) Acoustic D) Trigeminal
Ans: B The most common cranial nerve injury occurring during birth trauma involves facial nerve palsy. The optic, acoustic, and trigeminal nerves are not typically injured during birth trauma.
The nurse is caring for an infant with osteogenesis imperfecta and is providing instruction on how to reduce the risk of injury. Which response from the mother indicates a need for further teaching? A) "I need to avoid pushing or pulling on an arm or leg." B) "I must carefully lift the baby from under the armpits." C) "I should not bend an arm or leg into an awkward position." D) "We must avoid lifting the legs by the ankles to change diapers."
Ans: B The nurse needs to emphasize that the mother must not lift a baby or young child with osteogenesis imperfecta from under the armpits as it may cause harm. Avoiding pushing or pulling, not bending an arm or leg into an awkward position, and avoiding lifting the legs by the ankles are appropriate responses.
The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion? A) Deep-breathing exercises B) Upright positioning C) Coughing D) Chest percussion
Ans: B The nurse should emphasize that the child's position should be arranged to promote maximum chest expansion. This is usually in the upright position. Deep-breathing exercises are for strengthening/maintaining respiratory muscles. Coughing helps clear the airways. Chest percussion helps loosen secretions in lungs.
A nurse is providing instructions to the parents of a 3-month-old with developmental dysplasia of the hip who is being treated with a Pavlik harness. Which statements by the parents demonstrate understanding of the instructions? Select all that apply. A) "We need to adjust the straps so that they are snug but not too tight." B) "We should change her diaper without taking her out of the harness." C) "We need to check the area behind her knees for redness and irritation." D) "We need to send the harness to the dry cleaners to have it cleaned." E) "We need to call the doctor if she is not able to actively kick her legs."
Ans: B, C, E Instructions related to use of a Pavlik harness include changing the child's diaper while in the harness; checking the areas behind the knees and diaper area for redness, irritation, or breakdown; and calling the doctor if the child is unable to actively kick her legs. The straps are not to be adjusted without checking with the physician or nurse practitioner first. The harness can be washed with mild detergent by hand and air dried. A hair dryer can be used to dry the harness but only if the air fluffing setting is used.
A nursing instructor is preparing for a class discussion on spinal muscular atrophy (SMA). When describing type 2 SMA, which information would the instructor include? Select all answers that apply. A)Onset before 6 months of age B) Weakness most severe in shoulders and hips C) Difficulty with swallowing D) Slowly progressing condition E) Genetic disease with autosomal recessive inheritance
Ans: B, D, E Any type of spinal muscular atrophy is a genetic motor neuron disease due to autosomal recessive inheritance. Type 2 SMA usually occurs between 6 and 18 months of age, with weakness that is most severe in the shoulders, hips, thighs, and upper back. It is slower in progression than type 1. Survival into adulthood is common if respiratory status is maintained appropriately. Type 1 SMA occurs before birth to 6 months of age and the child usually has difficulty swallowing, sucking, and breathing.
When assessing a child for slipped capital femoral epiphysis, what would the nurse identify as possible risk factors? Select all answers that apply. A) Age younger than 8 years B) African American ethnicity C) History of cystic fibrosis D) Excessive activity E) Obesity
Ans: B, E Risk factors associated with slipped capital femoral epiphysis include age between 9 and 16 years, African American race, sedentary lifestyle, and being overweight or obese. A history of cystic fibrosis may contribute to rickets.
An 8-year-old boy with a fractured forearm is to have a fiberglass cast applied. What information would the nurse include when teaching the child about the cast? A) The cast will take a day or two to dry completely. B) The edges will be covered with a soft material to prevent irritation. C) The child initially may experience a very warm feeling inside the cast. D) The child will need to keep his arm down at his side for 48 hours.
Ans: C A fiberglass cast usually takes only a few minutes to dry and will cause a very warm feeling inside the cast. Therefore, the nurse needs to warn the child that this will occur. Fiberglass casts usually have a soft fabric edge so they usually do not cause skin rubbing at the edges and don't require petaling. The child should be instructed to elevate his arm above the level of the heart for the first 48 hours.
An 18-month-old was brought to the emergency department by her mother, who states, "I think she broke her arm." The child is sent for a radiograph to confirm the fracture. Additional assessment of the child leads the nurse to suspect possible child abuse. Which type of fracture would the radiograph most likely reveal? A) Plastic deformity B) Buckle fracture C) Spiral fracture D) Greenstick fracture
Ans: C A spiral fracture is very rare in children. A spiral femoral or humeral fracture, particularly in a child younger than 2 years of age, should always be thoroughly investigated to rule out the possibility of child abuse. Plastic, buckle, and greenstick fractures are common in children and do not usually suggest child abuse.
The nurse is caring for a 13-year-old boy in traction prior to surgery for slipped capital femoral epiphysis. He has been in an acute care setting for 2 weeks and will require an additional 10 days in the hospital. He is complaining that he feels isolated and is resisting further treatment. Which response by the nurse would be most appropriate? A) "I know it is boring, but you must remain immobile for 2 more weeks." B) "If there are no complications, you only have 2 more weeks here." C) "Let's come up with things to do like books, movies, games, and friends to visit." D) "If you resist your treatment, your condition will only get worse."
Ans: C After 2 weeks in traction, a teenager can become easily bored and isolated from usual peer interaction. The most helpful intervention would be to engage the help of the child to develop a list of books, games, movies, and other activities that he would enjoy. The nurse should also encourage visitation and phone calls from friends. Telling the adolescent that he needs to remain immobile or telling him that he has only 2 more weeks do not address the adolescent's issue. Telling the adolescent that his condition will worsen if he resists is threatening and inappropriate.
The nurse is developing a teaching plan for a child who is to have his cast removed. What instruction would the nurse most likely include? A) Applying petroleum jelly to the dry skin B) Rubbing the skin vigorously to remove the dead skin C) Soaking the area in warm water every day D) Washing the skin with dilute peroxide and water
Ans: C After a cast is removed, the child and family should be instructed to soak the area in warm water every day to help soften and remove the dry flaky skin. Moisturizing lotion, not petroleum jelly, should be applied to the skin. Vigorous rubbing would traumatize the skin and should be avoided. Warm soapy water, not dilute peroxide and water, should be used to wash the area.
The nurse is caring for an active 14-year-old boy who has recently been diagnosed with scoliosis. He is dismayed that a "jock" like himself could have this condition, and is afraid it will impact his spot on the water polo team. Which response by the nurse would best address the boy's concerns? A) "If you wear your brace properly, you may not need surgery." B) "The good news is that you have very minimal curvature of your spine." C) "Let's talk to another boy with scoliosis, who is winning trophies for his swim team." D) "Let's talk to the doctor about your treatment options."
Ans: C Because this boy is concerned about limiting his participation in water polo and perceives scoliosis as a disease that does not affect "jocks," putting the child in contact with someone with the same problem would be helpful. Telling the adolescent about not needing surgery if he wears his brace or that his curvature is minimal may or may not be true in his case and thus would be false reassurance. Although these suggestions and also the suggestion about talking to the doctor about treatment options could be helpful by engaging his input in the treatment, these do not address his specific concerns about his body image.
A child with spastic cerebral palsy is to receive botulin toxin. The nurse prepares the child for administration of this drug by which route? A) Oral B) Subcutaneous injection C) Intramuscular injection D) Intravenous infusion
Ans: C Botulin toxin is administered by injection into the muscle. It may cause dry mouth. It is not administered orally, by subcutaneous injection, or by intravenous infusion.
A nurse is preparing a program for a group of parents about injury prevention. What would the nurse include as an important contributing factor for cervical spine injury in a child? A) Exposure to teratogens while in utero B) Immaturity of the central nervous system C) Increased mobility of the spine D) Incomplete myelinization
Ans: C Compared to the adult, a child's spine is very mobile, especially in the cervical spine region, resulting in a higher risk for cervical spine injury. Exposure to teratogens in utero may lead to altered growth and development of the brain or spinal cord. Immaturity of the central nervous system places the infant at risk for insults that may result in delayed motor skill attainment or cerebral palsy. Incomplete myelinization reflects the lack of motor control.
The school nurse is presenting a class to a group of students about common overuse disorders. Which disorder would the school nurse include? A) Dislocated radial head B) Transient synovitis of the hip C) Osgood-Schlatter disease D) Scoliosis
Ans: C Overuse syndromes refer to a group of disorders that result from repeated force applied to normal tissue. An example is Osgood-Schlatter disease. Dislocated radial head, transient synovitis of the hip, and scoliosis are not considered overuse syndromes.
A 6-year-old boy with cerebral palsy has been admitted to the hospital for some tests. His condition is stable. The boy's mother remains with her son, but she is obviously exhausted and stressed. Which response by the nurse would be most appropriate? A) "Would you like me to bring you a blanket and pillow?" B) "You are doing such a wonderful job with your son." C) "He's in good hands; consider going home to get some sleep." D) "Are you planning to spend the night or to go home?"
Ans: C Providing daily, intense care can be quite demanding and tiring. When a child with cerebral palsy is admitted to the hospital, this may serve as a time of respite for family and primary caregivers. The nurse should remind the mother that her son is in good hands and urge her to go home. Asking her whether she is planning to stay might make the mother feel obligated to stay. Asking if she wants a blanket or pillow does not encourage the mother to leave the hospital. Telling the mother she is doing a good job is nice, but does not encourage her to take a break.
The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex. Which response from his mother indicates a need for further teaching? A) "He needs to get a medical alert identification." B) "I will need to discuss this with his caregivers." C) "A product's label indicates whether it is latex-free." D) "He must avoid all contact with latex."
Ans: C The Food and Drug Administration (FDA) requires that all medical supplies be labeled if they contain latex, but this is not the case with consumer products. The mother must be familiar with products that contain latex. The Spina Bifida Association of America maintains an updated list of latex-containing products. Getting a medical alert identification, talking with his caregivers, and avoiding all contact with latex are correct.
The nurse is caring for a female infant with torticollis and is providing instructions to the parents about how to help their daughter. Which statement by the parents indicates a need for further teaching? A) "We must encourage our daughter to turn her head both ways." B) "Flatness on one side of the head is a common side effect." C) "We must apply firm pressure and stretching every other day." D) "We will do a daily stretching regimen with multiple sessions."
Ans: C The nurse needs to remind the parents that the stretching exercises should be done several times a day. The stretching is applied with gentle, not firm, pressure and should be done every day for multiple sessions. The statements about turning the head both ways, flatness on one side as common, and daily stretching with multiple sessions are correct.
A child with cerebral palsy has undergone surgery for placement of a baclofen pump. Which instruction would the nurse include when teaching the parents about caring for their child? A) Waiting 48 hours before allowing the child to take a tub bath B) Not allowing the child to sleep on his side for about 4 weeks C) Calling the physician if the child's temperature is over 100.5°F D) Discouraging the child from stretching or bending forward for 4 weeks
Ans: D After insertion of a baclofen pump, the parents should discourage any twisting at the waist, reaching high overhead, stretching, or bending forward or backward for 4 weeks. The child would avoid tub baths for about 2 weeks and avoid sleeping on his stomach for 4 weeks. The parents should notify the physician or nurse practitioner if the child's temperature is greater than 101.5°F.
A child has undergone surgery using steel bar placement to correct pectus excavatum. What position would the nurse instruct the parents to avoid? A) Semi-Fowler B) Supine C) High Fowler D) Side-lying
Ans: D After surgery to correct pectus excavatum, the nurse would instruct the parents to avoid positioning the child on either side because this could disrupt the bar's position. Semi- or high Fowler's position and the supine position would be appropriate.
After teaching a class of nursing students about muscular dystrophy, the instructor determines that the teaching was successful when the students identify which type of muscular dystrophy as demonstrating an X-linked recessive pattern of inheritance? A) Limb-girdle B) Myotonic C) Distal D) Duchenne
Ans: D Duchenne muscular dystrophy follows an X-linked recessive inheritance pattern. Limb-girdle muscular dystrophy is believed to be autosomal or X-linked inherited. Myotonic and distal muscular dystrophy follow an autosomal dominant inheritance pattern.
A group of nursing students are reviewing information about the type of skin and skeletal traction. The students demonstrate understanding of this information when they identify which of these as a type of skeletal traction? A) Russell traction B) Bryant traction C) Buck traction D) Side arm 90-90 traction
Ans: D Side arm 90-90 traction is a type of skeletal traction with force applied through a pin in the distal femur. Russell traction, Bryant traction, and Buck traction are types of skin traction.
The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury? A) Recommend the bed's side rails be raised throughout the day and night. B) Suggest a caregiver be present continuously to prevent falls from bed. C) Encourage a loose restraint to be used when he is in bed. D) Recommend raising the bed's side rails when a caregiver is not present.
Ans: D The nurse should recommend that side rails on the bed be elevated when a caregiver is not present. The use of restraints should be avoided if at all possible. Suggesting that a caregiver be present at all times places undue stress on the family. Close observation is more appropriate. Recommending side rails be elevated at all times may be upsetting to the child and make him feel like a "baby."
The nurse is developing a teaching plan for the parents of a child with a myelomeningocele who will require clean intermittent catheterization. What information would the nurse include? A) Applying petroleum jelly to lubricate the catheter B) Cleaning the reusable catheter with peroxide after each use C) Storing the reusable cleaned catheter in a brown paper bag D) Soaking the catheter in a vinegar and water solution to sterilize
Ans: D When teaching parents how to perform clean intermittent catheterization, the nurse would instruct the parents to apply a water-based lubricant to the catheter, clean the reusable catheter with soap and water after each use, store the reusable clean catheter in a zip-top bag or other clean storage container, and soak the catheter in a 1:1 vinegar and water solution for about 30 minutes weekly, rinsing well before the next use or placing the catheter in boiling water for 10 minutes.
An 8-year-old girl was diagnosed with a closed fracture of the radius at approximately 2 p.m. The fracture was reduced in the emergency department and her arm placed in a cast. At 11 p.m. her mother brings her back to the emergency department due to unrelenting pain that has not been relieved by the prescribed narcotics. Which action would be the priority? A) Notifying the doctor immediately B) Applying ice C) Elevating the arm D) Giving additional pain medication as ordered
Ans:A The nurse should notify the doctor immediately because the girl's symptoms are the classic sign of compartment syndrome. Immediate treatment is required to prevent excessive swelling and to detect neurovascular compromise as quickly as possible. The ice should be removed and the arm brought below the level of the heart to facilitate whatever circulation is present. Giving additional pain medication will not help in this situation.
The nurse is caring for a 10-year-old in traction. While performing a skin assessment, the nurse notices that the skin over the calcaneus appears slightly red and irritated. Which action would the nurse take first? A) Reposition the child's foot on a pressure-reducing device. B) Apply lotion to his foot to maintain skin integrity. C) Make sure the skin is clean and dry. D) Gently massage his foot to promote circulation.
Ans:A The nurse's first action is to remove continuous pressure from this area. The other actions can help decrease the potential for skin breakdown, but the pressure must be relieved first.
The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting movements. What word would the nurse use when documenting these observations? A) Spastic B) Athetoid C) Ataxic D) Mixed
Ans:B Athetoid cerebral palsy is characterized by abnormal, involuntary movement. It affects all four extremities with possible involvement of the face, neck, and tongue. The movements increase in periods of stress. Dysarthria and drooling may be present as well. Spastic cerebral palsy is characterized by poor control of posture, balance, and movement; exaggeration of deep tendon reflexes; and hypertonicity of affected extremities. Ataxic is characterized by poor coordination, unsteady gait, and wide-based gait.
The nurse is assessing an 11-year-old girl with scoliosis. What would the nurse expect to find? Select all answers that apply. A) Complaints of severe back pain B) Asymmetric shoulder elevation C) Even curve at the waistline D) Pronounced one-sided hump on bending over E) Diminished motor function F) Hyperactive reflexes
Ans:B, D Assessment findings associated with scoliosis include asymmetric shoulder elevation, uneven curve at the waistline, rib hump on one side, and a pronounced hump on one side when bending over. Typically, only mild back discomfort is found and balance, motor strength, sensation, and reflexes are normal.
The nurse is caring for a 2-year-old girl in a bilateral brace with tibia vara. Her parents are upset by their toddler's limited mobility. Which response by the nurse would be most appropriate? A) "If you don't follow the therapy, your daughter could develop severe bowing of her legs." B) "It's important to use the brace or your daughter may need surgery." C) "You are doing a great job. Let's put our heads together on how to keep her busy." D) "You'll need to accept this since treatment may be required for several years."
Ans:C The nurse should support the parents by encouraging and praising their compliance with bracing. It is also important to work with the parents to help develop age-appropriate diversions to promote normal growth and development. Telling the parents that they must be compliant or their daughter could develop severe bowing does not teach, does not offer solutions, and does not address the parents' concerns. Telling the parents that they must simply accept this and that the treatment could take years is likely to upset them and does not teach. It also does not address their concerns.
