Chapter 48: Musculoskeletal or Articular Dysfunction

What effect does immobilization have on the cardiovascular system? A. Venous stasis B. Increased vasopressor mechanism C. Normal distribution of blood volume D. Increased efficiency of orthostatic neurovascular reflexes

ANS: A Because of decreased muscle contraction, the physiologic effects of immobilization include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased cerebral blood flow, and tachycardia. An altered distribution of blood volume is found, with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency of orthostatic neurovascular reflexes, with an inability to adapt readily to the upright position and pooling of blood in the extremities in the upright position.

Which condition can result from the bone demineralization associated with immobility? A. Osteoporosis B. Urinary retention C. Pooling of blood D. Susceptibility to infection

ANS: A Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of immobilization on the urinary tract. Pooling of blood is a result of the cardiovascular effects of immobilization. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems.

The nurse is preparing an adolescent with scoliosis for a Luque-rod segmental spinal instrumentation procedure. Which consideration should the nurse include? A. Nasogastric intubation and urinary catheter may be required B. Ambulation will not be allowed for up to 3 months C. Surgery eliminates the need for casting and bracing D. Discomfort can be controlled with nonpharmacologic methods

ANS: A Luque-rod segmental spinal instrumentation is a surgical procedure. Nasogastric intubation and urinary catheterization may be required. Ambulation is allowed as soon as possible. Depending on the instrumentation used, most patients walk by the second or third postoperative day. Casting and bracing are required postoperatively. The child usually has considerable pain for the first few days after surgery. Intravenous opioids should be administered on a regular basis.

Discharge planning for the child with juvenile arthritis includes the need for: A. Routine opthalmologic examinations to assess for visual problems B. A low-calorie diet to decrease or control weight in the less mobile child C. Avoiding the use of aspirin to decrease gastric irritation D. Immobilization the painful joints, which are the result of the inflammatory process

ANS: A The systemic effects of juvenile arthritis can result in visual problems, making routine eye examinations important. Children with juvenile arthritis do not have problems with increased weight and often are anorexic and in need of high-calorie diets. Children with arthritis are often treated with aspirin. Children with arthritis are able to immobilize their own joints. Range-of-motion exercises are important for maintaining joint flexibility and preventing restricted movement in the affected joints.

An advantage to using a fiberglass cast instead of a plaster cast is that a fiberglass cast: A. Is less expensive B. Dries rapidly C. Molds closely to body parts D. Has a smooth exterior

ANS: B A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry. Synthetic casts are more expensive. Plaster casts mold closer to body parts. Synthetic casts have a rough exterior, which may scratch surfaces.

The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complications should the nurse monitor? A. Hypocalcemia B. Decreased metabolic rate C. Positive nitrogen balance D. Increased production of stress hormones

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

When does idiopathic scoliosis become most noticeable? A. Newborn period B. When child starts to walk C. During preadolescent growth spurts D. Adolescence

ANS: C Idiopathic scoliosis is most noticeable during the preadolescent growth spurt and is seldom apparent before age 10 years.

The primary method of treating osteomyelitis is: 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. The treatment of choice is antibiotics. Joint replacement, bracing and casting, and long-term corticosteroids are not indicated for infectious processes.

An important nursing consideration when caring for a child with juvenile idiopathic arthritis (JIA) is to: A. Apply ice packs to relieve stiffness and pain B. Administer acetaminophen to reduce inflammation C. Teach child and family the 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.

The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome (Select all that apply)? A. Palpable distal pulse B. Capillary refill to extremity of <3 seconds C. Severe pain not relieved by analgesics D. Tingling of extremity

ANS: C, D, E Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity of <3 seconds are expected findings.

What would cause a nurse to suspect that an infection has developed under a cast? A. Complaint of paresthesia B. Cold toes C. Increased respirations D. "Hot spots" felt on cast surface

ANS: D If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so a window can be made in the cast to observe the site. The "five Ps" of ischemia from a vascular injury include pain, pallor, pulselessness, paresthesia, and paralysis. Paresthesia is an indication of vascular injury, not infection. Cold toes may be indicative of too tight a cast and need further evaluation. Increased respirations may indicate a respiratory infection or pulmonary emboli. This should be reported, and the child should be evaluated.

Which medication is usually tried first when a child is diagnosed with juvenile idiopathic arthritis (JIA)? A. Aspirin B. Cortiosteroids C. Cytotoxic drugs such as methotrexate D. Nonsteroidal antiinflammatory drugs (NSAIDs)

ANS: D NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, and tolmetin are approved for use in children. Aspirin, once the drug of choice, has been replaced by the NSAIDs because they have fewer side effects and easier administration schedules. Corticosteroids are used for life-threatening complications, incapacitating arthritis, and uveitis. Methotrexate is a second-line therapy for JIA.

The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which instructions should be included in the teaching? A. Swelling of the fingers is to be expected for the next 48 hours B. Immobilize the should to decrease pain in the arm C. Allow the affected limb to hang down for 1 hour each day D. Elevate casted arm when resting and when sitting up

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