NCLEX Pediatrics Musculoskeletal
The nurse is caring for a child who fractured the ulna bone and had a cast applied 24 hours ago. The child tells the nurse that the arm feels like it is falling asleep. Which nursing action is appropriate? 1. Encourage the child to keep the arm elevated. 2. Report the findings to the health care provider. 3. Document the findings and reassess the arm in 4 hours. 4. Tell the child that this is normal while the cast is drying.
2 A child's complaint of pins and needles or of the extremity falling asleep needs to be reported to the health care provider. These complaints indicate the possibility of circulatory impairment and paresthesia. Paresthesia is a serious concern because paralysis can result if the problem is not corrected. The five Ps of vascular impairment are pain, pallor, pulselessness, paresthesia, and paralysis. Prompt intervention is critical if neurovascular impairment is to be prevented.
A child must wear a brace for correction of scoliosis. The nurse creates a plan of care knowing the child is at risk for which problem? 1. Inability to ambulate 2. Breaks in skin integrity 3. Decreased oxygenation 4. Delayed growth and development
2 Braces for treatment of scoliosis usually are worn 16 to 23 hours a day. The skin should be kept clean and dry and inspected for signs of redness or breakdown. Therefore, breaks in skin integrity are the client problem that should be included in this child's plan of care. The brace assists with posture, so mobility is not an issue. The brace does not compromise the respiratory status, so oxygenation is not decreased. The child will not have a risk for delayed growth and development because normal developmental milestones can be met while wearing a brace.
A child has just returned from surgery and has a hip spica cast. What is the nurse's priority action for this client? 1. Elevate the head of the bed. 2. Assess the circulatory status. 3. Abduct the hips using pillows. 4. Turn the child onto the right side.
2 During the first few hours after a cast is applied, the chief concern is swelling, which may cause the cast to act as a tourniquet and obstruct circulation. Therefore, circulatory assessment is a high priority. Elevating the head of the bed of a child in a hip spica cast would cause discomfort. Using pillows to abduct the hips is not necessary because a hip spica cast immobilizes the hip and knee. Turning the child from one side to the other at least every 2 hours is important because it allows the body cast to dry evenly and prevents complications related to immobility; however, it is not a higher priority than checking circulation.
Russell's traction is prescribed for a child with a lower leg fracture. The mother of the child asks the nurse about the purpose of the traction. The nurse explains to the mother that which is the primary action of this type of traction? 1. Relieves the child's pain 2. Reduces or realigns a fracture site 3. Provides a form of restraint for the child 4. Keeps the child from moving around in bed
2 Russell's traction uses skin traction to realign a fracture in the lower extremity and to immobilize the hip and knee in a flexed position. It is important to keep the hip flexion at the prescribed angle to prevent fracture malalignment. The traction may also relieve pain by reducing muscle spasms, but this is not the primary reason for this traction. The child can still move in bed with some restriction as a result of the traction. Traction is never used to restrain a child.
An alert child, who is crying loudly, is brought to the hospital emergency department for a simple fracture to the lower right arm that occurred after a fall off a bicycle. What is the nurse's priority assessment? 1. Mobility 2. Skin integrity 3. Neurovascular 4. Level of consciousness
3 A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. The priority assessment is the neurovascular status in the affected arm. The affected arm should be immobilized. Skin integrity is a higher priority in a compound fracture since there is an open wound. The level of consciousness is already established, as the child is alert and crying.
Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? 1. "Treatment needs to be started as soon as possible." 2. "I realize my infant will require follow-up care until fully grown." 3. "I need to bring my infant back to the clinic in 1 month for a new cast." 4. "I need to come to the clinic every week with my infant for the casting."
3 Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.
An infant is brought to the child care clinic for a follow-up visit. The nurse notes that the infant is wearing this apparatus. The nurse documents that the infant is wearing which device? Refer to Figure. (Figure shows harness that is secured on chest with straps going to lower legs and feet, baby is shown with hips and knees bent) 1. A back brace for the treatment of scoliosis 2. Bilateral foot braces for the treatment of clubfoot 3. A shoulder brace for the treatment of shoulder dystocia 4. A Pavlik harness for the treatment of congenital hip dislocation
4 A Pavlik harness is a device that is used to treat congenital hip dislocation. It keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. The Pavlik harness is worn continuously for 3 to 6 months. It promotes the development of muscle and cartilage, resulting in a stable hip.
A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? 1. Administer an analgesic. 2. Release the skin traction. 3. Apply ice to the extremity. 4. Notify the health care provider (HCP).
4 An absent pulse to an extremity of the affected limb after a bone fracture could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation, and the HCP should be notified immediately. Administering analgesics would not improve circulation. The skin traction should not be released without an HCP's prescription. Applying ice to an extremity with absent perfusion is incorrect. Ice may be prescribed when perfusion is adequate to decrease swelling.
The nurse is assisting a health care provider (HCP) during the examination of an infant with developmental hip dysplasia. The HCP performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which finding is noted? 1. A shrill cry from the infant 2. Asymmetry of the affected hip 3. Reduced range of motion in the right and left hip 4. A palpable click during abduction of the affected hip
4 In the Ortolani maneuver, the examiner abducts both hips. A positive finding is a palpable click on the affected side during abduction. Crying is expected. Asymmetry and reduced range of motion of the affected hip are not positive signs of this maneuver.
A 9-year-old child fractures the left tibia along an epiphyseal line while using a skateboard. What is the nurse's priority concern during future growth? 1. Infection 2. Paralysis 3. Pressure ulcer 4. Uneven leg growth
4 The epiphyseal line is the area that is responsible for longitudinal bone growth. A fracture affecting this area places the child at risk for uneven future growth if proper healing does not occur. The epiphyses are located at the proximal and distal ends of a bone and are the insertion sites for muscles. The diaphysis is the shaft or main longitudinal portion of a long bone. The metaphysis is an area of flaring of bone, located between the epiphysis and the diaphysis. Paralysis, pressure ulcer, and infection are not priority concerns for future growth. Paralysis and neurovascular status are priority concerns during the immediate period postinjury, but not during future growth.
The nurse has reinforced teaching for a school-age child who was given a brace to wear for the treatment of scoliosis. The nurse determines that the child needs further teaching if the child makes which statement? 1. "This brace will correct my curve." 2. "I will wear my brace under my clothes." 3. "I may not need surgery if I wear my brace." 4. "I will do back exercises at least five times a week."
1 Bracing can halt the progression of most curvatures, but it is not curative for scoliosis. The statements in the remaining options represent correct understanding on the part of the child.
The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement by one of the parents indicates an understanding of the use of the harness? 1. "I can remove the harness to bathe my infant." 2. "I need to remove the harness to feed my infant." 3. "I need to remove the harness to change the diaper." 4. "My infant needs to remain in the harness at all times."
1 The harness should be worn 23 hours a day and can be removed only to check the skin and for bathing. The hips and buttocks should be supported carefully when the infant is out of the harness. The harness does not need to be removed for diaper changes or feedings.
The nurse is reinforcing instructions to the mother of a child who has a plaster cast applied to the left arm. Which statement by the mother indicates a need for further teaching? 1. "I will have to use a heat lamp to help the cast dry." 2. "I need to cover the cast with plastic during baths or showers." 3. "I should call the health care provider if the cast feels warm or hot or has an unusual smell or odor." 4. "I will keep small toys and sharp objects away from the cast and be sure that my child does not put anything inside the cast."
1 The mother needs to be instructed not to use a heat lamp to help the cast dry because of the risk associated with a burn injury from the heat lamp. The statements in the remaining options indicate understanding of instructions.
The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse should monitor for which sign of a serious complication associated with this type of traction? 1. Lack of appetite 2. Elevated temperature 3. Decrease in the urinary output 4. Increase in the blood pressure
2 The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis may occur with any open fracture. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from the fracture site, and an elevated temperature. The remaining options are not specifically associated with osteomyelitis.
The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which assessment finding should the nurse expect to note documented in the infant's record regarding this condition? 1. Full range of motion in the affected hip 2. An apparent short femur on the unaffected side 3. Asymmetrical adduction of the affected hip when placed supine, with the knees and hips flexed 4. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table
4 Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table is noted in hip dysplasia. Asymmetrical abduction of the affected hip when an infant is placed supine with the knees and hips flexed would also be an assessment finding in hip dysplasia in infants beyond the newborn period. An apparent short femur on the affected side is noted, as well as limited range of motion.
A neighborhood nurse is attending a soccer game at a local middle school. One of the students falls off the bleachers and sustains an injury to the left arm. The nurse quickly attends to the child and suspects that the child's arm may be broken. Which nursing action would be the priority before transferring the child to the hospital emergency department? 1. Immobilize the arm. 2. Ask for the name of the child's pediatrician or family health care provider so that he or she can be contacted. 3. Have someone call the radiology department of the local hospital to let staff know that the child will be arriving. 4. Tell the child that the arm probably is fractured but not to worry because permanent damage to the arm will not occur.
1 When a fracture is suspected, it is imperative that the area be splinted and immobilized before the injured person is transferred or moved. The nurse should remain with the child and provide realistic reassurance. Although it may be necessary to contact the child's pediatrician, this is not the priority. It is not necessary to notify the radiology department because this would be the responsibility of the emergency department staff when the child arrives if it is determined that the child needs a radiograph. The child should not be told that permanent damage will not occur.
A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? 1. "The cast may feel warm as the cast dries." 2. "I can use lotion or powder around the cast edges to relieve itching." 3. "A small amount of white shoe polish can touch up a soiled white cast." 4. "If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."
2 Teaching about cast care is essential to prevent complications from the cast. The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate statements.
A child with developmental dysplasia of the hip is placed in a Pavlik harness. The nurse should demonstrate to the parents how to place the child in this harness by placing the child's legs in which position? 1. Prone 2. Abduction 3. Adduction 4. Extension
2 The Pavlik harness consists of chest and shoulder straps and foot stirrups. The device, which is used to correct hip dislocations in infants with developmental dysplasia of the hip, consists of a set of straps that hold the hips in flexion and abduction. Therefore, the remaining options are incorrect positions.
The clinic nurse is assessing a child suspected of having juvenile rheumatoid arthritis (JRA). Which assessment findings should the nurse expect to note in a child who has been diagnosed with JRA? Select all that apply. 1. Hematuria 2. Morning stiffness 3. Painful, stiff, and swollen joints 4. Limited range of motion of the joints 5. Stiffness that develops later in the day 6. History of late-afternoon temperature
2.3.4.6. Clinical manifestations associated with JRA include intermittent joint pain that lasts longer than 6 weeks and painful, stiff, and swollen joints that are warm to the touch, with limited range of motion. The child will complain of morning stiffness and may protect the affected joint or refuse to walk. Systemic symptoms include malaise, fatigue, lethargy, anorexia, weight loss, and growth problems. A history of a late-afternoon fever with temperature spiking up to 105°F (40.6°C) will also be part of the clinical manifestations. Hematuria is not specifically associated with JRA.
The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. 1. Use the fingertips to lift the cast while it is drying. 2. Keep small toys and sharp objects away from the cast. 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. 5. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6. Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity.
2.5.6 While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified.
A child who sustained a fractured ankle has a short leg cast applied, and the nurse provides home care instructions to the mother. The mother returns to the emergency department 16 hours later because the child is complaining of severe pain. The nurse notes that the child's toes are cool, pale, and puffy and that the child is agitated and crying loudly. The mother states, "I gave her the pain medication you sent with us just like you told us, and I have kept her foot up on two pillows since we left, except when she gets up to go to the bathroom. I don't understand why she hurts so much. Do something!" What is the most likely clinical situation that occurred? 1. Compartment syndrome 2. Inadequate pain medication 3. Skin breakdown around the cast edges 4. Noncompliance with home care instructions
1 Compartment syndrome occurs as a result of pressure buildup within a tissue compartment bound by anatomical structures such as fascia. With a fracture, this pressure increase may occur as a result of the intense inflammatory response or severe bleeding caused by the bone injury, even when diligent nursing care has been provided. Pain disproportionate to the injury despite analgesic administration is the classic sign of compartment syndrome. The nurse should constantly assess for this complication and should instruct the caregiver about the manifestations associated with this complication.
An adolescent is seen in the emergency department for a suspected sprain of the ankle. X-rays have been obtained, and a fracture has been ruled out. Which instruction should the nurse provide to the adolescent regarding home care for treatment of the sprain? 1. Elevate the extremity, and maintain strict bed rest for a period of 7 days. 2. Immobilize the extremity, and maintain the extremity in a dependent position. 3. Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice. 4. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours.
4 The injured area should be wrapped immediately to support the joint and control the swelling. Ice is applied to reduce the swelling and should be applied for not longer than 30 minutes every 4 to 6 hours for the first 24 to 48 hours. The joint should be immobilized and elevated, but strict bed rest for a period of 7 days is not required. A dependent position will cause swelling in the affected area.
A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? 1. Ensure that all ropes are outside the pulleys. 2. Ensure that the weights are resting lightly on the floor. 3. Restrict diversional and play activities until the child is out of traction. 4. Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied.
4 When a child is in traction, the nurse would check the HCP's prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child.
