PEDs Chapt 23 Nursing Care of the Child with a Musculoskeletal Disorder

The nurse is teaching a group of peers regarding different types of fractures. Which of the following best describes an open fracture? a) A fracture in which there is a single break in the bone without penetration of the skin. b) A fracture in which the broken bone penetrates the skin. c) A fracture in which the fragments of the bone remain partially joined. d) A fracture in which the fragments of the bone are separated.

A fracture in which the broken bone penetrates the skin. Correct Explanation: The open fracture, also called a compound fracture, penetrates the skin. When the fragments of the bone are separated, the fracture is said to be complete.

A group of students are reviewing information about the skeletal development in children. The students demonstrate understanding of the information when they identify that ossification is complete by what age? a) Preschool age b) School age c) Adolescence d) Toddlerhood

Adolescence Correct Explanation: Ossification and conversion of cartilage to bone continue throughout childhood and are complete at adolescence.

A nurse is performing a physical examination of a child with a suspected fracture. Which assessment technique would the nurse be least likely to use? a) Palpation b) Observation c) Auscultation d) Inspection

Auscultation Explanation: The physical examination specific to fractures includes inspection, observation, and palpation. Auscultation is not used.

In understanding the development of the musculoskeletal system, the nurse recognizes that which of the following is implanted in a gel-like substance during fetal life? a) Ligaments b) Cartilage c) Joints d) Tendons

Cartilage Correct Explanation: During fetal life, tissue called cartilage, which is a type of connective tissue consisting of cells implanted in a gel-like substance, gradually calcifies and becomes bone.

The nurse is working with a group of caregivers of school-age children discussing fractures. The nurse explains that if the fragments of fractured bone are separated, the fracture is said to be which of the following? a) Incomplete b) Spiral c) Greenstick d) Complete

Complete Correct Explanation: If the fragments of fractured bone are separated, the fracture is said to be complete. If fragments remain partially joined, the fracture is termed incomplete. Green stick fractures are one kind of incomplete fracture, caused by incomplete ossification, common in children. Spiral fractures twist around the bone.

Fracture of the femur typically occurs when a small child is lifted by one hand, as happens when a parent pulls on one arm to lift the child over a curb or up a step. a) False b) True

False Correct Explanation: If a small child is lifted by one hand, as happens when a parent pulls on one arm to lift the child over a curb or up a step, the head of the radius may escape the ligament surrounding it and become dislocated (nursemaid's elbow). Fracture of the femur is rare and is typically caused by an automobile accident, a fall from a considerable height, or child maltreatment.

A type of traction sometimes used in the treatment of the child with scoliosis is called which of the following? a) Dunlop's traction b) Russell traction c) Halo traction d) Bryant's traction

Halo traction Correct Explanation: When a child has a severe spinal curvature or cervical instability, a form of traction known as halo traction may be used to reduce spinal curves and straighten the spine. Halo traction is achieved by using stainless steel pins inserted into the skull while counter-traction is applied by using pins inserted into the femur. Weights are increased gradually to promote correction.

The nurse is caring for a child with rickets. Which diagnostic test result would the nurse expect to find in the child's medical record? a) Low serum calcium levels b) X-ray confirmation of adequate bone shape c) Low alkaline phosphate levels d) High serum phosphate levels

Low serum calcium levels Correct Explanation: With rickets, serum calcium and phosphate levels are low and alkaline phosphate levels are elevated. Radiographs show changes in the shape and structure of the bone.

You meet a child with a slipped femoral epiphysis. In what type of child does this usually occur? a) Preadolescent girls b) Obese adolescent boys c) Tall, thin girls d) Active school-aged children

Obese adolescent boys Correct Explanation: A slipped epiphyseal femur injury most typically occurs in overweight preadolescent or adolescent boys. Stress increases the risk. A thin child would not have an increased risk, and the age range is past preadolescent and school age.

A nursing instructor is preparing a class presentation about tibia vara. Which of the following would the instructor include as a risk factor? a) Obesity b) Lack of sunlight exposure c) Late walking d) Hormonal alterations during puberty

Obesity Correct Explanation: Obesity is a risk factor for the development of tibia vara. Tibia vara occurs most frequently in children who are early walkers. Limited or lack of exposure to sunlight may lead to rickets. Hormonal alterations during puberty may play a role in the development of slipped capital femoral epiphysis.

The nurse is caring for a child admitted with Legg-Calvé-Perthes disease. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis? a) Pain in the groin and a limp b) Difficulty standing and walking c) Poor posture and malformed vertebrae d) Inflammation of the joints

Pain in the groin and a limp Correct Explanation: Symptoms first noticed in Legg-Calvé-Perthes disease are pain in the hip or groin and a limp accompanied by muscle spasms and limitation of motion.

A nurse is assessing a newborn and observes webbing of the fingers and toes. The nurse documents this finding as which of the following? a) Polydactyly b) Pectus carinatum c) Metatarsus adductus d) Syndactyly

Syndactyly Correct Explanation: Syndactyly refers to webbing of the fingers and toes. Polydactyly refers to the presence of extra digits on the hand or foot. Metatarsus adductus is a medial deviation of the forefoot. Pectus carinatum is a protuberance of the chest wall.

A neonatal nurse examines an infant and notes decreased hip motion that causes pain upon movement. This nurse suspects Legg-Calvé-Perthes disease, a common pediatric hip disorder that causes pain and decreased hip motion, possibly leading to a femoral head deformity. a) False b) True

True Correct Explanation: Legg-Calvé-Perthes disease is a common pediatric hip disorder that causes pain and decreased hip motion, possibly leading to a femoral head deformity. It has an incidence of 1 per 1,200 live births, with some hereditary factors influencing incidence.

An infant is placed in Bryant's traction. For Bryant's traction to be effective, the infant must be positioned on the a) back with hips flat on the bed. b) stomach with both legs extended. c) back with the injured hip flexed and the uninjured one extended. d) back with hips up off the bed.

back with hips up off the bed. Explanation: For there to be traction, the infant's hips must be off the bed. On the stomach or hips on the bed are not the correct positions for this patient.

In understanding the function of the musculoskeletal system, the nurse recognizes that which of the following allows for movement of the body parts? a) Joints b) Tendons c) Ligaments d) Cartilage

Joints Correct Explanation: Bones are attached to each other by connecting links called joints, which allow for movement of the body parts. Skeletal muscles attach to the bones, with a moveable joint between them. Tendons and ligaments hold the muscles and bones together. Cartilage is a type of connective tissue consisting of cells implanted in a gel-like substance, which gradually calcifies and becomes bone.

A nurse is reviewing the medical record of a child who has sustained a fracture. Documentation reveals a bowing deformity. The nurse interprets this fracture as which of the following? a) Significant bending without actual breaking b) Incomplete fracture c) Bone buckling due to compression d) Bone that breaks into two pieces

Significant bending without actual breaking Correct Explanation: A plastic or bowing deformity is one in which there is significant bending of the bone without breaking. A buckle fracture is one in which the bone buckles rather than breaks. This is usually due to a compression injury. An incomplete fracture of the bone is a greenstick fracture. A complete fracture is one in which the bone breaks into two pieces

The nurse is discussing types of treatment used when working with children who have orthopedic disorders. Which of the following forms of treatment covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open? a) External fixation device b) Stockinette c) Internal fixation device d) Spica cast

Spica cast Correct Explanation: The hip spica cast covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open. The cast maintains the legs in a frog-like position. Usually, there is a bar placed between the legs to help support the cast.

The nurse is caring for a child diagnosed with Legg-Calvé-Perthes disease. Of the following nursing interventions, which would be most important for the nurse to include in working with this child and the child's caregivers? a) The nurse should support the caregivers in restricting activity during the treatment. b) The nurse should help the caregivers to understand and the child to effectively use the corrective devices. c) The nurse should be a contact person when the child is hospitalized. d) The nurse should provide information when the child or caregiver requests it.

The nurse should help the caregivers to understand and the child to effectively use the corrective devices. Correct Explanation: Nursing care focuses on helping the child and caregivers to manage the corrective device and on the importance of compliance to promote healing and to avoid long-term disability.

The nurse is caring for a 14-year-old boy in Buck traction for a slipped capital femoral epiphysis (SCFE). Which of the following would the nurse include when completing a neurovascular assessment of the affected leg? Select all that apply. a) Sensation b) Vital signs c) Color d) Capillary refill e) Pulse

• Color • Sensation • Pulse • Capillary refill Explanation: A neurovascular assessment includes assessing for color, movement, sensation, edema, and quality of pulses. Vital signs are not a component of a neurovascular assessment.

A nurse is assisting the parents of a child who requires a Pavlik harness. The parents are apprehensive about how to care for their baby and concerned about holding and playing with him. How can the nurse best assist the parents? a) "The baby only needs the harness for 12 weeks." b) "Do not attempt to adjust the harness yourself." c) "Let's put you in touch with other families who have experienced this." d) "The harness does not hurt the baby."

"Let's put you in touch with other families who have experienced this." Correct Explanation: There are many helpful pointers and suggestions that are available from other parents and orthopedic organizations. Referring the parents to other families who have experienced a Pavlik harness will provide assurance and likely increase compliance with the regimen. The other responses are factual but do not address the parent's concerns.

The nurse is caring for a 6-year-old boy with Russell traction applied to his left leg. Which intervention would be most appropriate to prevent complications? a) Adjust the weights as needed. b) Clean and massage his entire leg daily. c) Provide pin care as needed. d) Assess the popliteal region carefully for skin breakdown.

Assess the popliteal region carefully for skin breakdown. Correct Explanation: The nurse would assess the popliteal region carefully for skin breakdown from the sling. The nurse would adjust the weights only per physician orders. Cleaning and massaging the skin is unrelated to care of the child with Russell traction. Russell traction is a form of skin traction, so there is no pin care.

The nurse is assessing a 10-year-old girl recently fitted with a cast on her wrist. Which assessment finding would alert the nurse to a possible infection? a) Diminished pulse b) Pallor of the fingers c) Drainage on the cast d) Delayed capillary refill

Drainage on the cast Correct Explanation: Drainage on the cast could indicate an infection. Pale fingers would suggest impaired circulation. Delayed capillary refill would suggest impaired circulation. Diminished pulse would suggest impaired circulation.

The nurse is caring for a child who has just had a plaster cast applied to the arm. The nurse is correct in doing which of the following with this child? a) Using only a draw sheet to move the casted arm. b) Handling the cast with open palms when moving the arm. c) Encouraging the child to move the arm slowly up and down to help the cast dry. d) Keeping a clove-hitch restraint gently tied on the hand to stabilize the arm.

Handling the cast with open palms when moving the arm. Correct Explanation: A wet plaster cast should be handled only with open palms because fingertips can cause indentations and result in pressure points. There is no reason the arm should be restrained or the arm moved to aid in the drying process.

The nurse is working with an 8-year-old girl who recently developed juvenile arthritis. The mother of the girl tells the nurse that she understands that exercise is important to help preserve muscle and joint function and asks the nurse for recommendations on types of exercise that would be appropriate. Which of the following should the nurse recommend? a) Jumping jacks b) Swimming c) Hiking d) Soccer

Swimming Correct Explanation: Swimming and tricycle or bicycle riding are excellent exercises because they provide smooth joint action. In contrast, to reduce joint destruction, activities that place excessive strain on joints, such as running, jumping, prolonged walking, and kicking, should be avoided.

A nurse is conducting a physical examination on an 11-year-old boy with Legg-Calvé-Perthes disease. Which assessment finding would be expected? a) Loss of strength in ankle dorsiflexion b) Trendelenburg gait c) Lordosis d) Kyphosis

Trendelenburg gait Correct Explanation: The nurse would expect to note a Trendelenburg gait due to pain. Lordosis is an excessive curvature of the spine and is not associated with Legg-Calvé-Perthes disease. Kyphosis is an excessive curvature of the spine and is not associated with Legg-Calvé-Perthes disease. Loss of strength in ankle dorsiflexion is associated with some neuromuscular disorders but not this condition.

A 14-year-old girl is diagnosed as having scoliosis. When doing scoliosis screening with her, an important observation would be to note a) her posterior spine when she bends forward. b) the angle of the iliac crest when she bends forward. c) the posterior spine when she bends sideways. d) the angle of her lower chest when she sits down.

her posterior spine when she bends forward. Correct Explanation: A lateral curvature of the spine (scoliosis) is best revealed when the child bends forward. Bending to the side would not provide an accurate assessment of the spine nor would assessing the iliac crest or the chest.

A girl with scoliosis is prescribed a body brace. The purpose of the brace is to a) improve spinal alignment. b) prevent herniation of a spinal disk. c) correct spinal curvature. d) prevent torticollis.

improve spinal alignment. Correct Explanation: Body bracing helps to hold the spine in alignment and prevent further curvature. The brace will not correct the problem. Herniation and torticollis are not associated with scoliosis.

While an adolescent wears a body brace for scoliosis, you would teach her a) that secondary sex changes will stop until the brace is removed. b) to continue with age-appropriate activities. c) to wear the brace a maximum of 20 hours each day. d) to stand absolutely still whenever she is out of the brace.

to continue with age-appropriate activities. Correct Explanation: Wearing a body brace should not interfere with normal activities, which are necessary to maintain adolescent self-esteem. Sex changes continue with or without bracing; the provider will determine the length of time for wearing the brace each day.

The nurse is doing patient teaching with a child who has been placed in a brace to treat scoliosis. Which of the following statements made by the child indicates an understanding of the treatment? a) "At least when I take a shower I have a few minutes out of this brace." b) "I am so glad I can take this brace off for the school dance." c) "When I start feeling tired, I can just take my brace off for a few minutes." d) Wearing this brace only during the night won't be so embarrassing."

"At least when I take a shower I have a few minutes out of this brace." Correct Explanation: The brace worn to treat scoliosis is worn day and night and should be removed only very briefly, such as for showering. The child needs to be taught that the brace must be worn at all times, during the day as well as the night.

In discussing the treatment for children with scoliosis, a group of pediatric nurses makes the following statements. Which statement is most accurate related to the treatment of scoliosis? a) "The only successful treatment for scoliosis is surgery within two weeks of the diagnosis." b) "Children treated for scoliosis by using braces have to wear the brace almost all the time." c) "Children with severe scoliosis are treated using electrical stimulation." d) "The treatment for children with scoliosis usually lasts three to four months."

"Children treated for scoliosis by using braces have to wear the brace almost all the time." Correct Explanation: The Boston brace and the TLSO brace are made of plastic and are customized to fit the child for treatment of scoliosis. The brace should be worn constantly, except during bathing or swimming, to achieve the greatest benefit.

After teaching the parents of a 6-year-old child about caring for a sprained wrist, which statement by the parents indicates the need for additional teaching? a) "We'll apply a warm moist compress to the wrist for 20 minutes at a time." b) "We'll use an elastic wrap to keep the swelling down." c) "We'll be sure she keeps her wrist elevated above her heart."

"We'll apply a warm moist compress to the wrist for 20 minutes at a time." Correct Explanation: Care for a sprain includes rest, ice, compression, and elevation. Cold therapy, not heat, is used for 20 to 30 minutes at a time, then removed for 1 hour and repeated for the first 24 to 48 hours. Compression via an elastic bandage, elevating above heart level, and limiting activity are appropriate measures.

You assist with the application of a full-body plaster cast to a child. The child immediately becomes diaphoretic and complains of being hot. Which nursing intervention would be indicated? a) Moisten the cast with cool water. b) Observe the child for infection. c) Advise the child that this is to be expected. d) Suggest removal of the cast to the orthopedist.

Advise the child that this is to be expected. Correct Explanation: Plaster becomes hot as it sets. This effect is reduced with newer plastic casts. This is a normal expectation about which to educate the child before the application of the cast. If discomfort continues, notify the provider. Infection would not present in this way with a cast application. Never moisten a case.

A 2-year-old is diagnosed with osteomyelitis. Which of the following would you anticipate as a primary nursing intervention to include in the child's plan of care? a) Maintaining intravenous antibiotic therapy b) Assisting the child with crutch walking c) Keeping the child quiet while in skeletal traction d) Restricting fluid to encourage red cell production

Maintaining intravenous antibiotic therapy Correct Explanation: Osteomyelitis is a serious infection. It is treated vigorously with intravenous antibiotics. It would not require traction. The stem does not indicate the location of the infection, so the child may not need crutches. Fluid restriction does not help red blood cell production.

The nurse is caring for a 10-year-old child in traction. After performing a skin assessment, she notices that the skin over the calcaneus appears slightly red and irritated. Which of the following should be the first intervention? a) Reposition the child's foot on a pressure-reducing device. b) Gently massage his foot and heel each shift. c) Apply lotion to his foot and avoid friction to the area. d) Make sure the skin and linens are clean and dry.

Reposition the child's foot on a pressure-reducing device. Correct Explanation: The nurse's first action is to remove continuous pressure from this area. The other actions can help decrease potential for skin breakdown, but the pressure must be relieved first.

The type of traction in which a pin, wire, tongs, or other device is surgically inserted through a bone is which of the following? a) Russell traction b) Skeletal traction c) Buck extension traction d) Skin traction

Skeletal traction Correct Explanation: Skeletal traction exerts pull directly on skeletal structures by means of a pin, wire, tongs, or other device surgically inserted through a bone. Skin traction applies pull on tape, rubber, or a plastic material attached to the skin, which indirectly exerts pull on the musculoskeletal system. Examples of skin traction are Bryant's traction, Buck extension traction, and Russell traction.

The nurse is reinforcing discharge teaching with the caregivers of a child who is going home after a cast has been applied. The nurse explains to the caregivers that which of the following should be reported if they occur or are seen related to this child? (Select all that apply) a) Drainage from under the cast b) Any pink color in the fingers or toes of casted extremity c) A foul odor under the cast d) Any area on the cast that is warm to the touch e) Any itching under or around the edges of the cast f) Looseness of the cast on the extremity

• Drainage from under the cast • A foul odor under the cast • Any area on the cast that is warm to the touch • Looseness of the cast on the extremity Correct Explanation: In addition to the five Ps, any foul odor or drainage on or under the cast, "hot spots" on the cast (areas warm to the touch), looseness or tightness, or any el evation of temperature must be noted, documented, and re ported. Family caregivers should be instructed to watch carefully for these same danger signals. Itching is common and does not need to be reported. Pink coloration of fingers and toes would be normal and not a concern.

The nurse is caring for a child after an accident in which the child fractured his arm. A cast has been applied to the child's right arm. Which of the following actions should the nurse implement? Select all that apply. a) Wear sterile gloves when removing or touching the cast. b) Monitor the color of the nail beds in the right hand. c) Check radial pulse in the both arms. d) Document any signs of pain. e) Wear a protective gown when moving the child's arm.

• Monitor the color of the nail beds in the right hand. • Check radial pulse in the both arms. • Document any signs of pain. Correct Explanation: Monitoring for signs of pain, decreased circulation, or change or variation in pulses in the extremity is important for the child in a cast. Pain can indicate serious complications, such as compartment syndrome. Wearing a gown or sterile gloves is unnecessary. Checking posterior pulses would be appropriate when a lower extremity is casted.

The nurse performing a focused health history on a newborn asks the parents if there are any hereditary disorders affecting musculoskeletal function in the family history. These disorders include (select all answers that apply): a) Clubfoot b) Scoliosis c) Hip dysplasia d) Limb deformities e) Brachial plexus injury

• Scoliosis • Clubfoot • Hip dysplasia Explanation: The nurse should explore the family history for any hereditary disorders. The presence of scoliosis, clubfoot, hip or skeletal dysplasia, or neuromuscular disorders in family members may help in diagnosing genetically linked orthopedic disorders.

The nurse is caring for a 3-year-old boy with a fracture of the humerus. His chart indicates "fracture is partially through the physis extending into the metaphysis." The nurse identifies this as which Salter-Harris classification? a) Type I b) Type V c) Type II d) Type IV

Type II Correct Explanation: According to the Salter-Harris classification, a type II fracture is partially through the physis extending into the metaphysis. A type I fracture is through the physis, widening it. A type IV fracture is through the metaphysis, physis, and epiphysis. A type V fracture is a crushing injury to the physis.

A nurse applies ice to a patient's leg to relieve the pain due to a soft tissue injury. Which of the following is a recommended guideline for use of cold therapy? a) Apply gel packs for no longer than 30 minutes and monitor closely for tissue damage. b) Apply ice for the first 24 to 48 hours after injury to reduce edema.

Apply ice for the first 24 to 48 hours after injury to reduce edema. Explanation: Application of ice is recommended for the first 24 to 48 hours after injury to reduce edema. Ice is usually applied as crushed ice in a bag, applied over a thin layer of cloth, or by immersing the injured part in cool water. Cold therapy is not recommended for persons with hypersensitivity to cold or with impaired circulation. Gel packs cool skin faster than an ice bag and should be applied for no more than 10 minutes.

The nurse is observing a 3-year-old boy who is sitting and playing in the waiting area of his pediatrician's office. The nurse calls the boy and his mother back for the boy's appointment. The boy rolls onto his stomach and pushes himself to his knees. Then he presses his hands against his ankles, knees, and thighs, walking up the front of his body, to stand. Which condition should the nurse suspect in this client? a) Duchenne muscular dystrophy b) Congenital myotonic dystrophy c) Juvenile arthritis d) Facioscapulohumeral muscular dystrophy

Duchenne muscular dystrophy Correct Explanation: By age 3, children with Duchenne muscular dystrophy can rise from the floor only by rolling onto their stomachs and then pushing themselves to their knees. To stand, they press their hands against their ankles, knees, and thighs (they "walk up their front"); this is a Gower sign. Symptoms of facioscapulohumeral muscular dystrophy begin after the child is 10 years old, and the primary symptom is facial weakness. The child becomes unable to wrinkle the forehead and cannot whistle. Congenital myotonic dystrophy begins in utero and typically leads to death before age 1 year because of inability to sustain respiratory function. The symptoms of juvenile arthritis are primarily stiff and painful joints.

The nurse caring for a patient in a body cast knows that immobility can cause contractures, loss of muscle tone, or fixation of joints. Which of the following nursing interdisciplinary interventions are recommended to help prevent these adverse conditions? a) Check for a normal capillary refill of 3 to 5 seconds on a daily basis to ensure there in adequate arterial supply. b) Encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion. c) Encourage child to stifle cough and take shallow breaths to prevent ineffective breathing patterns. d) Give the patient large, frequent meals with decreased fiber and increased protein and Vitamin C.

Encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion. Correct Explanation: The nurse should turn the patient and encourage active and passive range-of-motion activities to prevent ineffective tissue perfusion. The patient should be instructed to cough and breathe deeply to prevent respiratory complications. Normal capillary refill is 1 to 3 seconds. The patient should be given small, frequent meals with increased fiber, protein, and vitamin C to prevent malnutrition.

The caregiver of a 2-year-old who has a polyurethane resin cast on her arm calls the clinic to report that her child is crying and says that the cast has sand in it. The caregiver states that she has had casts of her own and knows how badly they can itch. She says she always used a hanger to scratch but is worried that it will be too sharp for the child. Which of the following statements would be appropriate for the nurse to make to this caregiver? a) "Since the child's cast is synthetic, she could soak it with cool water." b) "A plastic ruler is less likely than a hanger to cut the child's skin." c) "You could give the child an extra dose of acetaminophen and see if that helps." d) "Nothing should be put into the cast. You can blow cool air into it with a hair dryer."

"Nothing should be put into the cast. You can blow cool air into it with a hair dryer." Correct Explanation: Children and caregivers should be cautioned not to put anything inside the cast, no matter how much the casted area itches. Small toys and sticks or stick-like objects should be kept out of reach until the cast has been removed. Ice packs applied over the cast may help decrease the itching. Blowing cool air through a cast with a hair dryer set on a cool temperature or using a fan may help to relieve discomfort under a cast.

The nurse is caring for a group of children on the pediatric unit. The nurse should collect further data and explore the possibility of child abuse in which of the following situations? a) A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate. b) A 9-year-old with a compound fracture of the tibia, which the caregiver reports as having been caused when the child attempted a flip on a skateboard. c) A 10-year-old with a simple fracture of the femur, which the caregiver reports as having been caused when the child fell down a set of stairs. d) A 6-year-old with a greenstick fracture of the wrist, which the caregiver reports as having been caused when the child fell while ice-skating.

A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate. Correct Explanation: Spiral fractures, which twist around the bone, are fre quently associated with child abuse and are caused by a wrenching force. When a broken bone penetrates the skin, the fracture is called compound, or open. A simple, or closed, fracture is a single break in the bone without penetration of the skin. In a greenstick fracture, the bone bends and often just partially breaks.

A 3-year-old demonstrates lateral bowing of the tibia. Which of the following signs would indicate that the boy's condition is Blount disease rather than just the more typical developmental genu varum? a) A sharp, beaklike appearance to the medial aspect of the proximal tibia on x-ray b) The malleoli are touching c) The condition is bilateral d) The medial surfaces of the knees are more than 2 in apart

A sharp, beaklike appearance to the medial aspect of the proximal tibia on x-ray Correct Explanation: Blount disease is retardation of growth of the epiphyseal line on the medial side of the proximal tibia (inside of the knee) that results in bowed legs. Unlike the normal developmental aspect of genu varum, Blount disease is usually unilateral and is a serious disturbance in bone growth that requires treatment. In those with Blount disease, the medial aspect of the proximal tibia will show a sharp, beaklike appearance. The other answers all describe genu varum, not Blount disease.

The nurse is caring for an active 11-year-old presenting with tenderness in the shoulder. He is the pitcher for his baseball team and complains of shoulder pain with active internal rotation but is able to continue past the pain with full range of motion. Based on these reported symptoms, the nurse is aware that the disorder is most likely which of the following? a) Sever's disease b) Epiphysiolysis of the distal radius c) Osgood-Schlatter disease d) Epiphysiolysis of the proximal humerus

Epiphysiolysis of the proximal humerus Correct Explanation: Epiphysiolysis of the proximal humerus is an overuse disorder that occurs with rigorous upper extremity activity such as pitching and causes tenderness in the shoulder. Osgood-Schlatter disease causes knee pain and painful swelling or prominence of the anterior portion of the tibial tubercle. Sever disease causes pain over the posterior aspect of the calcaneus. Epiphysiolysis of the distal radius is an overuse disorder that causes wrist pain. It is common in gymnasts.

The nurse is doing neurovascular checks on a child who has had a cast applied to treat a fracture. The nurse observes for diminished or absent sensation and numbness or tingling. In doing this the nurse is monitoring for which of the following symptoms? a) Pallor b) Paralysis c) Pain d) Paresthesia

Paresthesia Correct Explanation: Paresthesia is diminished or absent sensation or numbness or tingling. Pallor is paleness of color and paralysis is the loss of function.

The nurse is reinforcing teaching with the caregivers of a child who has been placed in an external fixation device for the treatment of an orthopedic condition. Which of the following statements made by the caregivers indicate an understanding of the external fixation device? a) "If we see any drainage around the pins when we are cleaning them, we won't be concerned." b) "He is very sensitive about the way the device looks, I am glad that his clothes will fully cover it so his friends won't tease him." c) "We will have to get some of the elastic bandages to place around the pins and pin sites." d) "It will be hard, but we know our child will be in this device for a long time."

"It will be hard, but we know our child will be in this device for a long time." Correct Explanation: External fixation devices are sometimes left in place for as long as 1 year. The pin sites are left open to the air and should be inspected and cleansed every 8 hours. The child and caregiver should be able to recognize the signs of infection at the pin sites. The appearance of the pins puncturing the skin and the unusual appearance of the device can be upsetting to the child.

The nurse is presenting an in-service to a group of peers on the topic of traction. The nurse asks the group to give examples of types of skin traction. The following types were named by the nurses. Which of the following is an example of a type of skeletal traction? a) Balanced suspension traction b) Bryant's traction c) Russell traction d) Buck extension traction

Balanced suspension traction Correct Explanation: Skeletal traction exerts pull directly on skeletal structures by means of a pin, wire, tongs, or other device surgically inserted through a bone. Examples of skeletal traction are 90-degree traction and balanced suspension traction. Dunlop's traction, sometimes used for fractures of the humerus or the elbow, can be either skin or skeletal traction. It is skeletal traction if a pin is inserted into the bone to immobilize the extremity. Skin traction applies pull on tape, rubber, or a plastic material attached to the skin, which indirectly exerts pull on the musculoskeletal system. Examples of skin traction are Bryant's traction, Buck extension traction, and Russell traction.

In caring for a child in traction, of the following interventions, which is the highest priority for the nurse? a) The nurse should record accurate intake and output. b) The nurse should provide age-appropriate activities for the child. c) The nurse should monitor for decreased circulation every four hours. d) The nurse should clean the pin sites at least once every eight hours.

The nurse should monitor for decreased circulation every four hours. Correct Explanation: Any child in traction must be carefully monitored to detect any signs of decreased circulation or neurovascular complications. Cleaning pin sites is appropriate for a child in skeletal traction. Providing age-appropriate activities and monitoring intake and output are important interventions for any ill child but would not be the highest priority interventions for the child in traction.

When performing physical assessments of children with musculoskeletal disorders, the nurse distinguishes normal variations in children's muscles versus adult muscles. These variations include: a) The infant's muscles account for 45% of total body weight as opposed to 25% of adult body weight. b) During adolescence, muscle growth is influenced by increased production of androgenic hormones. c) The young child has rigid soft tissue, so dislocations and sprains are common occurrences. d) Rapid bone and muscle growth in adolescents increase their agility, thereby decreasing the incidence of injuries.

During adolescence, muscle growth is influenced by increased production of androgenic hormones. Correct Explanation: During adolescence, muscle growth is influenced by hormonal changes, primarily the increased production of androgenic hormones. The infant's muscles account for only 25% of total body weight, whereas they account for 40% to 45% in an adult. The young child has resilient soft tissue, so dislocations and sprains are unusual occurrences. Rapid bone and muscle growth may contribute to the appearance of "clumsy" and awkward motions of the adolescent who is trying to adjust to new body dimensions.

The nurse is caring for an 8-year-old girl in traction. She has been in an acute care setting for two weeks and will require an additional 10 days in the hospital. She is showing signs of regression with thumb sucking and pleas for her tattered baby blanket. Which of the following would be the most helpful intervention? a) "Do you want a book to read?" b) "Let's ask your mom to bring your friends for a visit." c) "Would you like a coloring book?" d) "You are too big to suck your thumb."

"Let's ask your mom to bring your friends for a visit." Correct Explanation: After two weeks in traction, a child can become easily bored and regress in social and personal skills. A visit from friends arranged by the girl's mother or supervised by the child-life specialist would help her adapt to her immobilized state. Telling the girl she is too big to suck her thumb is unhelpful. Suggesting a book or coloring book would be unhelpful at this point, as she has likely grown tired of books and coloring after two weeks.

The nurse is caring for a 10-year-old boy who plays on two soccer teams. He practices four days a week and his team travels to tournaments once a month. He has been diagnosed with a stress fracture in one of his vertebrae. Which of the following instructions is most important to emphasize to the boy and his parents? a) "Ice will help reduce the inflammation." b) "NSAIDs can help with pain control and inflammation." c) "You will need to see a physical therapist for stretching and strengthening exercises." d) "You and your coaches need to understand that you cannot play soccer for at least six weeks."

"You and your coaches need to understand that you cannot play soccer for at least six weeks." Correct Explanation: A child with an overuse injury needs to avoid the causative activity for six to eight weeks. The other suggestions are also important, but the nurse must emphasize to the boy and his parents that they must tell the coaches "no soccer for six weeks." In some situations, it is helpful to supply a written directive from the nurse or physician to help the parent avoid undue pressure from coaches.

A 14-year-old girl with a fractured leg is receiving instructions from the nurse on how to use crutches. Which of the following interventions should the nurse implement to help prevent nerve palsy in the client? a) Be certain the child is walking with the crutches about 6 inches to the side of the foot b) Caution parents to clear articles such as throw rugs out of paths at home c) Teach the client not to rest with the crutch pad pressing on the axilla d) Assess the tips of the crutches to be certain the rubber tip is intact

Teach the client not to rest with the crutch pad pressing on the axilla Correct Explanation: Pressure of a crutch against the axilla could lead to compression and damage of the brachial nerve plexus crossing the axilla, resulting in permanent nerve palsy. Teach children not to rest with the crutch pad pressing on the axilla but always to support their weight at the hand grip. Always assess the tips of crutches to be certain the rubber tip is intact and not worn through as the tip prevents the crutch from slipping. Be certain the child is walking with the crutches placed about 6 inches to the side of the foot. This distance furnishes a wide, balanced base for support. Caution parents to clear articles such as throw rugs, small footstools or toys out of paths at home, to avoid tripping the child.

A nurse is working with a 12-year-old girl with osteomyelitis who is recovering from surgery. Which of the following are nursing interventions that should be implemented in this case? *(Select all that apply.) a) Instituting infection-control precautions related to drainage tubes b) Administration of IV antibiotics at the hospital c) Instruction to the parents regarding how to care for an antibiotic IV line at home d) Casting of the affected limb e) Instruction to the parents regarding the importance of the child maintaining bed rest f) Instruction to the parents regarding proper traction of the limb

• Administration of IV antibiotics at the hospital • Instruction to the parents regarding how to care for an antibiotic IV line at home • Instruction to the parents regarding the importance of the child maintaining bed rest • Instituting infection-control precautions related to drainage tubes Explanation: Osteomyelitis is infection of the bone. Medical therapy includes limitation of weight bearing on the affected part, bed rest, immobilization, and a short administration of an IV antibiotic such as oxacillin (Bactocill), as indicated by the blood culture. Intravenous therapy is usually initiated in the hospital and then continued at home for as long as 2 weeks. When the child is discharged from the hospital, be certain to review with parents measures to care for the antibiotic intravenous line if this will be continued at home. Keep in mind young children are active, even if they are on bed rest so need age appropriate activities so they maintain rest, not activity. If a child had surgery and drainage tubes are in place, institute infection-control precautions, because the drain evacuates infected material. Neither casting nor traction is required for osteomyelitis.

A group of students are reviewing information about bone healing in children. The students demonstrate understanding of this information when they identify which of the following? a) A child's bones heal more quickly than those of an adult. b) The process of breaking down and forming new bone is decreased in children compared with adults. c) Callus production is slower but greater in amount in children than in adults. d) A fracture closer to the growth plate heals much slower than one in the metaphysis.

A child's bones heal more quickly than those of an adult. Correct Explanation: Bone healing occurs in the same fashion as in the adult, but it occurs more quickly in children because of the rich nutrient supply to the periosteum. The closer a fracture is to the growth plate, the more quickly the fracture heals. The capacity for remodeling (the process of breaking down and forming new bone) is increased in children compared with adults. Children's bones produce callus more rapidly and in larger quantities than do adults' bones.

The school nurse cares for children with overuse injuries and refers them for treatment. Which statements accurately describe conservative interventions to prevent or care for these types of injuries? Select all that apply. a) Avoid the causative activity for 6 to 8 weeks. b) Avoid using NSAIDs for pain control. c) Immobilize the muscles that are involved. d) Have the coach monitor the treatment program for sports injuries. e) Apply ice to the injured area to reduce inflammation. f) Link the chain of communication in the disciplinary approach.

• Avoid the causative activity for 6 to 8 weeks. • Apply ice to the injured area to reduce inflammation. • Link the chain of communication in the disciplinary approach. Explanation: Conservative treatment methods for the child with an overuse injury include avoiding the causative activity for 6 to 8 weeks and applying ice to the injured area to reduce the inflammation and irritation. NSAIDs (ibuprofen) are used for inflammation and pain control. The physical therapist institutes a stretching and strengthening program for the appropriate muscle groups. Parents and coaches may not understand that the level of activity that causes overuse symptoms varies from child to child. Notes or telephone conversations from the physician or nurse to the child's coach can clarify any misconceptions about what is expected during the recovery and recuperative periods.