The Point Chapter 44 Nursing Care of a Child with am Alteration in Mobility / Neuromuscular or Musculoskeletal Disorder

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 can wrap the wrist in an elastic bandage to help reduce the swelling." c. "She'll need to limit any activity that involves the wrist." d. "We'll make sure she keeps her arm above heart level."

a. "We'll apply a warm moist compress to the wrist for 20 minutes at a time." Rationale: 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.

A 9-year-old child is scheduled for a computed tomography with contrast medium. What would be most important for the nurse to assess? a. Allergies b. Swelling c. Pain d. White blood cell count

a. Allergies Rationale: Assessing for allergies would be the priority because a contrast medium is being used. Pain is an important assessment but is unrelated to the test scheduled. Swelling is an important assessment finding, but this is unrelated to the test scheduled. Although a white blood cell count is important for determining an infection, it is unrelated to the test scheduled.

After teaching a group of students about medications commonly used for neuromuscular disorders, the nursing instructor determines that the teaching was successful when the students identify which agent as a centrally acting skeletal muscle relaxant? a. Baclofen b. Botulin toxin c. Prednisone d. Lorazepam

a. Baclofen Rationale: Baclofen is a centrally acting skeletal muscle relaxant used to treat painful spasms and decrease spasticity in children with motor neuron lesions. Prednisone is a corticosteroid that is used to help slow the progression of Duchenne muscular dystrophy. Lorazepam is a benzodiazepine used for adjunctive relief of skeletal muscle spasm associated with cerebral palsy. Botulin toxin is a neurotoxin used to relieve spasticity in cerebral palsy.

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. Adolescence c. Toddlerhood d. School age

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

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

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

The nurse is caring for a 6-year-old boy with myelomeningocele. The nurse is teaching the mother how to promote appropriate bowel elimination and avoid constipation. Which response from the mother indicates a need for further teaching? a. "He must have an adequate amount of fluid." b. "I can palpate his abdomen to assess for constipation" c. "My son's activity is too limited to stimulate his bowels." d. "I need to figure out his usual pattern for passing stool."

c. "My son's activity is too limited to stimulate his bowels." Rationale: The nurse needs to point out to the mother that even minimal activity increases peristalsis. Together they can come up with appropriate activities within the child's limits or restrictions to promote peristalsis. It is important to determine the usual pattern for passing stool so that the mother and nurse can determine the best program. Palpating the abdomen can reveal distention suggesting constipation. Adequate fluid is necessary to stimulate peristalsis.

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. Delayed capillary refill b. Diminished pulse c. Drainage on the cast d. Pallor of the fingers

c. Drainage on the cast Rationale: 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 recently fitted with braces on both legs due to cerebral palsy (CP). What would the nurse emphasize in the discharge teaching? a. "It is very important to comply with the use of this brace." b. "If the brace is painful, feel free to take it off." c. "Please try and follow the therapist's on and off schedule." d. "Check the skin that is covered by the braces for redness and breakdown."

d. "Check the skin that is covered by the braces for redness and breakdown." Rationale: Assessing skin integrity should be the priority, as braces can lead to pressure ulcers and infection. Compliance is important, but attention to skin care is the priority teaching. Following the schedule is important for compliance, but skin integrity is the priority. Advising the parents to remove the brace if it is painful is inaccurate; the child may require pain management or further consultation with the physical therapist.

A nurse is conducting a physical examination of a 5-year-old boy with spinal muscular atrophy (SMA) type 2. What assessment findings would the nurse expect to find? a. Pectus excavatum b. Loss of strength in hip extension c. Loss of strength in ankle dorsiflexion d. Pseudohypertrophy of the calves

a. Pectus excavatum Rationale: Pectus excavatum develops in children with SMA type 1 and type 2 who exhibit paradoxical breathing. The chest becomes funnel shaped and the xiphoid process is retracted. Pseudohypertrophy of the calves is associated with Duchenne muscular dystrophy. Loss of strength in hip extension is associated with Duchenne muscular dystrophy. Loss of strength in ankle dorsiflexion is associated with Duchenne muscular dystrophy.

A child is in Buck traction to correct a hip problem. When caring for this child, it is most important for the nurse to implement which intervention? a. Remove the boot every 8 hours b. Administer antispasmodics every 4 hours c. Provide diversionary activities d. Keep the affected leg on a pillow

a. Remove the boot every 8 hours Rationale: Buck traction is a skin traction used to treat hip and knee problems. The traction is applied in a straight line with the extremity in a boot and weights attached that hang freely off the end of the bed. It is imperative the boot be removed every 8 hours for skin assessment. Due to the weight applied to the boot, skin integrity can easily become impaired. The affected leg should not be elevated on a pillow. Antispasmodics are generally prescribed but they would be used when needed, not scheduled. Diversionary activities should be provided but they do not take priority over skin assessment.

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

b. a child's bones heal more quickly than those of an adult. Rationale: 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.

A nurse is preparing a presentation for a health fair focusing on prevention of congenital neuromuscular disorders. What would the nurse emphasize as most important in preventing neural tube defects? a. Ultrasound screening at 16 weeks' gestation b. Genetic testing for gene identification c. Folic acid supplementation d. Maternal serum α-fetoprotein levels screening

c. Folic acid supplementation Rationale: Strong evidence exists that folic acid supplementation by the mother before conception decreases the incidence of neural tube defects by 50%. Ultrasound screening at 16 to 18 weeks' gestation can help identify fetuses at risk, but this would not prevent neural tube defects. Screening of maternal serum α-fetoprotein levels can help identify fetuses at risk, but this would not prevent neural tube defects. Neural tube defects are not related to genetic dysfunction, so genetic testing would be of no value.

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. Lordosis b. Kyphosis c. Trendelenburg gait d. Loss of strength in ankle dorsiflexion

c. Trendelenburg gait Rationale: 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 nurse is assessing a newborn and observes webbing of the fingers and toes. The nurse documents this finding as: a. pectus carinatum. b. metatarsus adductus. c. syndactyly. d. polydactyly.

c. syndactyly. Rationale: 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 nurse is performing a physical examination of a child with a suspected fracture. Which assessment technique would the nurse assume would not be used? a. Observation b. Inspection c. Palpation d. Auscultation

d. Auscultation Rationale: The physical examination specific to fractures includes inspection, observation, and palpation. The nurse may assume that auscultation is not used; however, auscultation of the child's lungs may reveal adventitious sounds that are often present when respiratory muscle function is impaired.

A 7-year-old boy is suspected of having transient synovitis of the hip. What findings would the nurse expect to assess? Select all that apply. a. History of recent otitis media b. High fever c. Internally rotated affected extremity d. Complaint of acute onset of moderate pain e. Pain worse in the morning on arising

a. History of recent otitis media d. Complaint of acute onset of moderate pain e. Pain worse in the morning on arising Rationale: Assessment findings associated with transient synovitis (inflammation of hip joint) of the hip include a recent upper respiratory tract infection, pharyngitis, and otitis media. Pain onset is acute and sudden, with pain ranging from moderate to severe that is worse in the morning. Temperature will be normal or a low-grade fever may be present. The child holds the affected hip flexed and externally rotated.

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 II b. Type IV c. Type V d. Type I

a. Type II Rationale: 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 is reviewing the medical record of a child who has sustained a fracture. Documentation reveals a bowing deformity. The nurse interprets this fracture as: a. significant bending without actual breaking. b. bone that breaks into two pieces. c. incomplete fracture. d. bone buckling due to compression.

a. significant bending without actual breaking. Rationale: 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.

A child is to undergo testing for suspected muscular dystrophy and is scheduled for the following tests. Which test would the nurse identify as most important to be completed first? a. Nerve conduction velocity b. Creatine kinase c. Electromyogram d. Muscle biopsy

b. Creatine kinase Rationale: The sample for creatine kinase must be obtained before the electromyogram or muscle biopsy because those tests may lead to a release of creatine kinase and provide false results. Nerve conduction velocity tests could be done at any time.

A child with cerebral palsy is referred for physical therapy. When describing the rationale for this therapy, the nurse would emphasize what as the primary goal? a. Promote optimal self-care ability b. Development of gross motor movement c. Enhance feeding capabilities d. Development of fine motor skills

b. Development of gross motor movement Rationale: Physical therapy focuses on assisting in the development of gross motor movements such as walking and positioning and helps the child develop independent movement. Occupational therapy assists in the development of fine motor skills and fashioning orthotics and splints. Occupational therapy assists the child in performing optimal self-care ability by working on skills such as activities of daily living. Speech therapy assists with feeding techniques for the child who has swallowing problems.

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

b. Obesity Rationale: 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 assessing a child with spastic cerebral palsy. What findings would the nurse expect to assess? Select all that apply. a. Drooling b. Poor control of balance c. Hemiplegia d. Dysarthria e. Hypertonicity f. Exaggerated deep tendon reflexes

b. Poor control of balance c. Hemiplegia e. Hypertonicity f. Exaggerated deep tendon reflexes Rationale: Spastic cerebral palsy is associated with exaggerated deep tendon reflexes; poor control of posture, balance, and movement; hypertonicity of the affected extremities; and hemiplegia, quadriplegia, or diplegia, based on the limbs affected. Drooling and dysarthria are associated with athetoid cerebral palsy.

The nurse is caring for an 11-year-old presenting with tenderness in the shoulder. He is the pitcher for his baseball team and reports 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 to be: a. epiphysiolysis of the distal radius. b. epiphysiolysis of the proximal humerus. c. Sever disease. d. Osgood-Schlatter disease.

b. epiphysiolysis of the proximal humerus. Rationale: 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 caring for a 10-year-old girl in traction. The girl is experiencing muscle spasms associated with the traction. What would the nurse expect to administer if ordered? a. Alendronate b. Diazepam c. Narcotic analgesics d. Pamidronate

b. Diazepam Rationale: Diazepam is an antianxiety drug that also has the effect of skeletal muscle relaxation; it is used for the treatment of muscle spasm associated with traction or casting. Narcotic analgesics are used for pain relief. Alendronate increases bone mineral density for children with osteogenesis imperfecta. Pamidronate increases bone mineral density for children with osteogenesis imperfecta.

A nurse is preparing a plan of care for an infant who has undergone surgery to repair a myelomeningocele. The nurse would include placing the infant in which positions postoperatively? Select all that apply. a. Semi-Fowler b. Left side lying c. Supine d. Right side lying e. Prone

b. Left side lying d. Right side lying e. Prone Rationale: Postoperatively, the nurse would position the infant in the prone or side-lying position to allow the incision to heal.

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. High serum phosphate levels b. Low serum calcium levels c. Low alkaline phosphate levels d. X-ray confirmation of adequate bone shape

b. Low serum calcium levels Rationale: 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.

The nurse is teaching the parents of a female child with a myelomeningocele how to perform clean intermittent catheterization. The nurse determines that the teaching was effective when the parents return demonstrate the procedure and state: a. "We need to apply some petroleum jelly to her labia and the catheter before we attempt to insert it." b. "When the urine stops flowing, we should press on the lower belly to ensure the bladder is empty." c. "Before inserting the catheter, we need to wipe her labia with normal saline from back to front." d. "We need to insert the catheter about 6 inches so that we make sure the catheter is in the bladder."

b. "When the urine stops flowing, we should press on the lower belly to ensure the bladder is empty." Rationale: When the urine stops flowing, the parents should press on the lower abdomen or have the child lean forward to tense the abdominals to ensure that no more urine is in the bladder. For a female, the catheter is inserted about 2 to 3 inches. For a male, the catheter is inserted about 4 to 6 inches. Before the catheter is inserted, the labia is cleaned with a washcloth or disposable wipe from front to back. A generous amount of water-soluble lubricant, not petroleum jelly, is applied to the catheter. There is no need to apply the lubricant to the labia.

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. Clean and massage his entire leg daily. b. Assess the popliteal region carefully for skin breakdown. c. Provide pin care as needed. d. Adjust the weights as needed.

b. Assess the popliteal region carefully for skin breakdown. Rationale: 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 child with spina bifida occulta. During the assessment, the parents say, "It's going to be so difficult taking care of our child. He'll never be able to walk." The nurse identifies which nursing diagnosis as the priority? a. Impaired physical mobility related to spinal cord defect b. Deficient knowledge related to diagnosis and condition c. Risk for injury related to lack of muscle control d. Ineffective coping related to diagnosis of chronic condition

b. Deficient knowledge related to diagnosis and condition Rationale: The parents' statement indicates a lack of understanding about the condition. Spina bifida is a term that is often used to refer to all neural tube disorders that affect the spinal cord. This can be confusing and a cause of concern for parents. There are well-defined degrees of spinal cord involvement, and it is important for healthcare professionals to use the correct terminology. Spina bifida occulta is a defect of the vertebral bodies without protrusion of the spinal cord or meninges. This defect is not visible externally and in most cases has no adverse affects. In most cases, spina bifida occulta is benign and asymptomatic and produces no neurologic signs; it may be considered a normal variant. Mobility typically is not impaired with spina bifida occulta. The child is at no greater risk for injury as any other child. The parents demonstrate a lack of knowledge, not problems with coping.

The nurse is caring for an infant with myelomeningocele prior to having repair surgery. What nursing intervention(s) is necessary to include in this infant's plan of care? Select all that apply. a. Provide a pacifier for nonnutritive sucking b. Keep the skin clean and dry c. Positioning of paralyzed legs to prevent contractures d. Protect knees and elbows from skin breakdown e. Use a high-calorie, concentrated formula for feeds

b. Keep the skin clean and dry c. Positioning of paralyzed legs to prevent contractures d. Protect knees and elbows from skin breakdown Rationale: A myelomeningocele is a spinal cord defect. The sac protrudes through the skin. The spinal cord ends at the level of the defect causing no motor or sensory function below that point. The infant must remain in a prone position to keep from causing damage to the sac until repair can be done. This also means no diapers. Skin integrity and positioning are essential. This infant could have breakdown on the knees and elbows and even the side of the head. The infant needs to be cleaned regularly and kept dry. Different types of mattresses can be used to reduce pressure on bony prominences. The paralyzed lower extremities need to be repositioned regularly to prevent contractures. A high-calorie, concentrated formula is not necessary. Regular-calorie formula is adequate. A pacifier for nonnutritive sucking is a good idea and may be a comfort to the infant but it is not essential.

The nurse is caring for a 2-year-old boy with cerebral palsy (CP). The medical record indicates "hypertonicity and permanent contractures affecting both extremities on one side." Based on these findings, the nurse identifies this type of CP as: a. mixed. b. spastic. c. ataxic. d. athetoid or dyskinetic.

b. spastic. Rationale: Spastic involves hypertonicity and permanent contractures on both extremities on one side. Athetoid (dyskinetic) involves abnormal involuntary movements affecting all four extremities and sometimes the face, neck, and tongue. Ataxic affects balance and depth perception. Spastic affects the lower extremities. Mixed is a combination of spastic, athetoid and ataxic.

An infant with a femur fracture is placed in Bryant traction. What would the nurse include in the infant's plan of care? a. Wrapping the bandages from the ankle to the knee b. Provide range of motion to the unaffected extremity c. Keeping the buttocks slightly elevated d. Removing the traction boot every 8 hours

c. Keeping the buttocks slightly elevated Rationale: With Bryant traction, the buttocks should be slightly elevated and clear of the bed. The bandages are wrapped from the ankles to midthigh in Bryant traction. The legs are wrapped from the ankle to knee. A traction boot is not used with Bryant traction. This action would be appropriate for Buck traction. With Bryant traction, both legs are extended vertically, so range of motion would not be appropriate.

The emergency department nurse is caring for a 3-year-old girl with an arm injury. The mother is very upset because she believes she broke her daughter's arm. "I was lifting her by her hands and felt a pop in her wrist. She instantly started screaming." The child is now guarding and refusing to move her arm. Which response by the nurse would be most appropriate? a. "This is most likely nursemaid's elbow; you will have to be more careful in the future." b. "You probably dislocated her radial head when you lifted her." c. "The popping noise was the ligament surrounding the radial head becoming entrapped." d. "Her arm isn't broken. This injury is common and easily fixed with no complications."

d. "Her arm isn't broken. This injury is common and easily fixed with no complications." Rationale: The nurse should quickly reassure the mother that this is a common occurrence, seen every day in the emergency department, and is easily fixed and resolves with no complications. Although a popping noise indicates entrapment of the ligament, this response does not address the mother's concerns. Although the radial head most likely dislocated, this response does not address the mother's concern. Although this condition is called nursemaid's elbow, telling the mother she has to be more careful only serves to put blame on the mother and does not address her concerns.