Ball3e Tif Ch35

Ball, Child Health Nursing, 3/E
Chapter 35
Question 1
Type: MCSA
The nurse in the newborn nursery is doing the admission assessment on a neonate. Which assessment finding
would lead the nurse to suspect unilateral congenital hip dysplasia?
1. Lordosis
2. Trendelenburg sign
3. Asymmetry of the gluteal and thigh fat folds
4. Telescoping of the affected limb
Correct Answer: 3
Rationale 1: Lordosis does not occur with hip dysplasia.
Rationale 2: Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with
congenital hip dysplasia.
Rationale 3: A sign of congenital hip dysplasia in the infant would be asymmetry of the gluteal and thigh fat
folds.
Rationale 4: Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with
congenital hip dysplasia.
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 35-1
Question 2
Type: MCMA
A school health nurse is screening for scoliosis. For what assessment findings would the nurse look?
Standard Text: Select all that apply.
1. Lordosis
Copyright 2014 by Pearson Education, Inc.
2. Prominent scapula
3. Pain
4. A one-sided rib hump
5. Uneven shoulders and hips
Correct Answer: 2,4,5
Rationale 1: Lordosis is not present with scoliosis.
Rationale 2: The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and
prominent scapula.
Rationale 3: Pain generally is not present with scoliosis unless it is severe.
prominent scapula.
prominent scapula.
Global Rationale:
Client Need:
Client Need Sub:
Question 3
Type: MCSA
The nurse has completed parent education related to treatment for a child with congenital clubfoot. The nurse
knows that parents need further teaching when they state:
1. "We're getting a special car seat to accommodate the casts."
2. "We'll watch for any swelling of the feet while the casts are on."
3. "We'll keep the casts dry."
4. "We're happy this is the only cast our baby will need."
Correct Answer: 4
Rationale 1: Using a car seat is the law. Special car seats to accommodate the casts are available and should be
utilized.
Rationale 2: Parents should be watching for swelling while the casts are on.
Rationale 3: Keeping the casts dry is important to prevent complications
Rationale 4: Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every one to
two weeks until the corrected foot position is achieved.
Global Rationale:
Cognitive Level: Analyzing
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Question 4
Type: MCSA
A child must wear a brace for correction of scoliosis. Which nursing diagnosis takes priority at this time?
1. Impaired gas exchange, risk for
2. Altered growth and development, risk for
3. Impaired skin integrity, risk for
4. Impaired mobility, risk for
Correct Answer: 3
Rationale 1: Risk for impaired gas exchange is a late effect of scoliosis and would not be the priority. If the
patient is compliant with wearing the brace, the risk should be minimized.
Rationale 2: The diagnosis of altered growth and development would not be the priority and should be corrected
by the wearing of the brace.
Rationale 3: The skin should be monitored for breakdown in any area where the brace might rub against the skin.
Rationale 4: The diagnosis of impaired mobility would not be the priority and should be corrected if the patient is
compliant with wearing the brace.
Global Rationale:
Client Need:
Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis
Question 5
Type: MCSA
An adolescent has just returned from surgery after spinal fusion surgery. Which assessment finding would take
priority at this time?
1. Sleeps when not bothered but arouses easily with stimuli
2. Impaired color, sensitivity, and movement to lower extremities
3. Nausea
4. Pain
Correct Answer: 2
Rationale 1: This is a normal response postanesthesia.
Rationale 2: When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement
to lower extremities.
Rationale 3: Nausea in the postoperative period is not uncommon, but it is not the priority at this time.
Rationale 4: Pain is a common finding in the postoperative period and should be addressed, but impaired color,
sensitivity, and movement of the lower extremities is the priority at this time.
Global Rationale:
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Question 6
Type: MCSA
The nurse has completed discharge teaching for the family of a child diagnosed with Legg-Calv-Perthes disease.
The nurse knows further teaching is needed about the condition if the family states:
1. "We're glad this will only take about six weeks to correct."
2. "We understand abduction of the affected leg is important."
3. "We know to watch for areas on the skin that the brace might rub."
4. "We understand swimming is a good sport for Legg-Calv-Perthes."
Correct Answer: 1
Rationale 1: The treatment for Legg-Calv-Perthes disease takes approximately two years.
Rationale 2: The leg should be kept in the abducted position to prevent damage to the head of the femur due to
Legg-Calv-Perthes disease.
Rationale 3: A brace is a component of the treatment of Legg-Calve-Perthes disease and is worn to prevent
damage to the head of the femur, so skin irritation should be monitored.
Rationale 4: Swimming is a good activity to increase mobility in a child with Legg-Calv-Perthes disease.
Global Rationale:
Client Need:
Client Need Sub:
Question 7
Type: MCSA
Which of the following would take priority when teaching the family how to care for an infant with osteogenesis
imperfecta?
1. Teaching the family how to care for an infant in a cast
2. Teaching the family that the trunk and extremities should always be supported when moving this infant
3. Teaching the family how to care for an infant postop spinal surgery
4. Teaching the family how to care for an infant in traction
Correct Answer: 2
Rationale 1: Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta.
Rationale 2: With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are
fragile, the entire body must be supported when the child is moved.
Global Rationale:
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Question 8
Type: MCSA
An infant has just returned from surgery for correction of bilateral congenital clubfeet. The infant has bilateral
long-leg casts. The toes on both feet are edematous, but there is color, sensitivity, and movement to them. What
should the nurse do first?
1. Apply a warm, moist pack to the feet.
2. Elevate the infants legs on pillows.
3. Encourage movement of the toes.
4. Call the physician to report the edema.
Correct Answer: 2
Rationale 1: Warm, moist heat will increase swelling and the moisture may cause the cast to disintegrate.
Rationale 2: The infants legs should be elevated on a pillow for 24 hours to promote healing and help with
venous return. This is the priority action.
Rationale 3: An infant would not be able to follow directions to move the toes, and in this case it would not be as
effective as would elevating the legs on pillows.
Rationale 4: Some amount of swelling can be expected, so it would not be appropriate to notify the physician,
especially if the color, sensitivity, and movement to the toes remained normal.
Global Rationale:
Client Need:
Client Need Sub:
Question 9
Type: MCSA
The nurse is teaching a family how to care for their infant in a Pavlik harness to treat congenital developmental
dysplasia of the hip. Which instruction is appropriate for the nurse to include in parental education in relation to
the Pavlik harness?
1. Apply lotion or powder to minimize skin irritation.
2. Check at least two or three times a day for red areas under the straps.
3. Put clothing over the harness for maximum effectiveness of the device.
4. Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper.
Correct Answer: 2
Rationale 1: Lotion or powder can contribute to skin breakdown and should not be used.
Rationale 2: The skin underneath the straps of the brace should be checked two or three times a day for red areas,
which might indicate skin breakdown.
Rationale 3: A light layer of clothing should be worn under the brace to assist in preventing skin breakdown, not
over the brace.
Rationale 4: The diaper should be placed under the brace, along with a light layer of clothing.
Global Rationale:
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Question 10
Type: MCSA
A child has experienced a sprain of the right ankle. The school nurse should:
1. Leave the ankle open to the air and avoid compressing the area to allow tissue swelling as necessary.
2. Perform passive range-of-motion to the extremity.
3. Lower the extremity below the level of the heart.
4. Apply ice to the extremity.
Correct Answer: 4
Rationale 1: For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed.
Therefore, the nurse should apply a compression bandage to the extremity.
Therefore, the nurse should rest the extremity rather than perform range-of-motion.
Therefore, the nurse should elevate the extremity.
Therefore, the nurse should apply ice to the extremity.
Global Rationale:
Client Need:
Client Need Sub:
Question 11
Type: MCMA
A nurse is assessing a child after an open reduction of a fractured femur. Which signs indicate that compartment
syndrome could be occurring?
1. Pink, warm extremity
2. Dorsalis pedis pulse present
3. Prolonged capillary refill time
4. Pain not relieved by pain medication
5. Paresthesia of the leg
Rationale 1: Pink, warm extremity is a normal finding post-fracture reduction.
Rationale 2: A present dorsalis pedis pulse would be a normal finding post-fracture reduction.
Rationale 3: A prolonged capillary refill time is a sign of compartment syndrome.
Rationale 4: A prolonged capillary refill time with loss of paresthesia and pain not relieved by medication are
signs of compartment syndrome.
Rationale 5: Paresthesia is tingling and numbness of the affected extremity and is a sign of compartment
syndrome.
Global Rationale:
Client Need:
Client Need Sub:
Question 12
Type: MCSA
A six-year-old boy is admitted to the hospital with a diagnosis of osteomyelitis of the left femur. The plan of care
includes a two-week round of intravenous antibiotics. The father questions why the child must be hospitalized and
why the child cannot receive oral antibiotics. The nurse explains:
1. The antibiotic of choice is not available in oral form.
2. Blood flow to bones is limited, and parenteral administration is necessary to get appropriate blood levels.
3. Because the child is older now, it is harder to get the child to cooperate with oral antibiotics.
4. Because two weeks of therapy is necessary, the intravenous route will produce fewer side effects.
Correct Answer: 2
Rationale 1: Most antibiotics are available in multiple forms.
Rationale 2: This is accurate information.
Rationale 3: The older child can understand the reason for antibiotics and cooperate.
Rationale 4: Both oral and intravenous antibiotics may have side effects.
Global Rationale:
Client Need:
Client Need Sub:
Question 13
Type: MCSA
A two-year-old child is placed in balanced Bryants traction for a fractured right femur. Which finding by the
nurse should be reported to the surgeon?
1. The child keeps trying to turn and lay on his belly.
2. The ropes are unequal in length.
3. The childs buttocks are resting on the bed.
4. The ace bandage wrapping the legs is wrinkled.
Correct Answer: 3
Rationale 1: This child needs a jacket restraint to maintain appropriate positioning if someone cannot stay with
him. It does not require notifying the surgeon.
Rationale 2: In balanced traction, the ropes and pulleys determine the traction and the length of the rope is
unimportant.
Rationale 3: In order to provide adequate counter-traction, the buttocks should be slightly elevated off the bed.
The surgeon should be notified.
Rationale 4: This is not a significant finding.
Global Rationale:
Client Need:
Client Need Sub:
Question 14
Type: MCMA
When assigned to the patient on complete bed rest for spinal fusion secondary to scoliosis, the nurse will want to
intervene to prevent common complications of immobility. Nursing interventions will include:
1. Encouraging use of the spirometer every two hours while the child is awake.
2. Log-rolling the patient every two hours while awake.
3. Increasing intake of milk to maintain bone calcium.

4. Increasing fruit and grains in the diet.
5. Limiting fluid intake to reduce the need to void.
Rationale 1: Respiratory complications are a common complication of immobility.
Rationale 2: Turning the patient frequently will reduce pressure on bony prominences.
Rationale 3: Calcium will be pulled from the bones due to immobility. Adding additional calcium in the form of
milk will increase the risk of kidney stones.
Rationale 4: Fruit and grains will provide extra fiber to reduce the risk of complication.
Rationale 5: Fluid intake should be increased to flush the kidneys.
Global Rationale:
Client Need:
Client Need Sub:
Question 15
Type: MCSA
While at recess, a child falls and hurts his arm. The school nurse is called and suspects a fractured arm. The nurse
will apply a splint before transporting the child to the hospital. The nurse will ensure that:
1. The splint is applied firmly enough to prevent swelling.
2. The arm is fully extended in the splint.
3. The splint is fully padded to prevent skin damage.
4. The joints above and below the suspected fracture are immobilized.
Correct Answer: 4
Rationale 1: The purpose of the splint is not to prevent swelling.
Rationale 2: The nurse will not want to manipulate the arm, so the nurse will splint the arm in the position it is
found.
Rationale 3: The splint does not need to be padded.

Rationale 4: This is the important concept in splintingimmobilizing the joint above and below the fracture to
prevent movement of the bones.
Global Rationale:
Client Need:
Client Need Sub:
Question 16
Type: MCSA
An 18-month-old child is admitted to the hospital unit for weakness of the lower extremities. Duchenne muscular
dystrophy is suspected. Which assessment finding on the admission history and physical is indicative of this
disorder?
1. Infant was post-mature by almost two weeks.
2. The child seems very muscular.
3. The child walked early and without support at 10 months.
4. The childs older sister developed scoliosis in the fourth grade.
Correct Answer: 2
Rationale 1: Post-maturity is not related to Duchenne muscular dystrophy.
Rationale 2: Duchenne muscular dystrophy is also called pseudohypertrophic due to the enlarged appearance of
the muscle. The pathophysiology is infiltration of the muscle fibers with fatty tissue.
Rationale 3: This finding is not indicative of Duchenne muscular dystrophy.
Rationale 4: The older sisters scoliosis is not related to MD. Duchenne MD is sex-linked recessive and affects
only boys.
Global Rationale:
Client Need:
Client Need Sub:
Question 17
Type: MCMA
An infant returns to the unit following casting of the leg for talipes equinovarus. Standing orders include
monitoring the neurovascular status. In addition to color, for what will the nurse monitor the infants foot?
1. Warmth
2. Capillary refill
3. Pedal pulse
4. Sensation
5. Movement of the toes
Correct Answer: 1,2,4,5
Rationale 1: The temperature of the foot of the casted leg should be compared to the temperature of the other
foot.
Rationale 2: This indicates blood return to the tissues and is an important finding.
Rationale 3: The pedal pulse cannot be reached in the casted foot.
Rationale 4: Nerve function is evaluated by touching the toes and noting the childs response.
Rationale 5: The child is encouraged to wiggle the toes. If the patient is an infant, tickling will cause the child to
respond with movement.
Global Rationale:
Client Need:
Client Need Sub:


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Ball, Child Health Nursing, 3/E

Client Need Sub:

3. Increasing intake of milk to maintain bone calcium.

Rationale 3: The splint does not need to be padded.

Ball, Child Health Nursing, 3/E

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