Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 036 (edited file)—"Musculoskeletal Disorders" 10/14/08, Page 1 of 9, 3 Figure(s), 0 Table(s), 3 Box(es

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36: Musculoskeletal Disorders
PRACTICE QUESTIONS
1. A nurse is assisting a physician during the examination of an infant with hip dysplasia and the physician performs the Ortolani maneuver. The nurse understands that this maneuver is performed to: 1. Push the unstable femoral head out of the acetabulum. 2. Reduce the dislocated femoral head back into the acetabulum. 3. Determine the extent of range of motion. 4. Check for asymmetry on the affected side. Answer: 2 Rationale: In the Barlow maneuver, the examiner pushes the unstable femoral head out of the acetabulum. In the Ortolani maneuver, the examiner reduces the dislocated femoral head back into the acetabulum. A positive effect of the Ortolani maneuver is a palpable clink on entry or exit of the femoral head over the acetabular ring. Options 3 and 4 are data collection techniques for identification of the clinical manifestations of hip dysplasia but do not describe the Ortolani maneuver. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are data collection techniques. From the remaining options, it is necessary to know the purpose of the Ortolani maneuver. Review the purpose of these maneuvers if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 33. Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 101. 2. A 6-month-old infant is seen in the clinic and is diagnosed with unilateral hip dysplasia. The nurse reviews the health care record and understands that which of the following findings is not associated with this condition? 1. An apparent short femur on the affected side 2. Limited range of motion in the affected hip 3. 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 Answer: 3 Rationale: Asymmetrical abduction of the affected hip, when placed supine with the knees and hips flexed, would be a finding in hip dysplasia in infants beyond the newborn period. Options 1, 2, and 4 are accurate assessment findings in this disorder. Test-Taking Strategy: Use the process of elimination and note the key words, not associated. This indicates a false response question and that you need to select the incorrect finding.

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Visualize each of the findings described in the options to assist in directing you to option 3. Review the findings in hip dysplasia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 101. 3. A nurse reinforces instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. The nurse tells the parents that the: 1. Harness must be worn 12 hours a day. 2. Harness must be removed for diaper changes and for feeding. 3. Harness is removed to check the skin and for bathing. 4. Infant should never be moved when out of the harness. Answer: 3 Rationale: The harness should be worn 23 hours a day and should 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. Test-Taking Strategy: Visualize this harness. This will assist in eliminating options 2 and 4. Select option 3 over option 1, because the time frame in option 1 is rather short. Also, note the absolute word “must” in options 1 and 2 and “never” in option 4. Review home care instruction regarding this harness if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 332. 4. A nurse provides information to the mother of a 2-week-old infant diagnosed with clubfoot at the time of birth. Which statement by the mother indicates a need for further instruction regarding this disorder? 1. “I need to bring my child back to the clinic in 1 month for a new cast.” 2. “Treatment needs to be started as soon as possible.” 3. “I need to come to the clinic every week with my child for the casting.” 4. “I realize my child will require follow-up care until full grown.” Answer: 1 Rationale: 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 is usually 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. Test-Taking Strategy: Use the process of elimination and focus on the issue, the treatment plan for clubfoot. Note the key words, indicates a need for further instruction, to assist in eliminating options 2 and 4. Recalling that serial manipulations and casting are required weekly will assist

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in directing you to option 1 from the remaining options. Review these treatment procedures if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 320. 5. A nurse is assigned to care for a child following spinal fusion for the treatment of scoliosis. The child complains of abdominal discomfort and begins to have episodes of vomiting. On further data collection, the nurse notes abdominal distention. The nurse takes which action? 1. Administers an antiemetic 2. Places the child in a side-lying Sims’ position 3. Notifies the registered nurse (RN) 4. Increases the IV fluids Answer: 3 Rationale: A complication following surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child’s abdominal contents, resulting from lengthening of the child’s body. It results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or those who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first, because it should not be implemented without a prescribed order. Eliminate option 2 next, because this child requires logrolling and the Sims’ position may cause injury following surgery. From the remaining options, note the signs and symptoms in the question. These should alert you that the RN needs to be notified. Review superior mesenteric artery syndrome if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1402. Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 333. 6. A nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates a need for further instruction? 1. “I will apply lotion under the brace to prevent skin breakdown.” 2. “I need to avoid applying powder under the brace because it will cake.” 3. “I need to have my child wear a soft fabric under the brace.” 4. “I need to encourage my child to perform prescribed exercises.” Answer: 1

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Rationale: Both the use of lotions or powders should be avoided because they can become sticky or cake under the brace, causing irritation. Options 2, 3, and 4 are appropriate statements regarding care of a child with a brace. Test-Taking Strategy: Use the process of elimination and note the key words, need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that lotions and powders need to be avoided will assist in directing you to option 1. Review home care instructions regarding the care of a child in a brace if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 331-332. 7. The mother of a child with juvenile rheumatoid arthritis (JRA) calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse makes which response to the mother? 1. “The ROM exercises must be performed every day.” 2. “Avoid all exercise during painful periods.” 3. “Administer additional pain medication before performing ROM exercises.” 4. “Have the child perform simple isometric exercises during this time.” Answer: 4 Rationale: During painful episodes, hot or cold packs, splinting, and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, it is important to begin simple isometric or tensing exercises as soon as the child is able. These exercises do not involve joint movement. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because of the words “must,” “all,” and “additional” in each of these options. Review pain management and care during exacerbations if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 581. 8. A 4-year-old child sustains a fall at home and is brought to the emergency room by the mother. Following x-ray, it has been determined that the child has a fractured arm and a plaster cast is applied. The nurse provides instructions to the mother regarding cast care for the child. Which statement by the mother indicates a need for further instruction? 1. “The cast may feel warm as the cast dries.” 2. “If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast.” 3. “A small amount of white shoe polish can touch up a soiled white cast.” 4. “I can use lotion or powder around the cast edges to relieve itching.”

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Answer: 4 Rationale: The mother needs 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, 2, and 3 are appropriate instructions. Test-Taking Strategy: Use the process of elimination and note the key words, indicates a need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Recalling the principles related to routine cast care should direct you to option 4. Review home care instructions regarding cast care if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1786. 9. A nurse is assigned to care for a child with a spica cast. The nurse avoids which of the following when caring for the child? 1. Checking neurovascular status of the extremities 2. Observing for nonverbal signs of pain 3. Placing the child on a stretcher and bringing the child to the playroom 4. Using pillows to elevate the head and shoulders Answer: 4 Rationale: Pillows should not be used to elevate the head or shoulders of a child in a body cast because the pillows will thrust the child’s chest against the cast and cause discomfort and respiratory difficulty. Neurovascular checks are a critical component of care to ensure that the cast is not causing circulatory compromise. The nurse should observe for nonverbal signs of pain and should ask the older child if pain is experienced. A ride on a stretcher to the playroom or around the hospital provides changes of position and scenery. Test-Taking Strategy: Use the process of elimination and note the key word, avoids. This word indicates a false response question and that you need to select the incorrect intervention. Visualize this type of cast to direct you to option 4. Review care of the child with a spica cast if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 332. 10. A child with a fractured femur is placed in Buck skin traction. The nurse plans care knowing that this type of traction: 1. Requires frequent pin care 2. Places the child at risk for infection 3. Is a type of skin traction that pulls the hip and leg into extension 4. Uses skeletal traction and weights to provide a counterforce

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Answer: 3 Rationale: Buck skin traction is a type of skin traction used in fractures of the femur and in hip and knee contractures. It pulls the hip and leg into extension. Countertraction is applied by the child’s body. Options 1, 2, and 4 describe skeletal traction. Test-Taking Strategy: Use the process of elimination. Noting the key word, skin, in the question will assist in directing you to option 3. Review the purpose of Buck traction if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 570. 11. A nurse is preparing to perform a neurovascular check for tissue perfusion in the child with an arm cast. Which of the following is the priority in performing this procedure? 1. Taking the blood pressure 2. Taking the temperature 3. Checking the apical heart rate 4. Checking the peripheral pulse in the affected arm Answer: 4 Rationale: The neurovascular check for tissue perfusion is performed on the toes or fingers distal to an injury or cast and includes peripheral pulse, color, capillary refill time, warmth, motion, and sensation. Options 1, 2, and 3 may be components of care but are not the priority in this situation. Test-Taking Strategy: Use the process of elimination and note the key word, priority. Option 4 is the only option that addresses a neurovascular check. Review the components of a neurovascular check if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 573. 12. A nurse is checking the capillary refill in a child with a cast applied to the left arm. The nurse compresses the nail bed of a finger and it returns to its original color in 2 seconds. Based on this finding, the nurse would: 1. Notify the registered nurse (RN). 2. Document the findings. 3. Prepare the child for bivalving the cast. 4. Elevate the extremity and recheck the capillary refill immediately. Answer: 2 Rationale: When checking capillary refill, the nurse would expect to note that a compressed nail bed will return to its original color in less than 3 seconds. Options 1, 3, and 4 are unnecessary actions.

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Test-Taking Strategy: Focus on the data in the question. Recalling the normal finding when checking the capillary refill will direct you to option 2. Review this data collection technique if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 574. 13. A nurse is performing a neurovascular check on a child with a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. The nurse would: 1. Ambulate the child with crutches 2. Elevate the extremity 3. Document the findings 4. Notify the registered nurse (RN) Answer: 4 Rationale: Reduced sensation to touch or complaints of numbness or tingling at a site distal to a fracture may indicate poor tissue perfusion. This finding should be reported to the RN. Options 1, 2, and 3 are inappropriate and would delay the required and immediate interventions. Test-Taking Strategy: Use the process of elimination and recall the signs of circulatory compromise. Noting the child’s complaint will assist in directing you to option 4. Review the complications associated with a cast if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 798. 14. A nurse is assigned to care for a child in skeletal traction. The nurse avoids which of the following when caring for the child? 1. Keeping the weights hanging freely 2. Placing the bed linen on the traction ropes 3. Ensuring that the ropes are in the pulleys 4. Ensuring that the weights are out of the child’s reach Answer: 2 Rationale: Bed linens should not be placed on the traction ropes because of the risk of disrupting the traction apparatus. Options 1, 3, and 4 are appropriate measures when caring for a child in skeletal traction. Test-Taking Strategy: Note the key word, avoids. This word indicates a false response question and that you need to select the incorrect intervention. Use the process of elimination and knowledge regarding the care to the child in traction to assist in directing you to option 2. Review these nursing measures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity

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Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 570. 15. The nurse is reinforcing information to the mother of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which of the following information will the nurse provide to the mother? 1. The cast takes 24 hours to dry. 2. The cast is heavier than a plaster cast. 3. The cast is stronger than a plaster cast. 4. The cast allows for greater mobility than a plaster cast. Answer: 4 Rationale: Synthetic casts dry quickly (in less than 30 minutes) and are lighter than plaster casts. Synthetic casts allow for greater mobility than a plaster cast. However, synthetic casts are not as strong as plaster casts and are more expensive. Test-Taking Strategy: Use the process of elimination and note the key word, synthetic. Recalling the differences between a plaster and a synthetic cast will assist in directing you to option 4. Review these differences if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 329-330. <AQ>16. A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Select all instructions that would be included on the list. ____Keep small toys and sharp objects away from the cast. ____Use fingertips to lift the cast while it is drying. ____Use a padded ruler or another padded object to scratch the skin under the cast if it itches. ____Contact the physician if the child complains of numbness or tingling in the extremity. ____Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. Answers: Keep small toys and sharp objects away from the cast. Contact the physician if the child complains of numbness or tingling in the extremity. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. Rationale: 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 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 physician is notified immediately if any signs of neurovascular impairment develop. Test-Taking Strategy: Use of the ABCs—airway, breathing, and circulation—and recalling the general principles related to care of a child with a cast will assist in answering the question.

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Review these general principles if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 798. Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 574.

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