TEST 8: The Child with Musculoskeletal Health Problems

Question 1

The Client with Torticollis, Legg-Calvé-Perthes
Disease, and Musculoskeletal Dysfunction
1. In planning the discharge for a newborn diagnosed with torticollis (wry neck), the nurse
should:
1. Teach the parent the side effects of botulinum toxin (BOTOX).
2. Coordinate outpatient physical therapy.
3. Verify the date for corrective surgery.
4. Demonstrate the use of positioning wedges for sleep.

Answer 1

The Client with Torticollis, Legg-Calvé-Perthes Disease, and
Musculoskeletal Dysfunction
1. 2. Physical therapy is the most important part of the child’s plan of care. Most cases of
torticollis respond to gentle stretching exercises, which the parents perform daily. Regular physical
therapy is needed to monitor the infant’s progress. Botox injections are not approved for children
under the age of 2 and would not be an appropriate first-line treatment for an infant. Surgery is only
done if physical therapy is not successful after several months. The use of wedges to position children
during sleep is not recommended because they increase the risk of SIDS.
CN: Management of care; CL: Create

Question 2

2. A child who limps and has pain has been found to have Legg-Calvé-Perthes disease. What
   should the nurse expect to include in the child’s plan of care?
3. Initiation of pain control measures, especially at night when acute.
4. Promotion of ambulation despite child’s discomfort in the affected hip.
5. Prevention of flexion in the affected hip and knee.
6. Avoidance of weight bearing on the head of the affected femur.

Answer 2

2. 4. Legg-Calvé-Perthes disease, also known as coxa plana or osteochondrosis, is characterized
      by aseptic necrosis at the head of the femur when the blood supply to the area is interrupted.
      Avoidance of weight bearing is especially important to prevent the head of the femur from leaving the
      acetabulum, thus preventing hip dislocation. Devices such as an abduction brace, a leg cast, or a
      harness sling are used to protect the affected joint while revascularization and bone healing occur.
      Surgical procedures are used in some cases. Although pain control measures may be appropriate,
      pain is not necessarily more acute at night. Initial therapy involves rest and non–weight bearing to
      help restore motion. Preventing flexion is not necessary.
      CN: Physiological adaptation; CL: Create

Question 3

3. When planning home care for the child with Legg-Calvé-Perthes disease, what should be the
   primary focus for family teaching?
4. Need for intake of protein-rich foods.
5. Gentle stretching exercises for both legs.
6. Management of the corrective appliance.
7. Relaxation techniques for pain control.

Answer 3

3. 3. Because most of the child’s care takes place at home, the primary focus of family teaching
      would be on the care and management of the corrective device. Devices such as an abduction brace, a
      leg cast, or a harness sling are used to protect the affected joint while revascularization and bone
      healing occur. As long as the child is eating a well-balanced diet, there is no need for an intake of
      protein-rich foods. The parents can encourage range of motion in the unaffected leg, but motion in the
      affected leg is limited until it heals. Once therapy has been initiated, pain is usually not a problem.
      The key is management of the corrective device.
      CN: Reduction of risk potential; CL: Create

Question 4

4. At the 2-week well-child visit a parent states, “My baby seems to keep his head tilted to the
   right. ” The nurse should further assess the:
5. Fontanel.
6. Cervical vertebrae.
7. Trapezius muscle.
8. Sternocleidomastoid muscle.

Answer 4

4. 4. The parent is describing symptoms consistent with torticollis, or wry neck syndrome. With
      this musculoskeletal disorder, the sternocleidomastoid muscle shortens causing the infant to drop the
      head toward the affected muscle and tilt the chin upward in the opposite direction. Frequently, a lump
      may be felt in the affected muscle. Palpating the fontanel is done to assess neurologic status, not
      musculoskeletal status. Torticollis does not involve the cervical vertebrae or trapezius muscle.
      CN: Physiological adaptation; CL: Analyze

Question 5

5. An adolescent tells the nurse that the area below his knee has been hurting for several weeks.
   The nurse should obtain history information about participation in which of the following?
6. Soccer.
7. Golf.
8. Diving.
9. Swimming.

Answer 5

5. 1. The adolescent’s problem should alert the nurse to the possibility of Osgood-Schlatter
      disease. This disease, found primarily in boys 10 to 15 years of age and in girls 8 to 13 years of age,
      occurs when the infrapatellar ligament of the quadriceps muscle is not well anchored to the tibial
      tubercle. Excessive activity of the quadriceps muscle results in microtrauma, which causes swelling
      and pain. Track, soccer, and football commonly produce this condition. Osgood-Schlatter disease is
      self-limited and usually responds to rest and application of ice.
      CN: Physiological adaptation; CL: Analyze

Question 6

6. An adolescent is on the football team and practices in the morning and afternoon before school
   starts for the year. The temperature on the field has been high. The school nurse has been called to the
   practice field because the adolescent is now reporting that he has muscle cramps, nausea, and
   dizziness. Which of the following actions should the school nurse do first?
7. Administer cold water with ice cubes.
8. Take the adolescent’s temperature.
9. Have the adolescent go to the swimming pool.
10. Move the adolescent to a cool environment

Answer 6

6. 4. The adolescent is most likely experiencing heat exhaustion or heat collapse, which are
      common after vigorous exercise in a hot environment. Symptoms result from loss of fluids and include
      nausea, vomiting, dizziness, headache, and thirst. Treatment consists of moving the adolescent to a
      cool environment and giving cool liquids. Cool liquids are easier to drink than cold liquids. Taking
      the adolescent’s temperature would be appropriate once these actions have been completed.
      However, the adolescent’s temperature is likely to be normal or only mildly elevated. The water in a
      swimming pool would be too cool, possibly causing the adolescent to shiver and thus raising his
      temperature.
      CN: Basic care and comfort; CL: Synthesize

Question 7

The Client with Cerebral Palsy
7. During a developmental screening, the nurse finds that a 3-year-old child with cerebral palsy
has arrested social and language development. The nurse tells the family:
1. “This is a sign the cerebral palsy is progressing.”
2. “Your child has reached his maximum language abilities.”
3. “I need to refer you for more developmental testing.”
4. “We need to modify your therapy plan.”

Answer 7

The Client with Cerebral Palsy
7. 3. It is important to identify primary developmental delays in children with cerebral palsy and
to prevent secondary and tertiary delays. The arrested development is worrisome and requires further
investigation. It is possible the lack of development indicates hearing loss or may be a sign of autism.
The brain damage caused by cerebral palsy is not progressive. The brain of a young child is quite
plastic; assuming the child’s development has peaked at age 3 would be a serious mistake. The
therapy plan will need to be modified, but a better understanding of the underlying problem will lead
to the greatest chance of creating a successful therapy plan.
CN: Health promotion and maintenance; CL: Synthesize

Question 8

8. A child with spastic cerebral palsy is to begin botulinum toxin type A (Botox) injections.
   Which treatment goals should the health care team set for the child related to Botox? Select all that
   apply.
9. Improved nutritional status.
10. Decreased pain from spasticity.
11. Improved motor function.
12. Enhanced self-esteem.
13. Reduced caregiver strain and improved self-care.
14. Decreased speech impediments.

Answer 8

h cerebral palsy. The injections can help decrease pain from spasticity. Injections improve motor
status by reducing rigidity and allowing for more effective physical therapy to improve range of
motion. Decreased spasms enhance self-esteem. Improved motor status facilitates the ability to
provide some aspects of care, especially transfers. Botox does not significantly affect nutritional
status or speech.
CN: Management of care; CL: Create

Question 9

9. The nurse judges that the mother understands the term cerebral palsy when she describes it as a
   term applied to impaired movement resulting from which of the following?
10. Injury to the cerebrum caused by viral infection.
11. Malformed blood vessels in the ventricles caused by inheritance.
12. Nonprogressive brain damage caused by injury.
13. Inflammatory brain disease caused by metabolic imbalances.

Answer 9

9. 3. The term cerebral palsy (CP) refers to a group of nonprogressive disorders of upper motor
      neuron impairment that result in motor dysfunction due to injury. In addition, a child may have speech
      or ocular difficulties, seizures, hyperactivity, or cognitive impairment. The condition of congenital
      malformed blood vessels in the ventricles is known as arteriovenous malformations. Viral infection
      and metabolic imbalances do not cause CP.
      CN: Physiological adaptation; CL: Evaluate

Question 10

10. When assessing the development of a 15-month-old child with cerebral palsy, which of the
    following milestones should the nurse expect a toddler of this age to have achieved?
11. Walking up steps.
12. Using a spoon.
13. Copying a circle.
14. Putting a block in cup.

Answer 10

10. 4. Delay in achieving developmental milestones is a characteristic of children with cerebral
       palsy. Ninety percent of 15-month-old children can put a block in a cup. Walking up steps typically is
       accomplished at 18 to 24 months. A child usually is able to use a spoon at 18 months. The ability tocopy a circle is achieved at approximately 3 to 4 years of age.
       CN: Health promotion and maintenance; CL: Analyze

Question 11

11. The parent of a child with spastic cerebral palsy and a communication disorder tells the
    nurse, “He seems so restless. I think he is in pain.” The nurse should:
12. Assess the child for pain using the Faces, Legs, Activity, Cry, Consolability (FLACC) scale.
13. Assess the child using the pediatric FACES scale.
14. Administer the pain medication that is prescribed to be given as needed and assess the
    response.
15. Notify the primary care provider of the change in behavior.

Answer 11

11. 3. The parent is the child’s primary care provider and may be very in tune to subtle changes in
       the child’s behavior. If the parent thinks the child is in pain, it is very likely to be so. The nurse should
       administer the pain medication and evaluate if the medication affected the child’s behavior. The
       FLACC scale may be difficult to interpret when the child has spasticity. The FACES scale requires
       self-report. The primary health care provider should be contacted regarding the change in behavior
       only if other available interventions are unsuccessful.
       CN: Basic care and comfort; CL: Synthesize

Question 12

12. The mother asks the nurse whether her child with hemiparesis due to spastic cerebral palsy
    will be able to walk normally because he can pull himself to a standing position. Which of the
    following responses by the nurse would be most appropriate?
13. “Ask the doctor what he thinks at your next appointment.”
14. “Maybe, maybe not. How old were you when you first walked?”
15. “It’s difficult to predict, but his ability to bear weight is a positive factor.”4. “If he really wants to walk, and works hard, he probably will eventually.”

Answer 12

12. 3. The nurse needs to respond honestly to the mother. Most children with hemiparesis due to
       spastic cerebral palsy are able to walk because the motor deficit is usually greater in the upper
       extremity. There is no need to refer the mother to the primary health care provider. The age at which
       the mother walked may be important to elicit, but this does not influence when the child will walk.
       The will to walk is important, but without neurologic stability the child may be unable to do so.
       CN: Physiological adaptation; CL: Synthesize

Question 13

13. The nurse assesses the family’s ability to cope with the child’s cerebral palsy. Which action
    should alert the nurse to the possibility of their inability to cope with the disease?
14. Limiting interaction with extended family and friends.
15. Learning measures to meet the child’s physical needs.
16. Requesting teaching about cerebral palsy in general.
17. Seeking advice on coping on social media.

Answer 13

13. 1. Limited interaction or lack of interaction with friends and family may lead the nurse to
       suspect a possible problem with the family’s ability to cope with others’ reactions and responses to a
       child with cerebral palsy. Learning measures to meet the child’s physical needs demonstrates some
       understanding and acceptance of the disease. Requesting teaching about the disease suggests curiosity
       or a desire for understanding, thus demonstrating the family dealing with the situation. Participating in
       social media may serve as a form of support and can be a healthy coping mechanism.
       CN: Psychosocial integrity; CL: Evaluate

Question 14

The Client with Duchenne’s Muscular Dystrophy
14. The mother of a child with Duchenne’s muscular dystrophy asks about the chance that her next
child will have the disease. The nurse responds based on the understanding of which of the
following?
1. Sons have a 50% chance of being affected.
2. Daughters have a 1 in 4 chance of being carriers.
3. Each child has a 1 in 4 chance of developing the disease.
4. Each child has a 50% chance of being a carrier.

Answer 14

The Client with Duchenne’s Muscular Dystrophy
14. 1. Duchenne’s muscular dystrophy is an X-linked recessive disorder. The gene is transmitted
through female carriers to affected sons 50% of the time. Daughters have a 50% chance of being
carriers.
CN: Physiological adaptation; CL: Apply

Question 15

15. A nurse is making an initial visit to a family with a 3-year-old child with early Duchenne’s
    muscular dystrophy. Which of the following findings is expected when assessing this child?
16. Contractures of the large joints.
17. Enlarged calf muscles.
18. Difficulty riding a tricycle.
19. Small, weak muscles.

Answer 15

15. 3. Usually the first clinical manifestations of Duchenne’s muscular dystrophy include difficulty
       with typical age-appropriate physical activities such as running, riding a bicycle, and climbing stairs.
       Contractures of the large joints typically occur much later in the disease process. Occasionally
       enlarged calves may be noted, but they are not typical findings in a child with Duchenne’s muscular
       dystrophy. Muscular atrophy and development of small, weak muscles are later signs.
       CN: Physiological adaptation; CL: Analyze

Question 16

16. The nurse observes as a child with Duchenne’s muscular dystrophy attempts to rise from a
    sitting position on the floor. After attaining a kneeling position, the child “walks” his hands up his
    legs to stand. The nurse documents this as which of the following?
17. Galeazzi’s sign.
18. Goodell’s sign.
19. Goodenough’s sign.
20. Gower’s sign.

Answer 16

16. 4. With Gower’s sign, the child walks the hands up the legs in an attempt to stand, a common
       approach used by children with Duchenne’s muscular dystrophy when rising from a sitting to a
       standing position. Galeazzi’s sign refers to the shortening of the affected limb in congenital hip
       dislocation. Goodell’s sign refers to the softening of the cervix, considered a sign of probable
       pregnancy. Goodenough’s sign refers to a test of mental age.
       CN: Physiological adaptation; CL: Analyze

Question 17

17. When developing the plan of care for a child with early Duchenne’s muscular dystrophy,
    which of the following nursing goals is the priority?
18. Encouraging early wheelchair use.
19. Fostering social interactions.
20. Maintaining function of unaffected muscles.
21. Preventing circulatory impairment.

Answer 17

17. 3. The primary nursing goal is to maintain function in unaffected muscles for as long as
       possible. There is no effective treatment for childhood muscular dystrophy. Children who remain
       active are able to forestall being confined in wheelchair. Remaining active also minimizes the risk for
       social isolation. Preventing rather than encouraging wheelchair use by maintaining function for as
       long as possible is an appropriate nursing goal. Children with muscular dystrophy become socially
       isolated as their condition deteriorates and they can no longer keep up with friends. Maintaining
       function helps prevent social isolation. Circulatory impairment is not associated with muscular
       dystrophy.
       CN: Physiological adaptation; CL: Create

Question 18

18. When interacting with the mother of a child who has Duchenne’s muscular dystrophy, the
    nurse observes behavior indicating that the mother may feel guilty about her child’s condition. The
    nurse interprets this behavior as guilt stemming from which of the following?
19. The terminal nature of the disease.
20. The dependent behavior of the child.
21. The genetic mode of transmission.
22. The sudden onset of the disease.

Answer 18

18. 3. The guilt that mothers of children with muscular dystrophy commonly experience usually
       results from the fact that the disease is genetic and the mother transmitted the defective gene. Although
       many children die from the disease, the disease is considered chronic and progressive. As the disease
       progresses, the child becomes more dependent. However, guilt typically stems from the knowledge
       that the mother transmitted the disease to her son rather than the dependency of the child. The disease
       onset is usually gradual, not sudden.
       CN: Psychosocial integrity; CL: Analyze

Question 19

19. The nurse teaches the mother of a young child with Duchenne’s muscular dystrophy about the
    disease and its management. Which of the following statements by the mother indicates successful
    teaching?
20. “My son will probably be unable to walk independently by the time he is 9 to 11 years old.”
21. “Muscle relaxants are effective for some children; I hope they can help my son.”
22. “When my son is a little older, he can have surgery to improve his ability to walk.”
23. “I need to help my son be as active as possible to prevent progression of the disease.”

Answer 19

19. 1. Muscular dystrophy is a progressive disease. Children who are affected by this disease
       usually are unable to walk independently by age 9 to 11 years. There is no effective treatment for
       childhood muscular dystrophy. Although children who remain active are able to avoid wheelchair
       confinement for a longer period, activity does not prevent disease progression.
       CN: Physiological adaptation; CL: Evaluate

Question 20

The Client with Developmental Dysplasia of the
Hip
20. A 16-month-old child is seen in the clinic for a checkup for the first time. The nurse notices
that the toddler limps when walking. Which of the following would be appropriate to use when
assessing this toddler for developmental dysplasia of the hip?
1. Ortolani’s maneuver.
2. Barlow’s maneuver.
3. Adam’s position.
4. Trendelenburg’s sign.

Answer 20

The Client with Developmental Dysplasia of the Hip
20. 4. In a toddler, weight bearing causes the pelvis to tilt downward on the unaffected side
instead of upward as it would normally. This is Trendelenburg’s sign, and it indicates developmental
dysplasia of the hip. Ortolani’s maneuver is used during the neonatal period to assess developmental
dysplasia of the hip in infants. With the infant quiet, relaxed, and lying on the back, the hips and knees
are flexed at right angles. The knees are moved to abduction and pressure is exerted. If the femoral
head moves forward, then it is dislocated. Barlow’s maneuver is used to assess developmental
dysplasia of the hip in infants. As the femur is moved into or out of the acetabulum, a “clunk” is
heard, indicating dislocation. Adam’s position is used to evaluate for structural scoliosis. The child
bends forward with feet together and arms hanging freely or with palms together.
CN: Reduction of risk potential; CL: Analyze

Question 21

21. The nurse is assessing the infant shown in the figure. On observing the client from this angle,
    the nurse should document that this infant has which of the following?
22. Ortolani’s “click.”
23. Limited abduction.
24. Galeazzi’s sign.
25. Asymmetric gluteal folds.

Answer 21

21. 4. This infant with congenital hip dysplasia has asymmetric gluteal folds. The Ortolani “click”
       occurs when the nurse feels the femur sliding into the acetabulum with a “click.” Limited abduction
       may be observed during an attempt to abduct the infant’s thighs. Galeazzi’s sign reveals femoral
       foreshortening and is observed by flexing the thighs.
       CN: Health promotion and maintenance; CL: Analyze

Question 22

22. The nurse teaches the parents of an infant with developmental dysplasia of the hip how to
    handle their child in a Pavlik harness. Which of the following is most appropriate?
23. Fitting the diaper under the straps.
24. Leaving the harness off while the infant sleeps.
25. Checking for skin redness under straps every other day.
26. Putting powder on the skin under the straps every day.

Answer 22

22. 1. The Pavlik harness is worn over a diaper. Knee socks are also worn to prevent the straps
       and foot and leg pieces from rubbing directly on the skin. For maximum results, the infant needs to
       wear the harness continuously. The skin should be inspected several times a day, not every other day,
       for signs of redness or irritation. Lotions and powders are to be avoided because they can cake andirritate the skin.
       CN: Reduction of risk potential; CL: Synthesize

Question 23

23. When developing the teaching plan for parents using the Pavlik harness with their child, what
    should be the nurse’s initial step?
24. Assessing the parents’ current coping strategies.
25. Determining the parents’ knowledge about the device.
26. Providing the parents with written instructions.
27. Giving the parents a list of community resources.

Answer 23

23. 2. Assessing the learner’s knowledge level is the initial step in any teaching plan to promote
       the maximum amount of learning. This assessment also provides the nurse with a starting point for
       teaching. Assessing coping strategies can provide important information to the development of the
       teaching plan but is not the initial step. Giving parents written instructions or a list of community
       resources is appropriate once the parents’ knowledge level has been determined and teaching has
       begun.
       CN: Reduction of risk potential; CL: Create

Question 24

24. When teaching the family of an older infant who has had a spica cast applied fordevelopmental dysplasia of the hip, which information should the nurse include when describing the
    abduction stabilizer bar?
25. It can be adjusted to a position of comfort.
26. It is used to lift the child.
27. It adds strength to the cast.
28. It is necessary to turn the child.

Answer 24

24. 3. The abduction bar is incorporated into the cast to increase the cast’s strength and maintain
       the legs in alignment. The bar cannot be removed or adjusted, unless the cast is removed and a new
       cast is applied. The bar should never be used to lift or turn the client, because doing so may weaken
       the cast.
       CN: Reduction of risk potential; CL: Synthesize

Question 25

25. The mother asks the nurse about using a car seat for her toddler who is in a hip spica cast.
    The nurse should tell the mother:
26. “You can use a seat belt because of the spica cast.”
27. “You will need a specially designed car seat for your toddler.”
28. “You can still use the car seat you already have.”
29. “You’ll need to get a special release from the police so that a car seat won’t be needed.”

Answer 25

25. 2. The toddler in a hip spica cast needs a specially designed car seat. The one that the mother
       already has will not be appropriate because of the need for the car seat to accommodate the cast and
       abductor bar.
       CN: Safety and infection control; CL: Synthesize

Question 26

The Client with Congenital Clubfoot
26. The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should
provide additional teaching to the parents if they state:
1. “I should call if I see changes in the color of the toes under the cast.”
2. “I should use a pillow to elevate my child’s foot as he sleeps.”
3. “My baby will need a series of casts to fix her foot.”
4. “Having a cast should not prevent me from holding my baby.”

Answer 26

The Client with Congenital Clubfoot
26. 2. Elevating the extremity at different points during the day is helpful to prevent edema, but
pillows should not be used in the crib because they increase the risk of sudden infant death syndrome
(SIDS). A change in the color of the toes is a sign of impaired circulation and requires medical
evaluation. Children typically need a series of 5 to 10 casts to correct the deformity. Infants with club
feet still need frequent holding like any other newborn.
CN: Safety and infection control; CL: Evaluate

Question 27

27. The parents of a neonate born with congenital clubfoot express feelings of helplessness and
    guilt, and are exhibiting anxiety about how the neonate will be treated. Which of the following actions
    by the nurse would be most appropriate initially?
28. Ask them to share these concerns with the primary care provider.
29. Arrange a meeting with other parents whose infants have had successful clubfoot treatment.
30. Discuss the problem with the parents and the current feelings that they are experiencing.
31. Suggest that they make an appointment to talk things over with a counselor.

Answer 27

27. 3. When an infant is born with an unexpected anomaly, parents are faced with questions,
       uncertainties, and possible disappointments. They may feel inadequate, helpless, and anxious. The
       nurse can help the parents initially by assessing their concerns and providing appropriate information
       to help them clarify or resolve the immediate problems. Referring the parents to the primary health
       care provider is not necessary at this time. The nurse can assist the parents by listening to their
       concerns. Having them talk with other parents would be helpful a little bit later, once the nurse
       assesses their concerns and discusses the problem and the parents’ current feelings. If the parents
       continue to have difficulties expressing and working through their feelings, referral to a counselor
       would be appropriate.
       CN: Psychosocial integrity; CL: Synthesize

Question 28

28. After teaching the parents of an infant with clubfoot requiring application of a plaster cast
    how to care for the cast, which of the following statements would indicate that the parents have
    understood the teaching?
29. “If the cast becomes soiled, we’ll clean it with soap and water.”
30. “We’ll elevate the leg with the cast on pillows, so the leg is above heart level.”
31. “We will check the color and temperature of the toes of the casted leg frequently.”
32. “The petals on the edge of the cast can be removed after the first 24 hours.”

Answer 28

28. 3. A cast that is too tight can cause a tourniquet effect, compromising the neurovascular
       integrity of the extremity. Manifestations of neurovascular impairment include pain, edema,
       pulselessness, coolness, altered sensation, and inability to move the distal exposed extremity. The
       toes of the casted extremity should be assessed frequently to evaluate for changes in neurovascular
       integrity. Wetting a plaster cast with water and soap softens the plaster, which may alter the cast’seffectiveness. There is no reason to elevate the casted extremities when a child with clubfoot is being
       treated with nonsurgical measures. The legs would be elevated if swelling were present. Petals,
       which are applied to cover the rough edges of the cast, are to be left in place to minimize the risk for
       skin irritation from the cast edges.
       CN: Reduction of risk potential; CL: Evaluate

Question 29

The Client with Juvenile Idiopathic Arthritis
29. The father of a preschool-age child with a tentative diagnosis of juvenile idiopathic arthritis
(JIA) asks about a test to definitively diagnose JIA. The nurse’s response is based on knowledge of
which of the following?
1. The latex fixation test is diagnostic.
2. An increased erythrocyte sedimentation rate is diagnostic.
3. A positive synovial fluid culture is diagnostic.
4. No specific laboratory test is diagnostic.

Answer 29

The Client with Juvenile Idiopathic Arthritis
29. 4. The nurse’s response to the father is based on the knowledge that there is no definitive test
for JIA. The latex fixation test, which is commonly used to diagnose arthritis in adults, is negative in
90% of children. The erythrocyte sedimentation rate may or may not be increased during active
disease. This test identifies the presence of inflammation only. Synovial fluid cultures are done to rule
out septic arthritis, not to diagnose JIA.
CN: Reduction of risk potential; CL: Analyze

Question 30

30. The parents of a child just diagnosed with juvenile idiopathic arthritis (JIA) tell the nurse that
    the diagnosis frightens them because they know nothing about the prognosis. What should the nurse
    include when teaching the parents about the disease?
31. Half of affected children recover without joint deformity.
32. Many affected children go into long remissions but have severe deformities.
33. The disease usually progresses to crippling rheumatoid arthritis.
34. Most affected children recover completely within a few years.

Answer 30

30. 1. In half of the children diagnosed with JIA, recovery occurs without joint deformity.
       Approximately one-third of the children will continue to have the disease into adulthood, and
       approximately one-sixth will experience severe, crippling deformities.
       CN: Physiological adaptation; CL: Apply

Question 31

31. The mother of a 4-year-old child with juvenile idiopathic arthritis (JIA) is worried that her
    child will have to stop attending preschool because of the illness. Which of the following responses
    by the nurse would be most appropriate?
32. “It may be difficult for your child to attend school because of the side effects of the
    medications he will be prescribed.”
33. “Your child should be encouraged to attend school, but he’ll need extra time to work out early
    morning stiffness.”
34. “You should keep your child at home from school whenever he experiences discomfort or pain
    in his joints.”
35. “Your child will probably need to wear splints and braces so that his joints will be supported
    properly.”

Answer 31

31. 2. Socialization is important for this preschool-age child, and activity is important to maintain
       function. Because children with JIA commonly experience most problems in the early morning after
       arising, they need more time to “warm up.” Adverse effects may or may not occur. The child’s normal
       routine needs to be maintained as much as possible. Although splints and braces may be needed, they
       are worn during periods of rest, not activity, to maintain function.
       CN: Physiological adaptation; CL: Synthesize

Question 32

32. A preschool-age child with juvenile idiopathic arthritis (JIA) has become withdrawn, and the
    mother asks the nurse what she should do. Which of the following suggestions by the nurse would be
    most appropriate?
33. Introduce the child to other children her age who also have JIA.
34. Tell the mother to spend extra time with the child and less time with her other children.
35. Recommend that the mother send the child to see a counselor for therapy.
36. Encourage the mother to be supportive and understanding of the child.

Answer 32

32. 4. Because the child is dealing with grief and loss associated with a chronic illness, parents
       need to be supportive and understanding. The child needs to feel valued and worthwhile. Introducing
       the child to others of the same age who also have JIA most probably would be ineffective because
       preschoolers are developmentally egocentric. Although the child needs to feel valued, the mother’s
       spending more time with the child and less time with her other children is inappropriate because the
       child with JIA may experience secondary gain from the illness if the family interaction patterns are
       altered. Also, this action reinforces the child’s withdrawal behavior. Psychological counseling is not
       needed at this time because the child’s reaction is normal.
       CN: Psychosocial integrity; CL: Synthesize

Question 33

33. Nonsteroidal anti-inflammatory drugs are the first choice in treating a child with juvenile
idiopathic arthritis. Which adverse effects should the nurse include in the teaching plan for the
parents? Select all that apply.
1. Weight gain.
2. Abdominal pain.
3. Blood in the stool.
4. Folic acid deficiency.
5. Reduced blood clotting ability.

Answer 33

33. 2,3,5. Adverse effects from nonsteroidal anti-inflammatory drugs include abdominal pain,
    blood in stool, and reduced clotting ability. Weight gain is common with corticosteroids. Folic acid
    deficiency is associated with methotrexate therapy.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 34

34. What should the nurse include when developing the teaching plan for the parents of a child
    with juvenile idiopathic arthritis who is being treated with naproxen (Naprosyn)?
35. Anti-inflammatory effect will occur in approximately 8 weeks.
36. Within 24 hours, the child will have anti-inflammatory relief.
37. The nurse should be called before giving the child any over-the-counter medications.
38. If a dose is forgotten or missed, that dose is not made up.

Answer 34

34. 3. The first group of drugs typically prescribed is the nonsteroidal anti-inflammatory drugs,
       which include naproxen. Naproxen is included in only a few over-the-counter medications but aspirin
       is in several. The family should check with the nurse before giving any over-the-counter medications.
       Once therapy is started, it takes hours or days for relief from pain to occur. However, it takes 3 to 4
       weeks for the anti-inflammatory effects to occur, including reduction in swelling and less pain withmovement. The missed dose will need to be made up to maintain the serum level and to maintain
       therapeutic effectiveness of the drug.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 35

The Client with a Fracture
35. A 10-year-old has 5 lb (2.27 kg) of Buck’s extension traction on his left leg. The nurse should
assess the child for which of the following? Select all that apply.
1. Dryness of the skin, by removing the foam wraps and boot.
2. Alignment of the shoulder, hips, and knees.
3. Frayed rope near pulleys.
4. Correct amount of traction weight on fracture.
5. Pressure on the coccyx.

Answer 35

The Client with a Fracture
35. 2,3,4,5. Buck’s traction provides a skin traction that keeps the extremity in straight alignment
and can be observed by noting a straight line formed between the shoulder, hips, and knees. The rope
must be intact to maintain the prescribed traction from the weights. The correct amount of traction
must be maintained to keep the fractured femur in correct alignment. Because the client is in a
recumbent position, the nurse should also inspect the skin on the back and buttocks for integrity. The
nurse should not remove the client’s wraps and boot unless she has a primary health care provider’s
prescription to do so.
CN: Physiological adaptation; CL: Analyze

Question 36

36. A 14-year-old has just had a plaster cast placed on his lower left leg. To provide safe cast
    care, the nurse should:
37. Petal the cast as soon as it is put on.
38. Keep the child in the same position for 24 hours until the cast is dry.
39. Use only the palms of the hand when handling the cast.
40. Notify the physician if the client feels heat.

Answer 36

36. 3. The wet plaster cast should be handled using only the palms of the hands to prevent
       indentations of the cast surface. Petaling a cast should be done only when the edges of the cast are
       rough and are causing irritation to the client’s skin. The nurse should not keep the child in the same
       position until the cast is dry. Doing so would prohibit proper toileting and elimination and would
       produce undue pressure on the coccyx. The cast typically emits heat as it dries, so notifying a primary
       health care provider is not necessary in this instance. If needed, a fan can be used to circulate the
       room air.
       CN: Health promotion and maintenance; CL: Evaluate

Question 37

37. The nurse is explaining the nature of the fracture to the parents of a 10-year-old who has a
    greenstick fracture. Which drawing should the nurse choose to explain the fracture to the parents?
38. (with photo)
    2.(with photo)
    3.(with photo)
    4.(with photo)

Answer 37

37. 3. The nurse should show the parents the figure of the greenstick fracture as noted in answer 3
       in which the fracture does not completely cross through the bone. Answer A is a plastic deformation,
       or a bend in the bone. Answer B is a buckle. Answer D is a complete fracture.

CN: Physiological adaptation; CL: Synthesize

Question 38

38. A 9-year-old is given morphine for postoperative pain. As the nurse is assessing the client for
    pain 4 hours later, his mother leaves the room and the child begins to cry. The nurse’s initial
    assessment of the child’s pain is that he is:
39. Not in pain because the crying began after the mother leaves.
40. Less tolerant of pain because he is upset.
41. In pain because he is crying.
42. Not in pain because he was medicated 4 hours ago.

Answer 38

38. 2. Emotional or physical stress lowers a person’s tolerance of pain. The mother’s presence
       may have distracted him and when she left it caused him to focus on the pain he was having. Crying
       does not automatically indicate pain. The nurse must further assess the client for pain. Although an
       analgesic was given 4 hours before, pain may be present.
       CN: Physiological adaptation; CL: Analyze

Question 39

39. A 13-year-old is having surgery to repair a fractured left femur. As a part of the preoperative
    safety checklist, the nurse should do which of the following?
40. Ask the teen to point to the surgery site.
41. Verify that the site, side, and level are marked.
42. Ask the parents if they have signed the operative permit.
43. Restate the surgery risks to the parents.

Answer 39

39. 2. As part of a surgery safety checklist, the nurse must verify that the site, side, and level are
       marked. Pointing to the area is not sufficient identification of the surgery site. The nurse must verify
       the form has been signed by reviewing the form. The surgeon holds primary responsibility for
       explaining the risks of surgery.
       CN: Safety and infection control; CL: Synthesize

Question 40

40. A child is admitted with a fracture of the femur and placed in skeletal traction. What should
the nurse assess first?
1. The pull of traction on the pin.
2. The Ace bandage.
3. The pin sites for signs of infection.
4. The dressings for tightness.

Answer 40

40. 1. Skeletal traction applies the pull directly to the skeletal structure by tongs, pin, or wire. The
       nurse should assess the pull of the traction on the pin first. This is critical to the success of the
       traction. Once this is assessed, then the pin sites are assessed for signs of infection. The dressings
       would be examined after the pull of the traction, neurovascular status, and pin sites were assessed.
       The Ace wrap is used to anchor skin traction nonadherent straps, not skeletal traction.
       CN: Reduction of risk potential; CL: Synthesize

Question 41

41. The nurse is caring for a child in Bryant’s traction (see figure). The nurse should:
42. Adjust the weights on the legs until the buttocks rest on the bed.
43. Provide frequent skin care.
44. Place a pillow under the buttocks.
45. Remove the elastic leg wraps every 8 hours for 10 minutes.

Answer 41

41. 2. The traction is positioned correctly; the nurse should provide frequent skin care to the back
       and shoulder areas. The hips and buttocks should be lifted off the bed to provide counter traction; the
       nurse should not adjust the weights. The nurse should not place a pillow under the buttocks as this
       would prevent counter traction. The elastic wraps should remain on the legs unless permitted by the
       primary health care provider.
       CN: Physiological adaptation; CL: Synthesize

Question 42

42. A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts.
    It is too early for pain medication. The nurse should:
43. Place a pillow under the child’s buttocks to provide support.
44. Remove the weight from the left leg.
45. Assess the feet for signs of neurovascular impairment.4. Reposition the pulleys so the traction is looser.

Answer 42

42. 3. The nurse should assess the client frequently for signs of neurovascular impairment of the
       feet, such as pallor, coldness, numbness, or tingling. Pillows are not placed under the buttocks
       because the pillows would alter the alignment of the traction. Weights provide traction and should not
       be removed. Pulleys help to maintain optimal alignment of the traction and therefore should be left
       alone.
       CN: Basic care and comfort; CL: Synthesize

Question 43

43. The nurse in the emergency department is caring for a 3-year-old child with a fractured
    humerus. The child is crying and screaming, “I hate you.” Which of the following would be most
    appropriate?
44. Tell the parents they will need to wait out in the lobby.
45. Ask the charge nurse to assign this client to another nurse.
46. Reassure the parents that this normal behavior under the circumstances.
47. Ask the parents to discipline the child so that the physician can treat her.

Answer 43

43. 3. Explaining to the parents that this is a normal reaction under the circumstances is most
       appropriate. The child’s outburst is related to the child’s fears of the unknown. The child is scared and
       anxious and needs the parents for support. Asking the parents to wait outside would only add to the
       child’s fear and anxiety. The reaction is normal for a child her age and does not usually call for a
       change in staff assignments. Asking the parents to discipline their child for her behavior is
       inappropriate. The nurse needs to handle the situation.
       CN: Health promotion and maintenance; CL: Synthesize

Question 44

44. After a plaster cast has been applied to the arm of a child with a fractured right humerus, the
    nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the
    mother agrees to seek medical advice if the child experiences which of the following?
45. Inability to extend the fingers on the right hand.
46. Vomiting after the cast is applied.
47. Coolness and dampness of the cast after 5 hours.
48. Fussiness with statements that the cast is heavy.

Answer 44

44. 1. Inability to extend the fingers of the involved arm may indicate neurologic impairment
       caused by pressure on soft tissue. It is not unusual for a child to vomit after experiencing a traumatic
       injury. It may take up to 72 hours for a plaster cast to dry. Until the cast dries, the dampness causes the
       sensation of coolness. The cast will seem heavy until the child adjusts to the extra weight. The child
       may exhibit fussiness (such as whining, crying or clinging) as a result of numerous causes, such as
       placement of the cast, the hospital experience, or pain. These reactions are normal and do not warrant
       medical advice.
       CN: Reduction of risk potential; CL: Evaluate

Question 45

45. The nurse should teach the mother of a child who has a new cast for a fractured radius to do
    which of the following for the first few days at home?
46. Use a hair dryer to dry the cast more quickly.
47. Have the child refrain from strenuous activities.
48. Check movement and sensation of the child’s fingers once a day.
49. Administer acetaminophen every 8 to 12 hours for discomfort.

Answer 45

45. 2. For the first few days after application of a plaster or fiberglass cast, the child should not
       engage in strenuous activities, to minimize swelling that would cause the cast to become too tight. Use
       of a hair dryer to complete the drying of the cast is not encouraged because the hair dryer only dries
       the outside of the cast. Movement and sensation of the fingers need to be checked several times a day
       for the first few days. Typically, the mother would be instructed to administer acetaminophen every 4
       to 6 hours, not every 8 to 12 hours, for discomfort.
       CN: Reduction of risk potential; CL: Synthesize

Question 46

46. While assessing a 3-year-old child who has had an injury to the leg, has pain, and refuses to
    walk, the nurse notes that the child’s left thigh is swollen. What should the nurse do next?
47. Assess the neurologic status of the toes.
48. Determine the circulatory status of the upper thigh.
49. Obtain the child’s vital signs.
50. Notify the physician immediately.

Answer 46

46. 1. Because the nurse suspects a possible fracture based on the child’s presentation, assessingthe neurologic and circulatory status of the toes, the tissues distal to the fracture, is important. Soft
       tissue contusions, which accompany femur fractures, can result in severe hemorrhage into the tissue
       and subsequent circulatory and neurologic impairment. Once this information has been obtained, vital
       signs can be assessed and the nurse can notify the primary health care provider and report the
       findings. In fractures, circulation impairment will occur distal to the injury.
       CN: Physiological adaptation; CL: Synthesize

Question 47

47. Anticipating that a 3-year-old child in traction will have need for diversion, what should the
nurse offer the child?
1. A video game.
2. Blocks.
3. Hand puppets.
4. Marbles

Answer 47

47. 3. Hand puppets would enable a 3-year-old child in traction to act out feelings within the
       constraints imposed by the traction. A 3-year-old needs creative play. The video game would make
       the child too active in bed and does not meet the child’s developmental need for creative play. Blocks
       would be more appropriate for a younger child. Marbles are unsafe at this age because they can be
       swallowed.
       CN: Health promotion and maintenance; CL: Synthesize

Question 48

48. The parents of a child who requires skeletal traction are unable to visit their child for more
    than 1 hour a day because there are five other children at home and both parents work outside of the
    home. The nurse recognizes expressions of guilt in both parents. To help alleviate this guilt, the nurse
    should make which of the following remarks?
49. “I’m sure you feel guilty about not being able to visit often.”
50. “It’s important that you visit even for 1 hour.”
51. “Not all parents can stay all the time.”
52. “Perhaps you could take turns visiting for a bit longer.”

Answer 48

48. 2. Stressing the importance of the parents’ visiting when they can helps to alleviate the guilt
       they feel. It allows the parents to feel that they are doing what they can. Acknowledging the guilt gives
       the parents an opportunity to talk about it but does not help alleviate it. Comparing the parents with
       other parents does not alleviate guilt feelings. The parents need reinforcement that what they are
       doing is appropriate. Suggesting that the parents take turns visiting implies that they should feel guilty
       because they may not be doing all they could.
       CN: Psychosocial integrity; CL: Synthesize

Question 49

49. The child in a new hip spica cast seems to be adjusting to the cast, except that after each mealthe child tells the nurse that the cast is too tight. Which of the following should the nurse plan to do?
50. Administer a laxative prior to each meal.
51. Offer smaller, more frequent meals.
52. Give the child a mechanical soft diet.
53. Offer the child more fruits and grains.

Answer 49

49. 2. A hip spica cast encircles the abdomen. When the child eats a large meal, abdominal
       pressure increases, causing the cast to feel tight. Therefore, the nurse should plan to offer smaller,
       more frequent meals to minimize abdominal distention. If the child’s appetite were decreased in
       conjunction with a feeling of fullness, the nurse might suspect that the child was becoming constipated
       and plan to use laxatives or a higher-fiber diet. A mechanical soft diet is indicated when the child has
       difficulty chewing food adequately. Giving the child more fruits and grains would contribute to
       abdominal distention and problems with the cast tightness after eating.
       CN: Reduction of risk potential; CL: Synthesize

Question 50

50. The nurse is helping a family plan for the discharge of their child, who will be going home in
    a spica cast. Which of the following points of information should be most important for the nurse to
    consider?
51. The bathrooms are all on the second floor.
52. The child’s bedroom is on the second floor.
53. A 16-year-old sister will care for the child during the day.
54. There are three steps up to the front door.

Answer 50

50. 2. The child with a hip spica cast who is going home and has a bedroom on the second floor
       of the home needs to have the bed moved to an area that is more central to family life. Negotiating a
       flight of steps at least twice a day (on awakening in the morning and before going to bed at night) with
       a child in a hip spica cast would be difficult and most likely dangerous. Because the child in a hip
       spica cast will need to use a bedpan or urinal, the bathrooms can be on any floor. Because the family
       is involved in the discharge, the 16-year-old sister should be taught appropriate care along with the
       rest of the family. The child can be carried up and down the three steps to the house the few times
       necessary after discharge.
       CN: Safety and infection control; CL: Create

Question 51

51. The nurse is measuring a child for crutches. What should the nurse consider? Select all that
    apply.
52. Type of gait child will be using.
53. Degree of child’s elbow flexion.
54. Space above the crutch to child’s axilla.
55. Weight of the child.
56. Whether child has to use the stairs.

Answer 51

51. 2,3. To ensure proper fit of crutches, the child’s elbow flexion should be 20 degrees, and the
    area above the top of the crutch to the child’s axilla should be 1 to 1 1/2 inches (2.5 to 3.8 cm). The
    type of gait, weight of the child, and use of stairs are not factors in the measurement.
    CN: Reduction of risk potential; CL: Apply

Question 52

The Client with Osteomyelitis
52. During the initial assessment of a child admitted to the pediatric unit with osteomyelitis of the
left tibia, when assessing the area over the tibia, which is an expected finding?
1. Diffuse tenderness.
2. Decreased pain.
3. Increased warmth.
4. Localized edema.

Answer 52

52. 3. Findings associated with osteomyelitis commonly include pain over the area, increased
       warmth, localized tenderness, and diffuse swelling over the involved bone. The area over the affected
       bone is red.
       CN: Physiological adaptation; CL: Analyze

Question 53

53. A child is to receive IV antibiotics for osteomyelitis. Before the initial dose of antibiotics can
    be given, the nurse confirms that a blood sample for which of the following tests has been drawn?
54. Creatinine.
55. Culture.
56. Hemoglobin.
57. White blood count.

Answer 53

53. 2. Cultures are used to determine exactly what organism is causing the inflammation. From the
       culture, sensitivities to various antibiotics may be determined. If the antibiotics are given before
       obtaining the culture, the antibiotics may inhibit the growth of the organism in the culture medium.
       This may lead to a delay in the most appropriate treatment. Unless a child has a known renal problem,
       baseline creatinine levels are not typically needed. However, levels may be needed during treatment
       depending on the medication. A complete blood count (CBC) with hemoglobin and white blood cell
       count is typically prescribed for any suspected infection, but these tests do not identify the causative
       organism.
       CN: Reduction of risk potential; CL: Apply

Question 54

A child is being treated with vancomycin 40 mg/kg/day IV divided into 3 doses for osteomyelitis. The
primary care provider has prescribed drug protocol management by pharmacy and a trough
vancomycin level 30 minutes before the third dose scheduled for 9 AM . The laboratory report returns
prior to the third dose:

0830 VANCOMYCIN
7 mcg/ml (4.8umol/L)

**

Therapeutic Range
10-15 mcg/ml (6.9 to 10.4 umol/L)

The nurse should:

1. Administer the 9 AM dose.
2. Notify the primary care provider.
3. Notify the pharmacist.
4. Draw a peak drug level.

Answer 54

54. 3. The vancomycin level is not therapeutic and will need to be adjusted. Drug management by
       the pharmacy is prescribed. This is very frequently done in institutions with pediatric clinical
       pharmacists. Thus, the nurse should notify the pharmacist to adjust the dose. Giving subtherapeutic
       doses may prolong care. The nurse should contact the health care provider designated to address the
       issue. If needed, the pharmacist would notify the primary care provider. Peak levels are not
       prescribed on this client.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 55

55. The nurse is caring for a child with osteomyelitis who will be receiving high-dose
    intravenous antibiotic therapy for 3 to 4 weeks. What should the nurse plan to monitor?
56. Blood glucose level.
57. Thrombin times.
58. Urine glucose level.
59. Urine specific gravity.

Answer 55

55. 4. Long-term, high-dose antibiotic therapy can adversely affect renal, hepatic, and
       hematopoietic function. Urine specific gravity would provide valuable information about the kidneys’
       ability to concentrate or dilute urine, thereby suggesting renal impairment. Blood glucose levels
       reveal how well the client’s body is using glucose. Thrombin times reveal information about the
       clotting mechanism. Urine glucose levels reveal information about the body’s use and excretion of
       glucose.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 56

56. To meet the developmental needs of an 8-year-old child who is confined to home with
    osteomyelitis, what should the nurse include in the care plan?
57. Encouraging the child to communicate with schoolmates.
58. Encouraging the parents to stay with the child.
59. Allowing siblings to visit freely throughout the day.4. Talking to the child about his interests twice daily.

Answer 56

56. 1. Encouraging contact with schoolmates allows the school-age child to maintain and develop
       socialization with peers, an important developmental task of this age group. Although having family
       visits and interacting with the child are important, they do not meet the child’s developmental needs.
       Talking to the child about his interests is important, but encouraging contact with schoolmates is
       crucial to maintain and develop socialization with peers.
       CN: Health promotion and maintenance; CL: Create

Question 57

57. A child with newly diagnosed osteomyelitis has nausea and vomiting. The parent wishes to
    give the child ginger snaps to help control the nausea. The nurse should tell the parent:
58. “You can try them and see how he does.”
59. “I will need to get a prescription.”
60. “Your child needs medication for the vomiting.”
61. “We discourage the use of home remedies in children.”

Answer 57

57. 1. Some clients find ginger snaps help relieve nausea. Ginger, in small doses such as would
       be found in the cookies, has few side effects. There is no reason that the parent should not try this
       dietary intervention; however, the nurse must monitor the client’s response. If the child has a diet as
       tolerated prescription, there is no need for an additional prescription. Ultimately, the child may need
       an antiemetic medication, but dietary strategies are often successful in treating vomiting related to
       osteomyelitis. Making a universal statement disregarding home remedies is not a client-centered
       approach.
       CN: Physiological adaptation; CL Synthesize

Question 58

The Client with Scoliosis

58. When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
59. Bend forward at the waist with arms hanging freely.
60. Lie flat on the floor and extend her legs straight from the trunk.
61. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
62. Stand against a wall while pressing the length of her back against the wall.

Answer 58

The Client with Scoliosis
58. 1. Scoliosis, a lateral deviation of the spine, is assessed by having the client bend forward at
the waist with arms hanging freely, then looking for lateral curvature of the spine and a rib hump. The
other positions will not reveal the deviation of the spine.
CN: Health promotion and maintenance; CL: Analyze

Question 59

59. After teaching the family of a child with scoliosis who needs to wear a Boston brace, which
    of the following activities, if stated by the child and family as occasions appropriate for removal of
    the brace, indicates successful teaching?
60. When bathing, for about 1 hour per day.
61. While eating, for a total of 3 hours a day.
62. During school, for about 8 hours a day.
63. When sleeping, for a total of 10 hours a day.

Answer 59

59. 1. One of the most effective spinal braces for correcting scoliosis, the Boston brace should be
       worn for at least 16 to 23 hours a day, except when carrying out personal hygiene measures.
       CN: Reduction of risk potential; CL: Evaluate

Question 60

60. When teaching the child with scoliosis being treated with a Boston brace about exercises, the
    nurse explains that the exercises are performed primarily for which of the following purposes?
61. To decrease back muscle spasms.
62. To improve the brace’s traction effect.
63. To prevent spinal contractures.
64. To strengthen the back and abdominal muscles.

Answer 60

60. 4. Exercises are prescribed for the child with scoliosis wearing a Boston brace to help
       strengthen spinal and abdominal muscles and provide support. Typically, children wearing a Boston
       brace do not have muscle spasms. Performing exercises provides no effect on the brace’s traction
       ability. Spinal contractures do not occur when a Boston brace is worn.
       CN: Physiological adaptation; CL: Apply

Question 61

61. A 14-year-old is being screened for scoliosis. Which of the following statements about
    scoliosis screening is true?
62. Teenagers aged 14 to 16 should be screened yearly.
63. A shirt and shorts are worn for screening.
64. The girl is assessed standing and bending forward.
65. The girl should refrain from eating 8 hours before the examination.

Answer 61

61. 3. Screening is done with the child wearing minimal clothing, standing and bending forward.
       The examination should be done on girls aged 10 to 12 years old, so a diagnosis can be made early
       and the scoliosis can be treated with exercises or bracing. Only underwear should be worn for the
       examination so that symmetry of the shoulders and hips can be observed. If the deviation on the
       scoliometer is <20 degrees, no treatment is indicated. The child does not need to refrain from eating
       prior to this test.
       CN: Physiological adaptation; CL: Apply

Question 62

62. A 10-year-old with scoliosis has to wear a brace. The nurse should develop a teaching plan
    with the client to include which of the following instructions?
63. Wear the brace during waking hours.
64. Use lotions to relieve skin irritations.
65. Wear a form-fitting, sleeveless T-shirt under the brace.
66. Bathe the skin under the brace once per week.

Answer 62

62. 3. A form-fitting, sleeveless T-shirt can be worn under the brace to prevent skin irritation and
       collect perspiration. Braces are worn 23 hours each day. Lotions may cause irritation and should not
       be used. The skin under the brace should be bathed daily to help prevent irritation from the brace. The
       brace can be removed for bathing so all the skin can be bathed.
       CN: Physiological adaptation; CL: Create

Question 63

Managing Care Quality and Safety
63. A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the
pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to
refill the baclofen pump today, but had to cancel the appointment when the child became ill. The nurse
should:
1. Explain that the medication should be discontinued during illness.
2. Arrange for the pump to be refilled in the hospital.
3. Reschedule the pump refill for the day of discharge.
4. Instruct caregivers to call for a refill when the low-volume alarm sounds.

Answer 63

Managing Care Quality and Safety
63. 2. To prevent a baclofen withdraw, pump refills are scheduled several days before anticipated
low-volume alarms. The nurse should make it a high priority to have the pump refilled as soon as
possible. Discontinuing baclofen suddenly can result in a high fever, muscle rigidity, change in level
of consciousness, and even death. Waiting until the child leaves the hospital for a refill may lead to a
low dose or withdraw. Waiting for the low-volume alarm puts the client at risk because medication
and team members who can refill the pump may not be readily available under all circumstances.
CN: Management of care; CL: Synthesize

Question 64

64. Which procedures can the nurse working on a pediatric floor safely delegate to the licensed
    practical nurse (LPN)? Select all that apply.
65. Refilling a baclofen pump.
66. Administering gastrostomy tube feedings.
67. Inserting hearing aids.
68. Giving an IV push medication.
69. Calling the AM blood sugars to the physician.

Answer 64

64. 2,3. In general, LPNs may perform skills related to feeding, oral medication administration,
    and activities of daily living, such as insertion of a hearing aid. Refilling a baclofen pump constitutes
    administering an intrathecal medication and is beyond the scope of practice for LPNs in most areas.
    Some institutions allow LPNs to give IV push medicines; however, special training is required.
    Communicating with the primary health care provider would require discussion of the client’s
    assessments and evaluations, which fall under the RN scope of practice.CN: Management of care; CL: Synthesize

Question 65

65. An 8-year-old child with juvenile idiopathic arthritis (JIA) is being admitted to the hospital
    for evaluation of progressively increasing symptoms. The child weighs 60 lb (27 kg) and is 50 inches
    (127 cm) tall. The nurse is reconciling the medications the parent brought from home with the
    medications the physician has prescribed. (See chart.)
    HOME MEDS
    Ibuprofen tab
    200mg PO 4x day (for arthritis)

Purchased over the counter

Cetirizine Hydrochloride tablet 10 mg PO daily (for allergies)

Purchased over the counter

PRESCRIBED MEDS
Ibuprofen tablet 200mg PO 4x day

Methotrexate Tablet
10 mg PO every Monday

1. Have the family give the child cetirizine daily using the medication they have from home.
2. Explain the need to limit over-the-counter medications while in the hospital.
3. Request a cetirizine prescription from the primary care provider.
4. Contact the primary care provider to question the methotrexate.

Answer 65

65. 3. If the child was taking cetirizine for allergies, the nurse should contact the primary care
       provider for a prescription to continue the medication in the hospital. The provider should either
       prescribe the medication or provide a valid reason to discontinue its use. Advising the family to take
       a home supply of medications increases the risk of adverse reactions because the provider would be
       unaware of potential medication interactions. Many allergy medications that formerly required a
       prescription are now available over the counter and because parents use them the nurse should be
       aware of the interactions and risks. The nurse does not need to question the methotrexate prescription
       as this medication is being added to treat the JIA.
       CN: Safety and infection control; CL: Synthesize

Question 66

66. A 4-year-old male presents to the emergency room. His father tearfully reports that his sonwas on his shoulders in the driveway playing when he began to fall. When the child began to fall, the
    father grabbed him by the leg, swinging him toward the grass to avoid landing on the pavement. As
    the father swung his son, the child hit his head on the driveway and twisted his right leg. After a
    complete examination, it is determined that the child has a skull fracture and a spiral fracture of the
    femur. Which of the following actions should the nurse take?
67. Restrict the father’s visitation.
68. Notify the police immediately.
69. Refer the father for parenting classes.
70. Record the father’s story in the chart.

Answer 66

66. 4. The father’s story is consistent with the injuries incurred by the child; therefore, the nurse
       should document the cause of injury. There is no need to restrict the father’s visitation because the
       injuries sustained by the child are consistent with the explanation given. The police only need to be
       notified if there is suspicion of child abuse. The injuries incurred by this child appear to be
       accidental. There is no need to refer the father for parenting classes. The father appears to be upset
       about the accident and will not likely repeat such reckless behavior. However, the nurse should
       educate the father regarding child safety.
       CN: Management of care; CL: Analyze