Chapter 53: Musculoskeletal or Articular Dysfunction

Question 1

1. What effect does immobilization have on metabolism?
   a. It causes hypocalcemia.
   b. It causes a decreased metabolic rate.
   c. It causes a positive nitrogen balance.
   d. It causes increased production of stress hormones.

Answer 1

ANS: B
Immobilization causes a decreased metabolic rate with the slowing of all systems and decreased food intake, leads to hypercalcemia, and causes a negative nitrogen balance secondary to muscle atrophy. The production of stress hormones decreases, resulting in reduced physical and emotional coping capacity.

Question 2

2. What effect does immobilization have on the cardiovascular system?
   a. Venous stasis
   b. Increased vasopressor mechanism
   c. Normal distribution of blood volume
   d. Increased efficiency of orthostatic neurovascular reflexes

Answer 2

ANS: A
Because of the decreased muscle contraction, the physiological effects of immobilization include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased cerebral blood flow, and tachycardia. The distribution of blood volume is altered, with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency in orthostatic neurovascular reflexes, with an inability to adapt readily to the upright position and pooling of blood in the extremities in the upright position.

Question 3

3. What can result from the bone demineralization associated with immobility?
   a. Osteoporosis
   b. Urinary retention
   c. Pooling of blood
   d. Susceptibility to infection

Answer 3

ANS: A
Bone demineralization leads to a negative calcium balance, osteoporosis, pathological fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of immobilization on the urinary tract. The pooling of blood is a result of the cardiovascular effects of immobilization. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems.

Question 4

4. A young girl has just injured her ankle at school. In addition to calling the child’s parents, what is the school nurse’s most appropriate, immediate action?
   a. Apply ice.
   b. Observe the ankle for edema and discolouration.
   c. Encourage the child to assume a comfortable position.
   d. Obtain parental permission for administration of acetaminophen or aspirin.

Answer 4

ANS: A
Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested and elevated and have compression applied. Observing for edema and discolouration, encouraging the child to assume a comfortable position, and obtaining parental permission or administration of acetaminophen or aspirin are not immediate priorities.

Question 5

5. What term is used to describe a fracture that does not produce a break in the skin? a. Simple
   b. Compound c. Complicated d. Comminuted

Answer 5

ANS: A
If a fracture does not produce a break in the skin, it is called a simple or closed fracture. A compound or open fracture is one with an open wound through which the bone protrudes. A complicated fracture is one in which the bone fragments damage other organs or tissues. A comminuted fracture occurs when small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue; these are rare in children.

Question 6

6. What is one advantage of using a fibreglass cast instead of a plaster one?
   a. It is less expensive.
   b. It dries rapidly.
   c. It moulds closely to body parts.
   d. It has a smooth exterior.

Answer 6

ANS: B
A synthetic casting material dries within minutes compared to a plaster cast, which takes several hours to dry. Synthetic casts are more expensive, not less. Plaster casts mould closer to body parts. Synthetic casts have a rough exterior, which may scratch surfaces.

Question 7

7. The nurse is teaching the parents of a 7-year-old child who has just had a cast applied to a fractured arm with the wrist and elbow immobilized. What instruction should the nurse include in the discharge information?
   a. Swelling of the fingers is to be expected for the next 48 hours.
   b. Immobilize the shoulder to decrease pain in the arm.
   c. Allow the affected limb to hang down for 1 hour each day.
   d. Elevate the casted arm when resting and sitting up.

Answer 7

ANS: D
The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. Swelling of the fingers may indicate neurovascular damage and should be reported immediately, since permanent damage can occur within 6 to 8 hours. Joints above and below the cast on the affected extremity should be moved. The child should not engage in strenuous activity for the first few days. Rest with the extremity elevated is encouraged.

Question 8

8. Why does a nurse use the palms of his hands when handling a wet cast?
   a. To assess the dryness of the cast
   b. To facilitate easy turning
   c. To keep the patient’s limb balanced
   d. To avoid indenting the cast

Answer 8

ANS: D
Wet casts should be handled with the palms of the hands, not the fingers, to prevent the creation of pressure points. Assessing dryness, facilitating easy turning, or keeping the patient’s limb balanced are not reasons for using the palms of the hand rather than the fingers when handling a wet cast.

Question 9

9. What causes a nurse to suspect that an infection has developed under a cast?
   a. Complaint of paresthesia
   b. Cold toes
   c. Increased respirations
   d. Hot spots on the cast’s surface

Answer 9

ANS: D
If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so a window can be made in the cast to observe the site. The five P’s of ischemia from a vascular injury include pain, pallor, pulselessness, paresthesia, and paralysis. Paresthesia is an indication of vascular injury, not infection. Cold toes may be indicative of a cast that’s too tight and need further evaluation. Increased respirations may indicate a respiratory infection or pulmonary emboli. This should be reported, and the child should be evaluated.

Question 10

10. A child is upset because, when the cast was removed from her leg, the skin surface was caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material?
    a. Soak in a bathtub.
    b. Vigorously scrub the leg.
    c. Apply powder to absorb the material.
    d. Carefully pick the material off of the leg.

Answer 10

ANS: A
Simply soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days to eliminate the accumulation completely. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child’s skin.

Question 11

11. Which type of traction uses skin traction on the lower leg and a padded sling under the knee?
    a. Dunlop
    b. Bryant
    c. Russell
    d. Buck extension

Answer 11

ANS: C
Russell traction involves skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows the lower extremity to be realigned and immobilizes the hips and knees in a flexed position. Dunlop traction is an upper extremity traction used for fractures of the humerus. Bryant traction is skin traction with the legs flexed at a 90-degree angle at the hip. Buck extension traction has the legs in an extended position and is used primarily for short-term immobilization, before surgery with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease.

Question 12

12. Which is an appropriate nursing intervention when caring for a child in traction?
    a. Remove adhesive traction straps daily to prevent skin breakdown.
    b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles.
    c. Provide active range-of-motion exercises to affected extremity three times a day.
    d. Keep the child in one position to maintain good alignment.

Answer 12

ANS: B
Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released or replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement is expected with children—each time the child moves, the nurse should check to ensure that proper alignment is maintained.

Question 13

13. Which should be included when the nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip?
    a. Apply lotion or powder to minimize skin irritation.
    b. Remove the harness several times a day to prevent contractures.
    c. Return to the clinic every week for assessment.
    d. Place a diaper over the harness, preferably using a superabsorbent disposable
    diaper that is relatively thin.

Answer 13

ANS: C
Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every week for possible adjustments. Lotions and powders should not be used with the harness. The harness should not be removed, except as directed by the practitioner. A thin, disposable diaper can be placed under the harness.

Question 14

14. A newborn is born with mild clubfeet. What should the nurse explain to the parents when they ask how this will be corrected?
    a. Traction is tried first.
    b. Surgical intervention is needed.
    c. Frequent, serial casting is tried first.
    d. Children outgrow this condition when they learn to walk.

Answer 14

ANS: C
Serial casting, the preferred treatment, is begun shortly after birth and before discharge from the nursery. Successive casts allow for gradual stretching of the skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.

Question 15

15. What term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? a. Scoliosis
    b. Ankylosis
    c. Lordosis
    d. Kyphosis

Answer 15

ANS: D
Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine. Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Ankylosis is the immobility of a joint. Lordosis is an accentuation of the cervical or lumbar curvature beyond physiological limits.

Question 16

16. When does idiopathic scoliosis become most noticeable?
    a. During the newborn period
    b. When the child starts to walk
    c. During the preadolescent growth spurt
    d. In adolescence

Answer 16

ANS: C
Idiopathic scoliosis is most noticeable during the preadolescent growth spurt and is seldom apparent before age 10 years.

Question 17

17. What is the primary method for treating osteomyelitis?
    a. Joint replacement
    b. Bracing and casting
    c. Intravenous antibiotic therapy
    d. Long-term corticosteroid therapy

Answer 17

ANS: C
Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus. The treatment of choice is antibiotics. Joint replacement, bracing and casting, and long-term corticosteroids are not indicated for infectious processes.

Question 18

18. Osteosarcoma is the most common bone cancer in children. What is the most common primary tumour site? a. Femur
    b. Humerus c. Pelvis
    d. Tibia

Answer 18

ANS: A
Osteosarcoma is the most frequently encountered malignant bone cancer in children. The peak incidence is between ages 10 and 25 years. More than half of the tumours occur in the femur. After the femur, most of the remaining sites are the humerus, tibia, pelvis, jaw, and phalanges.

Question 19

19. What sentence is most descriptive of the therapeutic management of osteosarcoma?
    a. Treatment usually consists of surgery and chemotherapy.
    b. Amputation of the affected extremity is rarely necessary.
    c. Intensive irradiation is the primary treatment.
    d. Bone marrow transplantation offers the best chance of long-term survival.

Answer 19

ANS: A
The optimal therapy for osteosarcoma is a combination of surgery and chemotherapy. Amputation is frequently required. Intensive radiation and bone marrow transplantation are usually not part of the therapeutic management.

Question 20

20. An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. How should the nurse approach this patient?
    a. Answer questions with straightforward honesty.
    b. Avoid discussing the seriousness of the condition.
    c. Explain that, although the amputation is difficult, it will cure the cancer.
    d. Assist the adolescent in accepting that the amputation as better than a long course
    of chemotherapy.

Answer 20

ANS: A
Honesty is essential to gain the cooperation and trust of the child. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared in advance for the surgery so that there is time for reflection about the diagnosis and subsequent treatment. This allows him to gain answers to his questions. To accept the need for radical surgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will not guarantee a cure. Chemotherapy is an integral part of the therapy, with surgery. The child should be informed before surgery of the need for chemotherapy and its adverse effects.

Question 21

21. Which medication is usually tried first when a child is diagnosed with juvenile idiopathic arthritis (JIA)?
    a. Aspirin
    b. Corticosteroids
    c. Cytotoxic drugs such as methotrexate
    d. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Answer 21

ANS: D
NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, indomethacin, celecoxib, meloxicam, aspirin, and tolmetin are approved for use in children. Aspirin, once the drug of choice, has been replaced by NSAIDs because they have fewer adverse effects and easier administration schedules. Corticosteroids are used for life-threatening complications, incapacitating arthritis, and uveitis. Methotrexate is a second-line therapy for JIA.

Question 22

22. What is an important nursing consideration when caring for a child with juvenile idiopathic arthritis (JIA)?
    a. Apply ice packs to relieve stiffness and pain.
    b. Administer acetaminophen to reduce inflammation.
    c. Teach the child and family the correct administration of medications.
    d. Encourage range-of-motion exercises during periods of inflammation.

Answer 22

ANS: C
The management of JIA is primarily pharmacological. The family should be instructed on how to administer the medications and the value of a regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that NSAIDs should not be given on an empty stomach and to be alert for signs of toxicity. Warm, moist heat is best for relieving stiffness and pain. Acetaminophen does not have anti-inflammatory effects. Range-of-motion exercises should not be done during periods of inflammation.

Question 23

23. The nurse is caring for an infant with developmental dysplasia of the hip. What clinical manifestation should the nurse expect to observe?
    a. Positive Ortolani click
    b. Lordosis
    c. Negative Babinski sign
    d. Telescoping of the affected limb

Answer 23

ANS: A
A positive Ortolani test and unequal gluteal folds are clinical manifestations of developmental dysplasia of the hip seen from birth to 2 to 3 months. Negative Babinski sign, telescoping of the affected limb, and lordosis are not clinical manifestations of developmental dysplasia of the hip.

Question 24

1. Which would the nurse expect to find when assessing a child with slipped capital femoral epiphysis? Select all that apply. Express answer with small letters followed by a comma and a space—e.g., a, b, c.
   a. Pain in the hip
   b. External rotation deformity
   c. Restricted internal rotation on adduction
   d. Limp on the unaffected side
   e. Lengthening of lower extremity
   f. No change in abduction

Answer 24

ANS: A, B, C
Clinical manifestation of slipped capital femoral epiphysis includes pain in the hip, either continuous or intermittent, external rotation deformity, and restricted internal rotation on adduction. The child would limp on the affected side and there would be a shortening of the lower extremity. Abduction is lost as severity increases.