Nokea
What would the nurse consider an abnormal finding on a musculoskeletal assessment of a 4-year-old child?
- A. Has inward-turned knees while standing.
- B. Walks on the toes.
- C. Appears to have flat feet.
- D. Swings his arms when walking.
Correct Answer: B
Rationale: Toe walking after age 3 may indicate a muscle problem, unlike other findings which are typical in young children.
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What characteristic manifestation does the nurse caring for a child with Duchenne's muscular dystrophy document?
- A. Ambulates by holding onto furniture.
- B. Exhibits atrophy of the calf muscles.
- C. Falls frequently and is clumsy.
- D. Has delayed fine-motor development.
Correct Answer: C
Rationale: Frequent falling and clumsiness are hallmark signs of Duchenne's muscular dystrophy due to muscle weakness.
The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation?
- A. Pulse is equal to uncasted limb.
- B. Patient is aware of touch and warm and cold application.
- C. Limb is cool to the touch.
- D. Capillary refill is 5 seconds.
- E. Distal limb can flex and extend.
Correct Answer: C,D
Rationale: Cool limbs and capillary refill over 3 seconds indicate altered circulation, requiring immediate reporting.
Which observation requires a nursing intervention?
- A. Child's heels are placed firmly against the foot of the bed.
- B. Head of bed is elevated 20 degrees.
- C. Weights are hanging freely.
- D. Ropes are on pulleys.
Correct Answer: A
Rationale: Heels against the bed disrupt Buck traction's counterweight mechanism, requiring intervention to elevate them.
Which nursing diagnosis takes highest priority for this child?
- A. Pain resulting from tissue trauma
- B. High risk for impaired skin integrity resulting from immobility
- C. Altered growth and development related to separation from family
- D. Altered urinary elimination related to immobility and traction
Correct Answer: A
Rationale: Pain from tissue trauma and muscle spasm is the highest priority due to its immediate impact on the child's comfort.
What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace?
- A. Wear the brace directly against the skin.
- B. Wear the brace over regular clothing.
- C. Wear the brace over a T-shirt 23 hours a day.
- D. Remove the brace before sleeping.
Correct Answer: C
Rationale: Wearing the Milwaukee brace over a T-shirt for 23 hours daily protects the skin while correcting scoliosis.