Mcsa: Question Stem

Question 136009
Id:
136009
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The nurse in the newborn nursery is doing the admission assessment on a neonate. Which assessment finding
would lead the nurse to suspect unilateral congenital hip dysplasia?
Stimulus
Answer
Choice 1
Lordosis
Rationale 1
Lordosis does not occur with hip dysplasia.
Answer 1
false
Choice 2
Trendelenburg sign
Rationale 2
Trendelenburg sign and telescoping of the affected limb are signs that
present in an older child with congenital hip dysplasia.
Answer 2
false
Choice 3
Asymmetry of the gluteal and thigh fat folds
Rationale 3
A sign of congenital hip dysplasia in the infant would be asymmetry of the

gluteal and thigh fat folds.
Answer 3
true
Choice 4
Telescoping of the affected limb
Rationale 4
Trendelenburg sign and telescoping of the affected limb are signs that
present in an older child with congenital hip dysplasia.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Nursing Process: Assessment
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126361
Source Chapter Number:

Source Chapter Title:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
admin
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Learning Outcome 10:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
57.1 Describe pediatric variations in the musculoskeletal system.
Question 136010
Id:
136010
Type:
MCMA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
A school health nurse is screening for scoliosis. For what assessment findings would the nurse look?
Standard Text
Select all that apply.
Stimulus
Answer
Choice 1
Lordosis
Rationale 1
Lordosis is not present with scoliosis.
Answer 1
false
Choice 2
Prominent scapula
Rationale 2
The classic signs of scoliosis include uneven shoulders and hips, a one-sided
rib hump, and prominent scapula.
Answer 2
true
Choice 3
Pain
Rationale 3
Pain generally is not present with scoliosis unless it is severe.
Answer 3
false
Choice 4
A one-sided rib hump
Rationale 4
Answer 4
true
Choice 5
Uneven shoulders and hips
Rationale 5
Answer 5
true
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126362

Source Au Title Ed:
Source Usage:
Writer First Name:
admin
Writer Last Name:

Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
57.1 Describe pediatric variations in the musculoskeletal system.
Question 136011
Id:
136011
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The nurse has completed parent education related to treatment for a child with congenital clubfoot. The nurse
knows that parents need further teaching when they state:
Stimulus
Answer
Choice 1
"We're getting a special car seat to accommodate the casts."
Rationale 1
Using a car seat is the law. Special car seats to accommodate the casts are
available and should be utilized.
Answer 1
false
Choice 2
"We'll watch for any swelling of the feet while the casts are on."
Rationale 2
Parents should be watching for swelling while the casts are on.
Answer 2
false
Choice 3
"We'll keep the casts dry."
Rationale 3
Keeping the casts dry is important to prevent complications
Answer 3
false
Choice 4
"We're happy this is the only cast our baby will need."
Rationale 4
Serial casting is the treatment of choice for congenital clubfoot. The cast is
changed every one to two weeks until the corrected foot position is achieved.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Nursing Process: Evaluation
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126363

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
admin
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
57.2 Plan nursing care for children with structural deformities of the foot, hip,
and spine.
Question 136012
Id:
136012
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
A child must wear a brace for correction of scoliosis. Which nursing diagnosis takes priority at this time?
Stimulus
Answer
Choice 1
Impaired gas exchange, risk for
Rationale 1
Risk for impaired gas exchange is a late effect of scoliosis and would not be
the priority. If the patient is compliant with wearing the brace, the risk
should be minimized.
Answer 1
false
Choice 2
Altered growth and development, risk for
Rationale 2
The diagnosis of altered growth and development would not be the priority
and should be corrected by the wearing of the brace.
Answer 2
false
Choice 3
Impaired skin integrity, risk for
Rationale 3
The skin should be monitored for breakdown in any area where the brace
might rub against the skin.
Answer 3
true
Choice 4
Impaired mobility, risk for
Rationale 4
The diagnosis of impaired mobility would not be the priority and should be
corrected if the patient is compliant with wearing the brace.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Nursing Process: Diagnosis
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126364

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
57.2 Plan nursing care for children with structural deformities of the foot, hip,
and spine.
Question 136013
Id:
136013
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
An adolescent has just returned from surgery after spinal fusion surgery. Which assessment finding would take
priority at this time?
Stimulus
Answer
Choice 1
Sleeps when not bothered but arouses easily with stimuli
Rationale 1
This is a normal response postanesthesia.
Answer 1
false
Choice 2
Impaired color, sensitivity, and movement to lower extremities
Rationale 2
When the spinal column is manipulated, there is a risk for impaired color,
sensitivity, and movement to lower extremities.
Answer 2
true
Choice 3
Nausea
Rationale 3
Nausea in the postoperative period is not uncommon, but it is not the priority
at this time.
Answer 3
false
Choice 4
Pain
Rationale 4
Pain is a common finding in the postoperative period and should be

addressed, but impaired color, sensitivity, and movement of the lower
extremities is the priority at this time.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Nursing Process: Planning
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126365

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:
admin
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
57.4 Partner with families to plan care for children with musculoskeletal
conditions that are chronic or require long-term care.
Question 136014
Id:
136014
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The nurse has completed discharge teaching for the family of a child diagnosed with Legg-Calv-Perthes
disease. The nurse knows further teaching is needed about the condition if the family states:
Stimulus
Answer
Choice 1
"We're glad this will only take about six weeks to correct."
Rationale 1
The treatment for Legg-Calv-Perthes disease takes approximately two

years.
Answer 1
true
Choice 2
"We understand abduction of the affected leg is important."
Rationale 2
The leg should be kept in the abducted position to prevent damage to the
head of the femur due to Legg-Calv-Perthes disease.
Answer 2
false
Choice 3
"We know to watch for areas on the skin that the brace might rub."
Rationale 3
A brace is a component of the treatment of Legg-Calve-Perthes disease and

is worn to prevent damage to the head of the femur, so skin irritation should
be monitored.
Answer 3
false
Choice 4
"We understand swimming is a good sport for Legg-Calv-Perthes."
Rationale 4
Swimming is a good activity to increase mobility in a child with LeggCalv-Perthes disease.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126367

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
Question 136015
Id:
136015
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
Which of the following would take priority when teaching the family how to care for an infant with
osteogenesis imperfecta?
Stimulus
Answer
Choice 1
Teaching the family how to care for an infant in a cast
Rationale 1
Traction, casts, and spinal surgery are not routinely done for osteogenesis
imperfecta.
Answer 1
false
Choice 2
Teaching the family that the trunk and extremities should always be
supported when moving this infant
Rationale 2
With osteogenesis imperfecta, nursing care focuses on preventing fractures.

Because the bones are fragile, the entire body must be supported when the
child is moved.
Answer 2
true
Choice 3
Teaching the family how to care for an infant postop spinal surgery
Rationale 3
imperfecta.
Answer 3
false
Choice 4
Teaching the family how to care for an infant in traction
Rationale 4
imperfecta.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Nursing Process: Implementation
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126369

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
Question 136016
Id:
136016
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
An infant has just returned from surgery for correction of bilateral congenital clubfeet. The infant has bilateral
long-leg casts. The toes on both feet are edematous, but there is color, sensitivity, and movement to them. What
should the nurse do first?
Stimulus
Answer
Choice 1
Apply a warm, moist pack to the feet.
Rationale 1
Warm, moist heat will increase swelling and the moisture may cause the cast
to disintegrate.
Answer 1
false
Choice 2
Elevate the infants legs on pillows.
Rationale 2
The infants legs should be elevated on a pillow for 24 hours to promote

healing and help with venous return. This is the priority action.
Answer 2
true
Choice 3
Encourage movement of the toes.
Rationale 3
An infant would not be able to follow directions to move the toes, and in this
case it would not be as effective as would elevating the legs on pillows.
Answer 3
false
Choice 4
Call the physician to report the edema.
Rationale 4
Some amount of swelling can be expected, so it would not be appropriate to

notify the physician, especially if the color, sensitivity, and movement to the
toes remained normal.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126371

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
57.5 Prioritize nursing interventions to promote safely and developmental

progression in children who require braces, casts, traction, and surgery.
Question 136017
Id:
136017
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
The nurse is teaching a family how to care for their infant in a Pavlik harness to treat congenital developmental
dysplasia of the hip. Which instruction is appropriate for the nurse to include in parental education in relation
to the Pavlik harness?
Stimulus
Answer
Choice 1
Apply lotion or powder to minimize skin irritation.
Rationale 1
Lotion or powder can contribute to skin breakdown and should not be used.
Answer 1
false
Choice 2
Check at least two or three times a day for red areas under the straps.
Rationale 2
The skin underneath the straps of the brace should be checked two or three
times a day for red areas, which might indicate skin breakdown.
Answer 2
true
Choice 3
Put clothing over the harness for maximum effectiveness of the device.
Rationale 3
A light layer of clothing should be worn under the brace to assist in

preventing skin breakdown, not over the brace.
Answer 3
false
Choice 4
Place a diaper over the harness, preferably using a thin, superabsorbent,

disposable diaper.
Rationale 4
The diaper should be placed under the brace, along with a light layer of
clothing.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Nursing Process: Planning
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126372

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

Question 136018
Id:
136018
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
A child has experienced a sprain of the right ankle. The school nurse should:
Stimulus
Answer
Choice 1
Leave the ankle open to the air and avoid compressing the area to allow
tissue swelling as necessary.
Rationale 1
For the first 24 hours for a sprain, rest, ice, compression, and elevation
(RICE) should be followed. Therefore, the nurse should apply a compression
bandage to the extremity.
Answer 1
false
Choice 2
Perform passive range-of-motion to the extremity.
Rationale 2
(RICE) should be followed. Therefore, the nurse should rest the extremity
rather than perform range-of-motion.
Answer 2
false
Choice 3
Lower the extremity below the level of the heart.
Rationale 3
(RICE) should be followed. Therefore, the nurse should elevate the
extremity.
Answer 3
false
Choice 4
Apply ice to the extremity.
Rationale 4
(RICE) should be followed. Therefore, the nurse should apply ice to the
extremity.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126373

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
admin
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

Question 136019
Id:
136019
Type:
MCMA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
A nurse is assessing a child after an open reduction of a fractured femur. Which signs indicate that
compartment syndrome could be occurring?
Standard Text
Stimulus
Answer
Choice 1
Pink, warm extremity
Rationale 1
Pink, warm extremity is a normal finding post-fracture reduction.
Answer 1
false
Choice 2
Dorsalis pedis pulse present
Rationale 2
A present dorsalis pedis pulse would be a normal finding post-fracture

reduction.
Answer 2
false
Choice 3
Prolonged capillary refill time
Rationale 3
A prolonged capillary refill time is a sign of compartment syndrome.
Answer 3
true
Choice 4
Pain not relieved by pain medication
Rationale 4
A prolonged capillary refill time with loss of paresthesia and pain not
relieved by medication are signs of compartment syndrome.
Answer 4
true
Choice 5
Paresthesia of the leg
Rationale 5
Paresthesia is tingling and numbness of the affected extremity and is a sign

of compartment syndrome.
Answer 5
true
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126374

Source Au Title Ed:
Source Usage:
Writer First Name:
admin
Writer Last Name:

Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
57.6 Develop a nursing care plan for fractures, including teaching for injury
prevention and nursing implementations for the child who has sustained a
fracture.
Question 136020
Id:
136020
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
A six-year-old boy is admitted to the hospital with a diagnosis of osteomyelitis of the left femur. The plan of
care includes a two-week round of intravenous antibiotics. The father questions why the child must be
hospitalized and why the child cannot receive oral antibiotics. The nurse explains:
Stimulus
Answer
Choice 1
The antibiotic of choice is not available in oral form.
Rationale 1
Most antibiotics are available in multiple forms.
Answer 1
false
Choice 2
Blood flow to bones is limited, and parenteral administration is necessary to

get appropriate blood levels.
Rationale 2
This is accurate information.
Answer 2
true
Choice 3
Because the child is older now, it is harder to get the child to cooperate with
oral antibiotics.
Rationale 3
The older child can understand the reason for antibiotics and cooperate.
Answer 3
false
Choice 4
Because two weeks of therapy is necessary, the intravenous route will

produce fewer side effects.
Rationale 4
Both oral and intravenous antibiotics may have side effects.
Answer 4
false
Choice 5
Rationale 5
Answer 5
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126366

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
admin
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
57.3 Recognize signs and symptoms of infectious musculoskeletal disorders

and refer for appropriate care.
Question 136021
Id:
136021
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
A two-year-old child is placed in balanced Bryants traction for a fractured right femur. Which finding by the
nurse should be reported to the surgeon?
Stimulus
Answer
Choice 1
The child keeps trying to turn and lay on his belly.
Rationale 1
This child needs a jacket restraint to maintain appropriate positioning if

someone cannot stay with him. It does not require notifying the surgeon.
Answer 1
false
Choice 2
The ropes are unequal in length.
Rationale 2
In balanced traction, the ropes and pulleys determine the traction and the
length of the rope is unimportant.
Answer 2
false
Choice 3
The childs buttocks are resting on the bed.
Rationale 3
In order to provide adequate counter-traction, the buttocks should be slightly

elevated off the bed. The surgeon should be notified.
Answer 3
true
Choice 4
The ace bandage wrapping the legs is wrinkled.
Rationale 4
This is not a significant finding.
Answer 4
false
Choice 5
Rationale 5
Answer 5
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126370

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
admin
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

Question 136022
Id:
136022
Type:
MCMA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
When assigned to the patient on complete bed rest for spinal fusion secondary to scoliosis, the nurse will want
to intervene to prevent common complications of immobility. Nursing interventions will include:
Standard Text
Stimulus
Answer
Choice 1
Encouraging use of the spirometer every two hours while the child is awake.
Rationale 1
Respiratory complications are a common complication of immobility.
Answer 1
true
Choice 2
Log-rolling the patient every two hours while awake.
Rationale 2
Turning the patient frequently will reduce pressure on bony prominences.
Answer 2
true
Choice 3
Increasing intake of milk to maintain bone calcium.
Rationale 3
Calcium will be pulled from the bones due to immobility. Adding additional
calcium in the form of milk will increase the risk of kidney stones.
Answer 3
false
Choice 4
Increasing fruit and grains in the diet.
Rationale 4
Fruit and grains will provide extra fiber to reduce the risk of complication.
Answer 4
true
Choice 5
Limiting fluid intake to reduce the need to void.
Rationale 5
Fluid intake should be increased to flush the kidneys.
Answer 5
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126368

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
admin
Stakes:
Special Handling:
Comments:
Meta 4
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Question 136023
Id:
136023
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
While at recess, a child falls and hurts his arm. The school nurse is called and suspects a fractured arm. The
nurse will apply a splint before transporting the child to the hospital. The nurse will ensure that:
Stimulus
Answer
Choice 1
The splint is applied firmly enough to prevent swelling.
Rationale 1
The purpose of the splint is not to prevent swelling.
Answer 1
false
Choice 2
The arm is fully extended in the splint.
Rationale 2
The nurse will not want to manipulate the arm, so the nurse will splint the
arm in the position it is found.
Answer 2
false
Choice 3
The splint is fully padded to prevent skin damage.
Rationale 3
The splint does not need to be padded.
Answer 3
false
Choice 4
The joints above and below the suspected fracture are immobilized.
Rationale 4
This is the important concept in splintingimmobilizing the joint above and

below the fracture to prevent movement of the bones.
Answer 4
true
Choice 5
Rationale 5
Answer 5
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
126375

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
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Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
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57.6 Develop a nursing care plan for fractures, including teaching for injury
prevention and nursing implementations for the child who has sustained a
fracture.
Question 136024
Id:
136024
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
An 18-month-old child is admitted to the hospital unit for weakness of the lower extremities. Duchenne
muscular dystrophy is suspected. Which assessment finding on the admission history and physical is indicative
of this disorder?
Stimulus
Answer
Choice 1
Infant was post-mature by almost two weeks.
Rationale 1
Post-maturity is not related to Duchenne muscular dystrophy.
Answer 1
false
Choice 2
The child seems very muscular.
Rationale 2
Duchenne muscular dystrophy is also called pseudohypertrophic due to the

enlarged appearance of the muscle. The pathophysiology is infiltration of the
muscle fibers with fatty tissue.
Answer 2
true
Choice 3
The child walked early and without support at 10 months.
Rationale 3
This finding is not indicative of Duchenne muscular dystrophy.
Answer 3
false
Choice 4
The childs older sister developed scoliosis in the fourth grade.
Rationale 4
The older sisters scoliosis is not related to MD. Duchenne MD is sex-linked

recessive and affects only boys.
Answer 4
false
Choice 5
Rationale 5
Answer 5
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
admin
Special Handling:
Comments:
Meta 4
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Standard 6:
57.3 Recognize signs and symptoms of infectious musculoskeletal disorders

and refer for appropriate care.
Question 136025
Id:
136025
Type:
MCMA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
An infant returns to the unit following casting of the leg for talipes equinovarus. Standing orders include
monitoring the neurovascular status. In addition to color, for what will the nurse monitor the infants foot?
Standard Text
Stimulus
Answer
Choice 1
Warmth
Rationale 1
The temperature of the foot of the casted leg should be compared to the
temperature of the other foot.
Answer 1
true
Choice 2
Capillary refill
Rationale 2
This indicates blood return to the tissues and is an important finding.
Answer 2
true
Choice 3
Pedal pulse
Rationale 3
The pedal pulse cannot be reached in the casted foot.
Answer 3
false
Choice 4
Sensation
Rationale 4
Nerve function is evaluated by touching the toes and noting the childs
response.
Answer 4
true
Choice 5
Movement of the toes
Rationale 5
The child is encouraged to wiggle the toes. If the patient is an infant, tickling
will cause the child to respond with movement.
Answer 5
true
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Source Au Title Ed:
Source Usage:
Writer First Name:
admin
Writer Last Name:

Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
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Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:


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Question 136009

Lordosis does not occur with hip dysplasia.

Asymmetry of the gluteal and thigh fat folds

A sign of congenital hip dysplasia in the infant would be asymmetry of the

Telescoping of the affected limb

Nursing Process: Assessment

Source Chapter Number:

57.1 Describe pediatric variations in the musculoskeletal system.

Lordosis is not present with scoliosis.

Pain generally is not present with scoliosis unless it is severe.

A one-sided rib hump

Uneven shoulders and hips

Nursing Process: Assessment

Source Chapter Number:

Writer Last Name:

57.1 Describe pediatric variations in the musculoskeletal system.

"We're getting a special car seat to accommodate the casts."

"We'll keep the casts dry."

Keeping the casts dry is important to prevent complications

Nursing Process: Evaluation

Source Chapter Number:

Impaired gas exchange, risk for

Altered growth and development, risk for

Impaired skin integrity, risk for

Impaired mobility, risk for

Nursing Process: Diagnosis

Source Chapter Number:

Sleeps when not bothered but arouses easily with stimuli

This is a normal response postanesthesia.

Impaired color, sensitivity, and movement to lower extremities

Pain is a common finding in the postoperative period and should be

Nursing Process: Planning

Source Chapter Number:

The treatment for Legg-Calv-Perthes disease takes approximately two

"We understand abduction of the affected leg is important."

A brace is a component of the treatment of Legg-Calve-Perthes disease and

"We understand swimming is a good sport for Legg-Calv-Perthes."

Swimming is a good activity to increase mobility in a child with LeggCalv-Perthes disease.

Nursing Process: Evaluation

Source Chapter Number:

Teaching the family how to care for an infant in a cast

With osteogenesis imperfecta, nursing care focuses on preventing fractures.

Teaching the family how to care for an infant in traction

Nursing Process: Implementation

Source Chapter Number:

Apply a warm, moist pack to the feet.

Elevate the infants legs on pillows.

The infants legs should be elevated on a pillow for 24 hours to promote

Encourage movement of the toes.

Call the physician to report the edema.

Some amount of swelling can be expected, so it would not be appropriate to

Nursing Process: Implementation

Source Chapter Number:

57.5 Prioritize nursing interventions to promote safely and developmental

Apply lotion or powder to minimize skin irritation.

A light layer of clothing should be worn under the brace to assist in

Place a diaper over the harness, preferably using a thin, superabsorbent,

Nursing Process: Planning

Source Chapter Number:

57.5 Prioritize nursing interventions to promote safely and developmental

Perform passive range-of-motion to the extremity.

Lower the extremity below the level of the heart.

Apply ice to the extremity.