Ch 25_ The Child with Cancer

A young child with leukemia has anorexia and severe stomatitis. The nurse should suggest that the parents try which intervention? a. Relax any eating pressures. b. Firmly insist that child eat normally. c. Begin gavage feedings to supplement diet. d. Serve foods that are either hot or cold.

ANS: A A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the parents should relax eating pressures. The nurse should suggest that the parents try soft, bland foods; normal saline or bicarbonate mouthwashes; and local anesthetics. The stomatitis is a temporary condition. The child can resume good food habits as soon as the condition resolves.

After chemotherapy is begun for a child with acute leukemia, prophylaxis to prevent acute tumor lysis syndrome includes which therapeutic intervention? a. Hydration b. Oxygenation c. Corticosteroids d. Pain management

ANS: A Acute tumor lysis syndrome results from the release of intracellular metabolites during the initial treatment of leukemia. Hyperuricemia, hypocalcemia, hyperphosphatemia, and hyperkalemia can result. Hydration is used to reduce the metabolic consequences of the tumor lysis. Oxygenation is not helpful in preventing acute tumor lysis syndrome. Allopurinol, not corticosteroids, is indicated for pharmacologic management. Pain management may be indicated for supportive therapy of the child, but it does not prevent acute tumor lysis syndrome.

What is appropriate mouth care for a toddler with mucosal ulceration related to chemotherapy? a. Mouthwashes with plain saline b. Lemon glycerin swabs for cleansing c. Mouthwashes with hydrogen peroxide d. Swish and swallow with viscous lidocaine

ANS: A Administering mouth care is particularly difficult in infants and toddlers. A satisfactory method of cleaning the gums is to wrap a piece of gauze around a finger; soak it in saline or plain water; and swab the gums, palate, and inner cheek surfaces with the finger. Mouth rinses are best accomplished with plain water or saline because the child cannot gargle or spit out excess fluid. Avoid agents such as lemon glycerin swabs and hydrogen peroxide because of the drying effects on the mucosa. Lidocaine should be avoided in young children

A child has been diagnosed with a Wilms tumor. What should preoperative nursing care include? a. Careful bathing and handling b. Monitoring of behavioral status c. Maintenance of strict isolation d. Administration of packed red blood cells

ANS: A Careful bathing and handling are important in preventing trauma to the Wilms tumor site

What are the most common clinical manifestations of brain tumors in children? a. Headaches and vomiting b. Blurred vision and ataxia c. Hydrocephalus and clumsy gait d. Fever and poor fine motor control

ANS: A Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestations of brain tumors in children. Diplopia (double vision), not blurred vision, can be a presenting sign of brainstem glioma. Ataxia is a clinical manifestation of brain tumors, but headaches and vomiting are the most common. Hydrocephalus can be a presenting sign in infants when the sutures have not closed. Children at this age are usually not walking steadily. Poor fine motor coordination may be a presenting sign of astrocytoma, but headaches and vomiting are the most common presenting signs of brain tumors

The nurse is teaching nursing students about childhood nervous system tumors. Which best describes a neuroblastoma? a. Diagnosis is usually made after metastasis occurs. b. Early diagnosis is usually possible because of the obvious clinical manifestations. c. It is the most common brain tumor in young children. d. It is the most common benign tumor in young children.

ANS: A Neuroblastoma is a silent tumor with few symptoms. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site. In only 30% of cases is diagnosis made before metastasis. Neuroblastomas are the most common malignant extracranial solid tumors in children. The majority of tumors develop in the adrenal glands or the retroperitoneal sympathetic chain. They are not benign but metastasize.

A nurse is conducting a staff in-service on childhood cancers. Which is the primary site of osteosarcoma? a. Femur b. Humerus c. Pelvis d. Tibia

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 occur in the femur. After the femur, most of the remaining sites are the humerus, tibia, pelvis, jaw, and phalanges.

One pediatric oncologic emergency is acute tumor lysis syndrome. Symptoms that this may be occurring include what? a. Muscle cramps and tetany b. Respiratory distress and cyanosis c. Thrombocytopenia and sepsis d. Upper extremity edema and neck vein distension

ANS: A Risk factors for development of tumor lysis syndrome include a high white blood cell count at diagnosis, large tumor burden, sensitivity to chemotherapy, and high proliferative rate. In addition to the described metabolic abnormalities, children may develop a spectrum of clinical symptoms, including flank pain, lethargy, nausea and vomiting, muscle cramps, pruritus, tetany, and seizures. Respiratory distress and cyanosis occur with hyperleukocytosis. Thrombocytopenia and sepsis occur with disseminated intravascular coagulation. Upper extremity edema and neck vein distention occur with superior vena cava syndrome

The nurse is administering an IV chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. Which is the most appropriate nursing action? a. Stop drug infusion immediately. b. Recheck rate of drug infusion. c. Observe child closely for next 10 minutes. d. Explain to child that this is an expected side effect.

ANS: A Stop drug infusion immediately.

The nurse should expect to care for which age of child if the admitting diagnosis is retinoblastoma? a. Infant or toddler b. Preschool- or school-age child c. School-age or adolescent child d. Adolescent

ANS: A The average age of the child at the time of diagnosis is 2 years, and bilateral and hereditary disease is diagnosed earlier than unilateral and nonhereditary disease.

The nurse is admitting a child with a Wilms tumor. Which is the initial assessment finding associated with this tumor? a. Abdominal swelling b. Weight gain c. Hypotension d. Increased urinary output

ANS: A The initial assessment finding with a Wilms (kidney) tumor is abdominal swelling. Weight loss, not weight gain, may be a finding. Hypertension occasionally occurs with a Wilms tumor. Urinary output is not increased, but hematuria may be noted.

The nurse is taking care of an adolescent with osteosarcoma. The parents ask the nurse about treatment. The nurse should make which accurate response about treatment for 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.

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

A child with cancer being treated with chemotherapy is receiving a platelet transfusion. The nurse understands that the transfused platelets should survive the body for how many days? a. 1 to 3 days b. 4 to 6 days c. 7 to 9 days d. 10 to 12 days

ANS: A Transfused platelets generally survive in the body for 1 to 3 days. The peak effect is reached in about 1 hour and decreased by half in 24 hours

What strategies should the nurse implement to increase nutritional intake for the child receiving chemotherapy? (Select all that apply.) a. Allow the child any food tolerated. b. Fortify foods with nutritious supplements. c. Allow the child to be involved in food selection. d. Encourage the parents to place pressure on the importance of eating. e. Encourage the child to eat favorite foods during infusion of chemotherapy medications.

ANS: A, B, C To increase nutritional intake for the child receiving chemotherapy, the nurse should allow the child any food tolerated, fortify foods with nutritious supplements, and allow the child to be involved in food selection. The parents should be encouraged to reduce pressure placed on eating. Some children develop aversions to certain foods if they are eaten during chemotherapy. It is best to refrain from offering the child's favorite foods while the child is receiving chemotherapy.

A child on chemotherapy has developed rectal ulcers. What interventions should the nurse teach to the child and parents to relieve the discomfort of rectal ulcers? (Select all that apply.) a. Warm sitz baths b. Use of stool softeners c. Record bowel movements d. Use of an opioid for discomfort e. Occlusive ointment applied to the area

ANS: A, B, C, E If rectal ulcers develop, meticulous toilet hygiene, warm sitz baths after each bowel movement, and an occlusive ointment applied to the ulcerated area promote healing; the use of stool softeners is necessary to prevent further discomfort. Parents should record bowel movements because the child may voluntarily avoid defecation to prevent discomfort. Opioids would cause increased constipation.

The treatment of brain tumors in children consists of which therapies? (Select all that apply.) a. Surgery b. Bone marrow transplantation c. Chemotherapy d. Stem cell transplantation e. Radiation f. Myelography

ANS: A, C, E Treatment for brain tumors in children may consist of surgery, chemotherapy, and radiotherapy alone or in combination. Bone marrow and stem cell transplantation therapies are used for leukemia, lymphoma, and other solid tumors where myeloablative therapies are used. Myelography is a radiographic examination after an intrathecal injection of contrast medium. It is not a treatment.

The nurse is precepting a new graduate nurse at an ambulatory pediatric hematology and oncology clinic. What cardinal signs of cancer in children should the nurse make the new nurse aware of? (Select all that apply.) a. Sudden tendency to bruise easily b. Transitory, generalized pain c. Frequent headaches d. Excessive, rapid weight gain e. Gradual, steady fever f. Unexplained loss of energy

ANS: A, C, F The cardinal signs of cancer in children include a sudden tendency to bruise easily; frequent headaches, often with vomiting; and an unexplained loss of energy. Other cardinal signs include persistent, localized pain; excessive, rapid weight loss; and a prolonged, unexplained fever.

Essential postoperative nursing management of a child after removal of a brain tumor includes which nursing care? a. Turning and positioning every 2 hours b. Measuring all fluid intake and output c. Changing the dressing when it becomes soiled d. Using maximum lighting to ensure accurate observations

ANS: B After brain surgery, cerebral edema is a risk. Careful monitoring is essential. All fluids, including intravenous antibiotics, are included in the intake. Turning and positioning depend on the surgical procedure. When large tumors are removed, the child is usually not positioned on the operative side. The dressing is not changed. It is reinforced with gauze after the amount of drainage is marked and estimated. A quiet, dimly lit environment is optimum to decrease stimulation and relieve discomfort such as headaches.

A young boy will receive a bone marrow transplant (BMT). This is possible because one of his older siblings is a histocompatible donor. Which is this type of BMT called? a. Syngeneic b. Allogeneic c. Monoclonal d. Autologous

ANS: B Allogeneic transplants are from another individual. Because he and his sibling are histocompatible, the BMT can be done. Syngeneic marrow is from an identical twin. There is no such thing as a monoclonal BMT. Autologous refers to the individual's own marrow.

An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that the bone marrow will be administered by which method? a. Bone grafting b. Intravenous infusion c. Bone marrow injection d. Intraabdominal infusion

ANS: B Bone marrow from a donor is infused intravenously, and the transfused stem cells migrate to the recipient's marrow and repopulate it.

Which is often administered to prevent or control hemorrhage in a child with cancer? a. Nitrosoureas b. Platelets c. Whole blood d. Corticosteroids

ANS: B Most bleeding episodes can be prevented or controlled with the administration of platelet concentrate or platelet-rich plasma. Nitrosoureas, whole blood, and corticosteroids would not prevent or control hemorrhage.

The nurse is collecting a 24-hour urine sample on a child with suspected diagnosis of neuroblastoma. What finding in the urine is expected with neuroblastomas? a. Ketones b. Catecholamines c. Red blood cells d. Excessive white blood cells

ANS: B Neuroblastomas, particularly those arising on the adrenal glands or from a sympathetic chain, excrete the catecholamines epinephrine and norepinephrine. Urinary excretion of catecholamines is detected in approximately 95% of children with adrenal or sympathetic tumors.

What childhood cancer may demonstrate patterns of inheritance that suggest a familial basis? a. Leukemia b. Retinoblastoma c. Rhabdomyosarcoma d. Osteogenic sarcoma

ANS: B Retinoblastoma is an example of a pediatric cancer that demonstrates inheritance. The absence of the retinoblastoma gene allows for abnormal cell growth and the development of retinoblastoma. Chromosome abnormalities are present in many malignancies. They do not indicate a familial pattern of inheritance. The Philadelphia chromosome is observed in almost all individuals with chronic myelogenous leukemia. There is no evidence of a familial pattern of inheritance for rhabdomyosarcoma or osteogenic sarcoma cancers

A 5-year-old boy is being prepared for surgery to remove a brain tumor. Nursing actions should be based on which statement? a. Removal of tumor will stop the various symptoms. b. Usually the postoperative dressing covers the entire scalp. c. He is not old enough to be concerned about his head being shaved. d. He is not old enough to understand the significance of the brain.

ANS: B The child should be told what he will look and feel like after surgery. This includes the size of the dressing. The nurse can demonstrate on a doll the expected size and shape of the dressing. Some of the symptoms may be alleviated by the removal of the tumor, but postsurgical headaches and cerebellar symptoms such as ataxia may be aggravated. Children should be prepared for the loss of their hair, and it should be removed in a sensitive, positive manner if the child is awake. Children at this age have poorly defined body boundaries and little knowledge of internal organs. Intrusive experiences are frightening, especially those that disrupt the integrity of the skin.

A boy with leukemia screams whenever he needs to be turned or moved. Which is the most probable cause of this pain? a. Edema b. Bone involvement c. Petechial hemorrhages d. Changes within the muscles

ANS: B The invasion of the bone marrow with leukemic cells gradually causes a weakening of the bone and a tendency toward fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain. Edema, petechial hemorrhages, and changes within the muscles would not cause severe pain.

Which is the usual presenting symptom for testicular cancer? a. Hard, painful mass b. Hard, painless mass c. Epididymis easily palpated d. Scrotal swelling and pain

ANS: B The usual presenting symptom for testicular cancer is a heavy, hard, painless mass that is either smooth or nodular and palpated on the testes. A hard, painful mass, an epididymis easily palpated, and scrotal swelling and pain are not the clinical presentations of testicular cancer

The mother of an infant tells the nurse that sometimes there is a whitish "glow" in the pupil of his eye. The nurse should suspect which condition? a. Brain tumor b. Retinoblastoma c. Neuroblastoma d. Rhabdomyosarcoma

ANS: B When the nurse examines the eye, the light will reflect off of the tumor, giving the eye a whitish appearance. This is called a cat's eye reflex. Brain tumors are not usually visible. Neuroblastoma usually arises from the adrenal medulla and sympathetic nervous system. The most common presentation sites are in the abdomen, head, neck, or pelvis. Supraorbital ecchymosis may be present with distant metastasis. Rhabdomyosarcoma is a soft tissue tumor that derives from skeletal muscle undifferentiated cells.

What guidelines should the nurse follow when handling chemotherapeutic agents? (Select all that apply.) a. Use clean technique. b. Prepare medications in a safety cabinet. c. Wear gloves designed for handling chemotherapy. d. Wear face and eye protection when splashing is possible. e. Discard gloves and protective clothing in a special container.

ANS: B, C, D, E Safe handling of chemotherapeutic agents includes preparing medications in a safety cabinet, wearing gloves designed for handling chemotherapy, wearing face and eye protection when splashing is possible, and discarding gloves and protective clothing in a special container. Aseptic, not clean, technique should be used

A clinic nurse is conducting a staff in-service for other clinic nurses about signs and symptoms of a rhabdomyosarcoma tumor. Which should be included in the teaching session? (Select all that apply.) a. Bone fractures b. Abdominal mass c. Sore throat and ear pain d. Headache e. Ecchymosis of conjunctiva

ANS: B, C, E The initial signs and symptoms of rhabdomyosarcoma tumors are related to the site of the tumor and compression of adjacent organs. Some tumor locations, such as the orbit, manifest early in the course of the illness. Other tumors, such as those of the retroperitoneal area, only produce symptoms when they are relatively large and compress adjacent organs. Unfortunately, many of the signs and symptoms attributable to rhabdomyosarcoma are vague and frequently suggest a common childhood illness, such as "earache" or "runny nose." An abdominal mass, sore throat and ear pain, and ecchymosis of conjunctiva are signs of a rhabdomyosarcoma tumor. Bone fractures would be seen in osteosarcoma, and a headache is a sign of a brain tumor.

What chemotherapeutic agent can cause an anaphylactic reaction? a. Prednisone (Deltasone) b. Vincristine (Oncovin) c. L-Asparaginase (Elspar) d. Methotrexate (Trexall)

ANS: C A potentially fatal complication is anaphylaxis, especially from L-asparaginase, bleomycin, cisplatin, and etoposide (VP-16).

The nurse is preparing a child for possible alopecia from chemotherapy. What information should the nurse include? a. Wearing hats or scarves is preferable to a wig. b. Expose head to sunlight to stimulate hair regrowth. c. Hair may have a slightly different color or texture when it regrows. d. Regrowth of hair usually begins 12 months after chemotherapy ends.

ANS: C Alopecia is a side effect of certain chemotherapeutic agents and cranial irradiation. When the hair regrows, it may be of a different color or texture. Children should choose the head covering they prefer. A wig should be selected similar to the child's own hairstyle and color before the hair loss. The head should be protected from sunlight to avoid sunburn. The hair usually grows back within 3 to 6 months after the cessation of treatment.

Chemotherapeutic agents are classified according to what feature? a. Side effects b. Effectiveness c. Mechanism of action d. Route of administration

ANS: C Chemotherapeutic agents are classified according to mechanism of action. For example, antimetabolites resemble essential metabolic elements needed for growth but are different enough to block further deoxyribonucleic acid (DNA) synthesis. Although the side effect profiles may be similar for drugs within a classification, they are not the basis for classification. Most chemotherapeutic regimens contain combinations of drugs. The effectiveness of any one drug is relative to the cancer type, combination therapy, and protocol for administration. The route of administration is determined by the pharmacodynamics and pharmacokinetics of each drug.

A child with leukemia is receiving intrathecal chemotherapy to prevent which condition? a. Infection b. Brain tumor c. Central nervous system (CNS) disease d. Drug side effects

ANS: C Children with leukemia are at risk for invasion of the CNS with leukemic cells. CNS prophylactic therapy is indicated. Intrathecal chemotherapy does not prevent infection or drug side effects. A brain tumor in a child with leukemia would be a second tumor, and additional appropriate therapy would be indicated.

The nurse is monitoring a 7-year-old child post surgical resection of an infratentorial brain tumor. Which vital sign findings indicate Cushing's triad? a. Increased temperature, tachycardia, tachypnea b. Decreased temperature, bradycardia, bradypnea c. Bradycardia, hypertension, irregular respirations d. Bradycardia, hypotension, tachypnea

ANS: C Cushing's triad is a hallmark sign of increased intracranial pressure (ICP). The triad includes bradycardia, hypertension, and irregular respirations. Increased or decreased temperature is not a sign of Cushing's triad.

What description identifies the pathophysiology of leukemia? a. Increased blood viscosity b. Abnormal stimulation of the first stage of coagulation process c. Unrestricted proliferation of immature white blood cells (WBCs) d. Thrombocytopenia from an excessive destruction of platelets

ANS: C Leukemia is a group of malignant disorders of the bone marrow and lymphatic system. It is defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the body. Increased blood viscosity may result secondary to the increased number of WBCs. The coagulation process is unaffected by leukemia. Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow.

A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. Which is the most appropriate nursing action to prevent or minimize these reactions with subsequent treatments? a. Encourage drinking large amounts of favorite fluids. b. Encourage child to take nothing by mouth (remain NPO) until nausea and vomiting subside. c. Administer an antiemetic before chemotherapy begins. d. Administer an antiemetic as soon as child has nausea.

ANS: C The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer the antiemetic before the chemotherapy is begun. The goal is to prevent anticipatory symptoms. Drinking fluids will add to the discomfort of the nausea and vomiting. Waiting until nausea and vomiting subside will help with this episode, but the child will have the discomfort and be at risk for dehydration. Administering an antiemetic as soon as the child has nausea does not prevent anticipatory nausea.

The school nurse is discussing testicular self-examination with adolescent boys. Why is this important? a. Epididymitis is common during adolescence. b. Asymptomatic sexually transmitted diseases may be present. c. Testicular tumors during adolescence are generally malignant. d. Testicular tumors, although usually benign, are common during adolescence.

ANS: C Tumors of the testes are not common, but when manifested in adolescence, they are generally malignant and demand immediate evaluation. Epididymitis is not common in adolescence. Asymptomatic sexually transmitted disease would not be evident during testicular self-examination. The focus of this examination is on testicular cancer. Testicular tumors are most commonly malignant.

What is an important priority in dealing with the child suspected of having Wilms tumor? a. Intervening to minimize bleeding b. Monitoring temperature for infection c. Ensuring the abdomen is protected from palpation d. Teaching parents how to manage the parenteral nutrition

ANS: C Wilms tumor, or nephroblastoma, is the most common malignant renal and intraabdominal tumor of childhood. The abdomen is protected, and palpation is avoided. Careful handling and bathing are essential to prevent trauma to the tumor site. Before chemotherapy, the child is not myelosuppressed. Bleeding is not usually a risk. Infection is a concern after surgery and during chemotherapy, not before surgery. Parenteral therapy is not indicated before surgery

What is a common clinical manifestation of Hodgkin disease? a. Petechiae b. Bone and joint pain c. Painful, enlarged lymph nodes d. Nontender enlargement of lymph nodes

ANS: D Asymptomatic, enlarged cervical or supraclavicular lymphadenopathy is the most common presentation of Hodgkin disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin disease. The enlarged nodes are rarely painful

What pain management approach is most effective for a child who is having a bone marrow test? a. Relaxation techniques b. Administration of an opioid c. EMLA cream applied over site d. Conscious or unconscious sedation

ANS: D Children need explanations before each procedure that is being done to them. Effective pharmacologic and nonpharmacologic measures should be used to minimize pain associated with procedures. For bone marrow aspiration, conscious or unconscious sedation should be used. Relaxation, opioids, and EMLA can be used to augment the sedation

A child with leukemia is receiving triple intrathecal chemotherapy consisting of methotrexate, cytarabine, and hydrocortisone. What will the triple intrathecal chemotherapy prevent? a. Infection b. Brain tumor c. Drug side effects d. Central nervous system (CNS) disease

ANS: D For certain children, CNS prophylactic therapy is indicated. This drug regimen is used to prevent CNS leukemia and will not prevent infection or drug side effects. If the child has a brain tumor in addition to leukemia, additional therapy would be indicated.

What specific gravity of the urine is desired so that hemorrhagic cystitis is prevented? a. 1.035 b. 1.030 c. 1.025 d. 1.005

ANS: D Sterile hemorrhagic cystitis is a side effect of chemical irritation to the bladder from chemotherapy or radiotherapy. It can be prevented by a liberal oral or parenteral fluid intake (at least one and a half times the recommended daily fluid requirement). The urine should be dilute so 1.005 is the expected specific gravity

Myelosuppression, associated with chemotherapeutic agents or some malignancies such as leukemia, can cause bleeding tendencies because of a(n): a. decrease in leukocytes. b. increase in lymphocytes. c. vitamin C deficiency d. decrease in blood platelets.

ANS: D The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an increase in bleeding. The child and family should be alerted to avoid risk of injury. Decrease in leukocytes, increase in lymphocytes, and vitamin C deficiency would not affect bleeding tendencies.

What immunization should not be given to a child receiving chemotherapy for cancer? a. Tetanus vaccine b. Inactivated poliovirus vaccine c. Diphtheria, pertussis, tetanus (DPT) d. Measles, mumps, rubella (MMR)

ANS: D The vaccine used for MMR is a live virus and can cause serious disease in immunocompromised children. The tetanus vaccine, inactivated poliovirus vaccine, and DPT are not live vaccines and can be given to immunosuppressed children. The immune response is likely to be suboptimum, so delaying vaccination is usually recommended

Total-body irradiation is indicated for what reason? a. Palliative care b. Lymphoma therapy c. Definitive therapy for leukemia d. Preparation for bone marrow transplant

ANS: D Total-body irradiation is used as part of the destruction of the child's immune system necessary for a bone marrow transplant. The child is at great risk for complications because there is no supportive therapy until engraftment of the donor marrow takes place. Irradiation for palliative care is done selectively. The area that is causing pain or potential obstruction is irradiated. Lymphoma and leukemia are treated through a combination of modalities. Total-body irradiation is not indicated.