Chapter 37: The Child with a Cardiovascular/Hematologic Disorder

A group of nurses is reviewing the cardiovascular system and its function. Which statement is the most accurate regarding the cardiovascular system in the child? A) At birth the right and left ventricles are about the same size B) Between the ages of 5 and 6 the left ventricle grows to about two times the size of the right C) The heart rate of the child decreases if the child has a fever D) The heart matures and functions like an adult's between 12 and 15 years of age.

Ans: A Feedback: At birth, both the right and left ventricles are about the same size, but by a few months of age, the left ventricle is about two times the size of the right. If the infant has a fever, respiratory distress, or any increased need for oxygen, the pulse rate goes up to increase the cardiac output. Although the size is smaller, by the time the child is 5 years old, the heart has matured, developed, and functions just as the adult's heart.

When administering corticosteroids to a child with rheumatic fever, what should the nurse recognize as an important aspect of giving this classification of medications for this diagnosis? A) The drug should be stopped gradually by giving decreasing dosages B) The drug will be given for the rest of the child's life C) The drug should be taken for a full course, usually 10 days D) The drug should be taken using a metered-dose inhaler

Ans: A Feedback: Corticosteroid drugs should be stopped gradually by decreasing dosages. The drug will be given to control symptoms but not for life. Antibiotics are given for a full course of 10 days. Corticosteroids can be given by metered-dose inhaler, but not for this diagnosis.

A symptom often seen in the child diagnosed with hemophilia is bleeding into the joints. How should the nurse document this finding? A) Hemarthrosis B) Nuchal rigidity C) Encephalopathy D) Purpuric rash

Ans: A Feedback: Many patients with hemophilia have repeated episodes of hemarthrosis or bleeding into the joints and develop functional impairment of the joints, despite careful treatment. Nuchal rigidity or stiff neck is a symptom seen in Haemophilus influenzae meningitis that may progress to opisthotonos or arching of the back. Encephalopathy is an abnormal condition of the brain tissues. Bleeding under the skin causes a purpuric rash.

When caring for a child with rheumatic fever which medication would the nurse likely administer? A) Aspirin B) Tylenol C) Insulin D) Dilantin

Ans: A Feedback: Salicylates are administered in the form of aspirin to reduce fever and to relieve joint inflammation and pain in the child with rheumatic fever. Although salicylates as a general rule are not given to children, they continue to be the treatment of choice for rheumatic fever. Tylenol is not effective for the inflammation. Insulin would be given for diabetes and Dilantin for seizure disorders.

In a child diagnosed with sickle cell disease, which clinical manifestation would the nurse most likely assess? A) Decreased hemoglobin level B) Increased appetite C) Strawberry-colored tongue D) Hyperactive bowel sounds

Ans: A Feedback: Sickle cell disease causes chronic anemia, with a hemoglobin level of 6 to 9 g/dL (the normal level in an infant is 11 to 15 g/dL). The chronic anemia causes the child to have a poor appetite and severe, acute abdominal pain - caused by sludging which leads to enlargement of the spleen - and an absence of bowel sounds. A strawberry-colored tongue is seen in the diagnosis of Kawasaki disease.

The nurse is caring for an infant with possible congestive heart failure (CHF). Which manifestation would the infant most likely exhibit? A) Feeding problems B) Rapid weight gain C) Bradycardia D) Yellowish color

Ans: A Feedback: The indications of CHF vary in children of different ages. Signs in the infant may be hard to detect because they are subtle, but in infants, feeding problems are often seen. In infants and older children, tachycardia is one of the first signs of CHF. The heart beats faster in an attempt to increase blood flow. Failure to gain weight, weakness, and an enlarged liver and heart are other possible indicators of CHF but are not as common as tachycardia and may take longer to develop.

When caring for a child who has hemophilia which nursing interventions would be most appropriate for this child? (Select all that apply.) A) Performing passive range-of-motion exercises B) Promoting bed rest C) Applying splints to extremities D) Encouraging physical therapy E) Providing diversional activities

Ans: A, C, D Feedback: Passive range-of-motion exercises help prevent the development of joint contractures. Splints and devices are used to position the limb in a functional position. Physical therapy is helpful after the bleeding episode is under control. A child with hemophilia is healthy between bleeding episodes and does not need to be on bed rest, and can participate in normal activities appropriate for the child's age

The parent of a child with iron-deficiency anemia asks what foods would be good for the child to eat. What foods should the nurse identify for the parent? (Select all that apply.) A) Egg yolks B) Milk C) Raisins D) Peanut butter E) Cheese F) Oatmeal

Ans: A, C, D, F Feedback: Egg yolks, raisins, peanut butter, and oatmeal are food sources high in iron. Milk and cheese are not food sources that are high in iron.

The nurse is discussing the causes of iron-deficiency anemia in children with a group of nurses. Which statement is a misconception related to iron-deficiency anemia? A) "A family's economic problems are often a cause of malnutrition." B) "Milk is a perfect food, and babies should be able to have all the milk they want." C) "Caregivers sometimes don't understand the importance of iron and proper nutrition." D) "Children have a hard time getting enough iron from food during their first few years."

Ans: B Feedback: Babies with an inordinate fondness for milk can take in an astonishing amount and, with their appetites satisfied, may show little interest in solid foods. These babies are prime candidates for iron-deficiency anemia. Many children with iron-deficiency anemia; however, are undernourished because of the family's economic problems. A caregiver knowledge deficit about nutrition is often present. Because only 10% of dietary iron is absorbed, a diet containing 8 to 10 mg of iron is needed for good health. During the first years of life, obtaining this quantity of iron from food is often difficult for a child. If the diet is inadequate, anemia quickly results.

In understanding the cardiovascular and hematologic systems of the body it is important to know that the blood is made up of plasma, red blood cells, white blood cells, and platelets. Where are the blood cells formed? A) Arteries B) Bone marrow C) Capillaries D) Lymph nodes

Ans: B Feedback: Blood is a fluid composed of many elements, including plasma, red blood cells, white blood cells, and platelets. Each of these elements has a different function. These blood cells are formed in the bone marrow. Arteries carry blood away from the heart to the body, and veins collect the blood and return it to the heart. Capillaries are the exchange vessels for the materials that flow through the body. The lymph nodes filter the lymph.

The care provider has ordered the drug furosemide (Lasix) to treat a child diagnosed with congestive heart failure. Why is the child receiving this medication? A) Increase vasodilation B) Eliminate excess fluids C) Slow the heart rate D) Strengthen the heart's contractility

Ans: B Feedback: Diuretics, such as furosemide (Lasix), thiazide diuretics, or spironolactone (Aldactone), and fluid restriction in the acute stages of CHF help to eliminate excess fluids in the child with congestive heart failure. Vasodilators are used to dilate the blood vessels. Digoxin is used to improve the cardiac efficiency by slowing the heart rate and strengthening the cardiac contractility.

Which type of medication might the child with thalassemia be given to prevent a complication frequently seen with the treatment of this disorder? A) Vitamin supplements B) Iron-chelating drugs C) Factor VIII preparations D) Potassium supplements

Ans: B Feedback: Frequent transfusions can lead to complications and additional concerns for the child, including the possibility of iron overload. For these children, iron-chelating drugs such as deferoxamine mesylate (Desferal) may be given. Vitamin and potassium supplements would not be given to treat the iron overload. Factor VIII preparations are given to the child with hemophilia.

The nurse is discussing the stages of Kawasaki disease with a group of peers. When is the child at the greatest risk for having an aneurysm? A) The acute stage B) The subacute stage C) The convalescent stage D) The chronic stage

Ans: B Feedback: Kawasaki disease occurs in three stages: Acute—high fever that does not respond to antibiotics or antipyretics; child is irritable. Subacute—fever resolves, irritability continues; greatest risk for aneurysms. Convalescent—symptoms are gone; phase continues until laboratory values are normal and child's energy, appetite, and temperament have returned. The chronic stage is not one of the identified stages of the disorder.

The nurse is teaching a group of nurses on the care of children with rheumatic fever. Which statement is most accurate regarding the diagnosis of rheumatic fever? A) "This disorder is caused by genetic factors." B) "Children who have this diagnosis may have had strep throat." C) "Being up to date on immunizations is the best way to prevent this disorder." D) "The onset and progression of this disorder is rapid."

Ans: B Feedback: Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle.

The nurse is explaining possible side effects of corticosteroids to the caregiver of a child diagnosed with rheumatic fever. What should the nurse explain about hirsutism? A) Abnormal facial grimaces B) Abnormal hair growth C) A "moon face" appearance D) Repetitive movements

Ans: B Feedback: The child whose pain is not controlled with salicylates may be prescribed corticosteroids. Side effects such as hirsutism or abnormal hair growth and "moon face" may be noted. Facial grimaces and repetitive involuntary movements are symptoms of chorea.

A child with hemophilia is crying and complaining of pain. What should the nurse to do to relieve the child's pain? A) Give aspirin as ordered B) Immobilize the affected extremity C) Distract the child with an age-appropriate activity D) Have the child do range-of-motion exercises

Ans: B Feedback: The involved extremity should be promptly immobilized to prevent contractures of soft tissues, to decrease bleeding, and to relieve pain. Aspirin and drugs containing aspirin should not be given to children with hemophilia because it may prolong bleeding. While diversionary activities can help the child deal with pain, they will not relieve it. Range-ofmotion exercises should not be done during or right after an acute episode because stretching of the joint capsule may cause additional bleeding.

A toddler is diagnosed with hemophilia. Which deficiency does this child most likely have? A) Factor V B) Factor VIII C) Factor X D) Factor XIII

Ans: B Feedback: The most common types of hemophilia are factor VIII deficiency and factor IX deficiency, which are inherited as sex-linked recessive traits, with transmission to male offspring by carrier females. Factors V, X, and XIII are not types of hemophilia.

Which site is most frequently used to perform a bone marrow aspiration? A) Humerus B) Iliac crest C) Rib cage D) Femur

Ans: B Feedback: The preferred site for bone marrow aspiration in children is the iliac crest. The other sites are not used for a bone marrow aspiration.

Following the administration of liquid ferrous sulfate, what should the child be encouraged to do? A) Drink a glass of milk B) Brush the teeth C) Rinse the mouth with water D) Not eat or drink for one hour

Ans: B Feedback: To prevent staining of the teeth, the child should brush the teeth after administration of iron preparations such as ferrous sulfate. There is no need to drink milk or to refrain from eating or drinking for one hour. Rinsing the mouth with water is helpful, but brushing the teeth is the best choice.

The nurse is teaching a group of nurses on the topic of sickle cell anemia. Which statement is most accurate regarding sickle cell anemia? A) "The trait or the disease is seen in one generation and skips the next generation." B) "If the trait is inherited from both parents the child will have the disease." C) "The disease is most often seen in individuals of Asian descent." D) "Males are much more likely to have the disease than females."

Ans: B Feedback: When the trait is inherited from both parents (homozygous state), the child has sickle cell disease, and anemia develops. The trait does not skip generations. The trait occurs most commonly in African Americans. Either sex can have the trait and disease

The nurse is collecting data from a caregiver, and the caregiver states that a child has had a "strawberry-colored tongue." Which health problem is associated with this clinical finding? A) Congestive heart failure B) Rheumatic fever C) Kawasaki disease D) Hemophilia

Ans: C Feedback: A strawberry-colored tongue is a symptom seen in the child with Kawasaki disease. This symptom is not seen in congestive heart failure, rheumatic fever, or in hemophilia.

The nurse is planning care for a child with rheumatic fever. Which nursing diagnosis would be the most important to include in this child's plan of care? A) Delayed growth and development B) Risk for aspiration C) Risk for acute pain D) Disturbed body image

Ans: C Feedback: Acute pain related to joint pain when extremities are touched or moved is a concern for the child with rheumatic fever. Diversional activities are important, but growth and development is not likely to be delayed. Chorea may be frustrating to the child but body image is not altered. Respiratory issues are not noted with rheumatic fever.

The nurse is administering iron-dextran (Imferon) to a child diagnosed with irondeficiency anemia. How should the nurse give this medication? A) Intravenous B) Rectal C) Intramuscular D) Subcutaneous

Ans: C Feedback: Because of its irritating nature, an iron-dextran mixture (Imferon) should be administered in the vastus lateralis by intramuscular injection using the Z-track method to avoid leakage into the subcutaneous tissues. It is not given through IV, rectal, or subcutaneous routes.

The nurse is teaching the mother of a child recovering from sickle cell crisis. Which statement indicates that additional teaching is needed? A) "She loves popsicles, so I'll let her have them as a snack or for dessert." B) "I bought the medication to give to her when she complains of pain." C) "She has been down, but playing in soccer camp will cheer her up." D) "I put her legs up on pillows when her knees start to hurt."

Ans: C Feedback: Following a sickle cell crisis the child should avoid extremely strenuous activities that may cause oxygen depletion. Fluids are encouraged, pain management will be needed, and the child's legs may be elevated to relieve discomfort, so these are all statements that indicate an understanding of caring for the child who has had a sickle cell crisis.

In addition to the child's history, symptoms, and blood studies, what helps to confirm the diagnosis of leukemia? A) Genetic studies B) Modified Jones criteria C) Bone marrow aspiration D) Chest x-rays

Ans: C Feedback: In addition to the history, symptoms, and laboratory blood studies, a bone marrow aspiration must be done to confirm the diagnosis of leukemia. Genetic studies are done for hereditary diseases such as sickle cell anemia and hemophilia. The modified Jones criteria are used as a guide to note the manifestations of rheumatic fever, and chest x-rays help in diagnosing congestive heart failure.

The nurse is collecting data on a 5-year-old child with congestive heart failure. What did the nurse most likely assess in this child? A) Jerking movements of the arms and legs B) Scissoring of the legs with toes pointed down C) Failure to gain weight D) Clubbing of the fingers

Ans: C Feedback: In infants and older children, one of the first signs of CHF is tachycardia. Other signs of CHF often seen in the older child include failure to gain weight; weakness; fatigue; restlessness; irritability; and a pale, mottled, or cyanotic color. Rapid respirations or tachypnea, dyspnea, and coughing with bloody sputum also are seen. Edema and enlargement of the liver and heart may be present. Jerking movements indicate seizure activity. Scissoring of the legs is seen in cerebral palsy, and clubbing of the fingers is seen in cystic fibrosis.

The most serious concern for a child diagnosed with Kawasaki disease is the effect on which body organ? A) Brain B) Lungs C) Heart D) Kidneys

Ans: C Feedback: In the child with Kawasaki disease, inflammation of the arteries, veins, and capillaries occurs, and this inflammation can lead to serious cardiac concerns. The other organs are not at as great a risk for complications in the child with Kawasaki disease.

A child with rheumatic fever has polyarthritis. Which laboratory result would the nurse expect with this child's diagnosis and symptoms? A) Increased clotting time B) Decreased white blood cell (WBC) count C) Increased erythrocyte sedimentation rate (ESR) D) Decreased leukocyte count

Ans: C Feedback: In the child with rheumatic fever who has polyarthritis, the ESR is increased. Although the clotting time may be altered with the use of aspirin, this is not anticipated with the treatment. The WBC and leukocyte counts would be elevated

The caregiver of a child with sickle cell disease asks the nurse how much fluid the child should have each day. How much fluid should the nurse instruct the caregiver to provide to the child? A) 300 to 800 mL of fluid per day B) 1,000 to 1,200 mL of fluid per day C) 1,500 to 2,000 mL of fluid per day D) 2,500 to 3,200 mL of fluid per day

Ans: C Feedback: Prevention of crises is the goal between episodes. Adequate hydration is vital; fluid intake of 1,500 to 2,000 mL daily is desirable for a child weighing 20 kg and should be increased to 3,000 mL during the crisis.

The nurse is teaching the caregivers of a child with rheumatic fever. Which statement indicates that the caregivers understand the treatment for this disorder? A) "She will be on a high sodium diet until the symptoms go away." B) "Keeping her involved in her regular sports activities will be important." C) "We don't let her watch TV, but while she is in bed we will let her watch some." D) "If she cuts herself, we know to keep that part of her body elevated above the heart."

Ans: C Feedback: The chief concern in caring for a child with rheumatic fever is the prevention of residual heart disease. Bed rest is important and the length of bed rest is determined by the degree of carditis present. Residual heart disease is treated in accordance with its severity and its type with digitalis, restricted activities, diuretics, and a low-sodium diet as indicated. Bleeding is not a concern with rheumatic fever.

A child who will soon begin chemotherapy as treatment for acute leukemia is worried that when her hair falls out her friends won't like her or want to play with her anymore. What should the nurse respond to this child? A) Reassure her that her hair will grow back in three to six months B) Tell her that having chemotherapy is the only way she'll get better C) Talk with her and her family about wearing a wig, cap, or scarf D) Distract her with a book or educational computer games

Ans: C Feedback: The child undergoing chemotherapy may want to wear a wig, especially when returning to school. Encourage the family to choose the wig before chemotherapy is started so that it matches the child's hair and the child has time to get used to it. A cap or scarf often is appealing to a child, particularly if it carries a special meaning for him or her. Her hair will most likely grow back, chemotherapy is necessary, and distraction can decrease the anxiety, but these are not the best responses for this child.

The nurse is caring for a child with leukemia. Which nursing intervention would be the highest priority for this child? A) Encouraging the child to share feelings B) Grouping nursing care C) Following guidelines for protective isolation D) Providing age-appropriate activities

Ans: C Feedback: The child with leukemia is susceptible to infection, especially during chemotherapy. Infections such as meningitis, septicemia, and pneumonia are the most common causes of death. To protect the child from infectious organisms, follow standard guidelines for protective isolation. Grouping nursing care to provide rest is important, but not the highest priority. Encouraging the child to share feelings and providing age-appropriate activities are important, but psychological issues are a lower priority than physical.

The nurse is reinforcing teaching with the caregiver of a child with iron-deficiency anemia. Which statement made by the caregivers is correct regarding giving ferrous sulfate? A) "When I give my son ferrous sulfate I know he also needs potassium supplements." B) "I always give the ferrous sulfate with meals." C) "My husband gives our son orange juice when he takes her ferrous sulfate, so he gets Vitamin C." D) "We watch closely for any diarrhea since that usually happens when he takes ferrous sulfate."

Ans: C Feedback: When ferrous sulfate is administered, it should be given between meals with juice (preferably orange juice, because vitamin C aids in iron absorption). For best results, iron should not be given with meals. Ferrous sulfate can cause constipation or turn the child's stools black.

What nursing intervention is highest priority when caring for a child with rheumatic fever? A) Position the child to relieve joint pain B) Monitor the C-reactive protein and ESR levels C) Provide age-appropriate diversional activities D) Promote rest periods and bed rest

Ans: D Feedback: As long as the rheumatic process is active, progressive heart damage is possible. To prevent heart damage, bed rest is essential to reduce the heart's work load. Laboratory tests for ESR and C-reactive protein can be used to evaluate disease activity and guide treatment, but they do not improve the child's health itself. The child's comfort is important, so it is essential to relieve joint pain and prevent injury with padded bed rails. But these measures are less important than rest when it comes to preventing long-term complications such as residual heart disease.

For the child with Kawasaki disease who is treated with immunoglobulin (IG) it is most important to delay the administration of which immunization for three to six months following the treatment? A) DTaP (diphtheria, tetanus, acellular pertussis) B) Hepatitis B C) Inactivated poliovirus D) MMR (measles, mumps, rubella)

Ans: D Feedback: Following treatment of Kawasaki disease with immunoglobulins, live vaccines such as MMR should not be given for three to six months to a child who has been treated with IG. The IG prevents the body from building antibodies, so the vaccine will likely be ineffective in preventing the disease that it is being given to prevent. Although immunizations in general are not given, in particular the MMR should not be given.

A child has bronze-colored jaundiced skin. Which disorder should the nurse suspect this child is experiencing? A) Hemophilia B) Sickle cell disease C) Kawasaki disease D) Thalassemia

Ans: D Feedback: In the child with thalassemia the skin may appear bronze colored or jaundiced. The child with hemophilia may have bruised areas on the skin. The skin color in children with sickle cell disease may be pale, and with Kawasaki disease the child may have a rash on the trunk and extremities.

The nurse is caring for a child with acute lymphatic leukemia. What is a characteristic of the sanctuary phase of treatment? A) Suffer a relapse B) Have a complete remission C) Be given a bone marrow transplant D) Have methotrexate injected into cerebrospinal fluid

Ans: D Feedback: Intensive chemotherapy is initially divided into three phases: induction, which is geared to achieving a complete remission with no leukemia cells; sanctuary, preventing the invasion of the central nervous system by leukemia cells; and maintenance, or maintaining the remission. During the sanctuary phase, intrathecal administration of methotrexate is used to eradicate leukemia cells in the central nervous system. Two additional phases are instituted for children who suffer a relapse: reinduction and bone marrow transplant.

Which is the highest priority goal when caring for a child with sickle cell disease? A) The family caregivers' anxiety will be reduced B) The child's skin integrity will be maintained C) The family will verbalize understanding of the disease crisis D) The child's fluid intake will improve

Ans: D Feedback: The child is prone to dehydration because of the kidneys' inability to concentrate urine, so increasing fluid intake is the highest priority. Other goals include improving physical mobility, maintaining skin integrity, reducing the caregivers' anxiety, and increasing the caregivers' knowledge about the causes of crisis episodes, but these goals are not the highest priority

The nurse is caring for a child with congestive heart failure and is administering the drug digoxin. Why is digitalization done at the beginning of treatment for this health problem? A) To decrease the pain to a tolerable level B) To increase the heart rate C) To establish a maintenance dose of the drug D) To build the blood levels to a therapeutic level

Ans: D Feedback: The use of large doses of digoxin at the beginning of therapy, administered to buildup the blood levels of the drug to a therapeutic level, is known as digitalization. A maintenance dose is given, usually daily, after digitalization. Digoxin is used to improve the cardiac efficiency by slowing the heart rate and strengthening the cardiac contractility. Digoxin is not indicated for relief of pain.

The most serious concern for the child with Kawasaki disease is the development of _______________ involvement, which may not be seen for a period of time after the child's initial recovery.

Cardiac

a pink-red rash on the trunk seen in acute rheumatic fever.

Erythema marginatum

Acetaminophen is the drug of choice given to relieve the pain and inflammation in rheumatic fever. TRUE OR FALSE

False

Purpura is the uncontrolled reproduction of deformed white blood cells and its cause is unknown. TRUE OR FALSE

False

bleeding into the joints

Hemarthrosis

Abnormal bleeding beginning in infancy when combined with a positive family history suggests the disorder known as _____________.

Hemophilia

Congestive heart failure occurs because the heart is not able to pump and circulate enough blood to supply oxygen and nutrients to the cells. TRUE OR FALSE

True

Rheumatic fever is usually precipitated by a streptococcal infection such as strep throat or scarlet fever. TRUE OR FALSE

True

The most common symptom during a sickle cell crisis is severe abdominal pain. TRUE OR FALSE

True

enlarged lymph glands

adenopathy

loss of hair

alopecia

painful joints

arthralgia

decreased pulse rate

bradycardia

inflammation of the heart

carditis

continuous, rapid, jerky, involuntary movements.

chorea

the result of impaired pumping capability of the heart. It may appear in the first year of life in infants with conditions such as large ventricular septal defects, coarctation of the aorta, and other defects that place an increased workload on the ventricles.

congestive heart failure

the use of large doses of digoxin, at the beginning of therapy, to build up the blood levels of the drug to a therapeutic level.

digitalization

nosebleed

epistaxis

type of white blood cell; divided into eosinophils, basophils, and neutrophils.

granulocytes

Sickle cell disease is a ________________ trait occurring most commonly in African Americans.

hereditary

a one-time dose of medication placed into the spinal fluid (in the subarachnoid space), also known as a spinal block.

intrathecal administration

To prevent staining of the teeth, a child's teeth should be brushed following the administration of an ______________ preparation such as ferrous sulfate.

iron

The most common type of cancer in children is _______________.

leukemia

uncontrolled reproduction of deformed white blood cells.

leukemia

a lymphocyte that has been changed by antigenic stimulation to a structurally immature lymphocyte

lymphoblast

single nucleus, nonphagocytic leukocytes that are instrumental in the body's immune response.

lymphocytes

5% to 10% of white blood cells that defend the body against infection.

monocytes

a small hemorrhage appearing as a non-raised, purplish-red spot of the skin, nail beds, or mucous membranes.

petechiae

inflammation of several joints

polyarthritis

hemorrhages into the skin or mucous membranes

purpura