PEDS Chapter 28: Nursing Care of the Child with a Neoplastic Disorder
The nurse realizes that the chemotherapy agents and radiation that a child is receiving are likely to irritate the bladder. What are the best measures that the nurse can take to diminish this risk?
Keep intravenous (IV) fluids running to maintain excellent hydration and frequent voids Explanation: IV fluids are given before, during, and after radiation and chemotherapy drugs; bladder irritation results from the need to dilute and remove them from the body. This reduces the need for the child to drink large quantities. Administering the drug during sleep and having the child retain urine would cause irritating chemicals to be kept in contact with the bladder mucosa. No benefit is associated with providing cranberry juice.
Which of the following is a well-defined risk management technique that the nurse can teach children and parents to prevent cancer?
Limit sun exposure throughout childhood and adolescence Explanation: Limiting sun exposure by using shade, clothing, and sunscreen applied correctly will reduce the risk of skin cancer. Sun exposure is cumulative throughout life; the greatest exposure tends to occur in childhood and adolescence. Tanning booths should not be used. The other choices could have some merit, but none has been scientifically confirmed.
A 15-year-old boy has been diagnosed with an osteogenic sarcoma of the distal femur. He also demonstrates a chronic cough, dyspnea, and chest pain, along with chronic leg pain. Based on these findings, the nurse should suspect metastasis to which body area?
Lungs Correct Explanation: Metastasis occurs early with bone tumors because of the extensive vascular system in bones. Metastasis to the lungs is very common; as many as 25% of adolescents will have lung metastasis already by the time of initial diagnosis. When this is present, the adolescent usually has noticed a chronic cough, dyspnea, and chest pain in addition to chronic leg pain. Other common sites of metastasis are brain and other bone tissue.
A 14-year-old patient experiencing difficulty breathing is sent for a radiograph. The nurse knows that this sign may be indicative of:
Mediastinal mass Explanation: Difficulty breathing or respiratory distress may indicate a mediastinal mass (which may be seen on a radiograph). Presence of a white reflection in the pupil of the eye may indicate retinoblastoma. Enlarged or tender axillary lymph nodes may indicate lymphadenopathy. Hepatomegaly or splenomegaly may be caused by an infection or tumor in the liver or abdomen.
Which intervention is best to use with the 6-year-old who has developed stomatitis as a side effect of chemotherapy?
Practice frequent, gentle oral hygiene Correct Explanation: Frequent, gentle oral hygiene will keep the vulnerable oral mucosa clean and will prevent secondary infection. Offering only cool, clear liquids will limit nutrition. "Child freely choosing foods and beverages" gives some control to the 6-year-old but is likely to result in ingestion of foods that are irritating to the mouth, lips, and throat. Lidocaine used as a rinse can create risks for children younger than 8 years because often some is swallowed, and this inhibits the gag reflex.
The nurse is caring for a child who is receiving peripheral intravenous (IV) chemotherapy. The child tells the nurse that the IV "hurts." The nurse finds that the insertion site is reddened and edematous. Which is the first action the nurse should take?
Stop the infusion. Explanation: Stopping the infusion prevents additional sclerosing drug from entering the tissue. Warmth increases tissue absorption/damage. Distraction lessens discomfort but not tissue damage. Retaping is inappropriate.
Parents ask why their child is receiving prednisone to treat leukemia, because it is not a chemotherapy drug. How should the nurse answer?
"Prednisone decreases edema cause by tumor necrosis." Explanation: Prednisone is not a chemotherapeutic agent, but a hormone and it is given in conjunction with chemotherapy to decrease edema caused by tumor necrosis or the tumor. Reducing inflamm ... (more) Prednisone is not a chemotherapeutic agent, but a hormone and it is given in conjunction with chemotherapy to decrease edema caused by tumor necrosis or the tumor. Reducing inflammation, stimulating appetite, and promoting weight gain are some actions and possible side effects of prednisone but do not provide the reason why the medication is used to treat leukemia.
The parents of a child diagnosed with cerebral astrocytoma ask the nurse about their child's prognosis. Which of the following would be an accurate response?
"The prognosis is favorable with complete surgical resection, with minimal neurologic deficits postoperatively." Correct Explanation: The prognosis is favorable with complete surgical resection, and patients have minimal neurologic deficits postoperatively.Slow course with insidious onset. Responsive to chemotherapy, often resectable. Causes slowly increasing intracranial pressure. Low-grade tumor may be removed completely. High-grade tumors have poor prognosis.
The nurse is teaching the parents of a 15-year-old boy who is being treated for acute myelogenous leukemia about the side effects of chemotherapy. For which symptoms should the parents seek medical care immediately?
Temperature of 101° F (38.3° C) or greater Correct Explanation: The parents should seek medical care immediately if the child has a temperature of 101°F (38.3° C) or greater. This is because many chemotherapeutic drugs cause bone marrow suppression; the parents must be directed to take action at the first sign of infection in order to prevent overwhelming sepsis. The appearance of earache, stiff neck, sore throat, blisters, ulcers, or rashes, or difficulty or pain when swallowing are reasons to seek medical care, but are not as grave as the risk of infection.
The nurse is assessing a 4-year-old girl whose mother reports that she is not eating well, is losing weight, and has started vomiting after eating. Which risk factor from the health history suggests the child may have a Wilms tumor?
The child has Beckwith-Wiedemann syndrome. Explanation: Along with the symptoms reported by the mother, the fact that the child has Beckwith-Wiedemann syndrome suggests that the child could have a Wilms tumor. Down syndrome would point to leukemia or brain tumor. Schwachman syndrome would suggest leukemia. A family history of neurofibromatosis is a risk factor for brain tumor, rhabdomyosarcoma, or acute myelogenous leukemia.
When explaining the procedure of bone marrow aspiration to a child with leukemia, what would be the best explanation?
"You will feel pressure on your hip from the needle." Explanation: Bone marrow aspiration requires hard pressure to allow the needle to puncture the bone. It is usually done under local anesthesia or conscious sedation.
The child has been prescribed chemotherapy. In order to properly calculate the child's dose, the nurse must first figure the child's body surface area (BSA). The child is 130 cm tall and weighs 27 kg. Calculate the child's BSA. Record your answer using two decimal places.
0.99
Place the following steps of stem cell transplantation in the order in which they occur in the process:
ANC reaches 500 for 3 consecutive days Conditioning Extensive physical and psychosocial evaluation One day of rest Development of neutropenia Hematopoietic stem cells are infused into patient
A 4-year-old has developed acute lymphocytic leukemia (ALL). Nursing care for the child with ALL involves taking axillary, rather than rectal, temperatures because the child
has a low platelet count. Explanation: Children with leukemia develop lesions of the gastrointestinal tract. If touched by a thermometer, these bleed easily; blood coagulation is poor because of a decreased platelet count.
Children with ALL may need periodic lumbar punctures. You would teach the mother this is done to assess for
leukemic cells. Explanation: Leukemic cells in cerebrospinal fluid must be identified because, if present, they require additional therapy.
A child with ALL is given leucovorin, a folinic acid, after high-dose methotrexate therapy. It is important to administer this drug because leucovorin
prevents methotrexate that is not incorporated into leukemia cells from entering normal cells. Explanation: Leucovorin "rescue" prevents methotrexate from entering normal cells.
The nurse caring for adolescents with cancer uses the following recommended psychosocial interventions to help the adolescents cope with their disease (select all answers that apply):
• Encourage adolescents to engage in their usual activities. • Encourage the adolescents to make plans for the future. • Control the amount of information given out about the adolescents' conditions. Explanation: The nurse should encourage usual activities and plans for the future and control the amount of information outsiders know about the child's condition. Relationships with other cancer patients should be encouraged as well as an early return to school. The nurse should be a friend as well as an advisor to the adolescents.
A 4-year-old child diagnosed with Wilms tumor is admitted for surgery. Which of the following would be most important for the nurse to include in the child's preoperative plan of care?
Avoiding further abdominal palpation Correct Explanation: After the initial assessment is performed on a child with Wilms tumor, further palpation of the abdomen should be avoided because the tumor is highly vascular and soft. Therefore, excessive handling of the tumor may result in tumor seeding and metastasis. Preoperatively, the child with Wilms tumor does not have a wound; therefore, dressing changes are not necessary. Although the child may experience abdominal pain, avoiding further abdominal palpation would be the priority. Surgical removal of the tumor and affected kidney is the treatment of choice for Wilms tumor. Amputation would be more likely for a child with osteosarcoma.
The nurse is admitting to an examination room a child with the diagnosis of "probable acute lymphoblastic leukemia." What will confirm this diagnosis?
Bone marrow aspiration Explanation: Bone marrow aspiration and biopsy are diagnostic. An abnormal white blood count and symptoms of lethargy, bruising, and pallor only create suspicion of leukemia; a twin may or may not be affected.
The nurse is preparing a discharge teaching plan for the parents of an 8-year-old girl with leukemia. Which instruction would be the priority?
Calling the doctor if the child gets a sore throat Explanation: Calling the doctor if the child gets a sore throat is the priority. Because of the child's impaired immune system, any sign of potential infection, such as sore throat, must be evaluated by a physician. Using acetaminophen if the child needs an analgesic, writing down phone numbers and appointments, and keeping a written copy of the treatment plan are important teaching points but secondary to guarding against infection.
The father of an 8-year-old boy who is receiving radiation therapy is upset that his son has to go through 6 weeks of treatments. He doesn't understand why it takes so long. In explaining the need for radiation over such a long time, which of the following should the nurse mention?
Cells are only susceptible to treatment by radiation during certain phases of the cell cycle Explanation: Radiation is not effective on cells that have a low oxygen content (a proportion of cells in every tumor), nor is it effective at the time of cell division (mitosis). Therefore, radiation schedules are designed so that therapy occurs over a period of 1 to 6 weeks and includes time intervals when cells will be in a susceptible stage.
A nursing student compares and contrasts childhood and adult cancers. Which statement does so accurately?
Children's cancers, unlike those of adults, often are detected accidentally, not through screening. Explanation: Children's cancers are often found during a routine checkup, following an injury, or when symptoms appear---not through screening procedures or other specific detection practices. A very small percentage of children may be followed closely because they are known to be at high risk genetically. Most children's cancers are highly responsive to therapy. Few prevention strategies are available for children, although many are known to be effective for adults. Several lifestyle and environmental influences regarding children's cancers are suspect, but few have been scientifically documented. The reverse is true in the adult population.
The pediatric nurse examines the radiographs of a patient that show that there are lesions on the bone. This finding is indicative of:
Ewing sarcoma Explanation: Radiographs that show lesions on the bone may indicate tumors (e.g., Ewing sarcoma, osteosarcoma) or metastasis of tumors and warrant further investigation by bone scan, CT, or MRI. Positron emission tomography is the most effective test to diagnose Hodgkin disease, non-Hodgkin lymphoma, a neuroblastoma, bone tumors, lung and colon cancers, and brain tumors.
The nurse explains to the teenager that which alterations may occur when steroids are added to the cancer therapy regimen?
Facial changes Explanation: Facial changes are common and include a round face with full cheeks, often reddened, described as "moon face." Weight gain and fat pads may appear in various areas of the body. Appetite is likely to increase. Urinary incontinence and nighttime itching are not related to steroid therapy.
The nurse is assessing a 14-year-old girl with a tumor. Which finding indicates Ewing sarcoma?
Palpation reveals swelling and redness on the right ribs. Explanation: Ewing sarcoma may result in swelling and erythema at the tumor site. Common sites are chest wall, pelvis, vertebrae, and long bone diaphyses. Dull bone pain in the proximal tibia is indicative of osteosarcoma. Persistent pain after an ankle injury is not indicative of Ewing sarcoma. An asymptomatic mass on the upper back suggests rhabdomyosarcoma.
The toddler with a cancer diagnosis is seen for a well-child checkup. Which health maintenance activity will the nurse exclude?
Administering the measles, mumps, rubella (MMR) vaccine Explanation: Live vaccines (viral or bacterial) should not be administered to an immune suppressed child because of the risk of causing disease. The other health maintenance activities are important for the health maintenance of the toddler and should be included during the well-child visit.
A preschooler who received chemotherapy in the pediatric oncology outpatient department 1 week ago now has a temperature of 101.5°F (38.6°C). Which is the most appropriate response by the nurse?
Have the parent bring the child to the pediatric oncology clinic as soon as possible Correct Explanation: The preschooler is considered immune suppressed following recent chemotherapy. A fever can mean sepsis, which would require immediate investigation of blood and other body fluids to identify the organism, plus prompt treatment with an IV antibiotic. This can be accomplished only by seeing the pediatric oncologist and is likely to result in hospitalization.
Parents tell the nurse who is admitting their infant for a well-child exam that they recently saw a "white glow" in their child's left pupil. What is the nurse's best response?
"I will report this to the pediatrician." Explanation: The "white glow" may indicate retinoblastoma; immediate investigation is needed. The red reflex is indicative of eye health. Eye rubbing and a plugged tear duct are unrelated to the symptom described.
When reviewing information about the incidence of the various types of childhood cancer, nursing students demonstrate understanding of the information when they identify which of the following as having the highest incidence?
Acute lymphocytic (lymphoblastic) leukemia Explanation: Acute lymphocytic leukemia accounts for approximately 32% of all childhood cancers. Neuroblastomas account for 8%; non-Hodgkin's lymphoma accounts for 6%; osteogenic sarcoma accounts for 3%.
How can the nurse most simply describe for distressed parents a rhabdomyosarcoma that has been found in their 5-year-old?
Call it a tumor of muscle tissue Correct Explanation: A rhabdomyosarcoma is a tumor of striated muscle that most commonly develops in the head, neck, arms, and legs, as well as in the genitourinary tract, of children. The other descriptors are incorrect.
How can the nurse most simply describe for distressed parents a rhabdomyosarcoma that has been found in their 5-year-old?
Call it a tumor of muscle tissue Explanation: A rhabdomyosarcoma is a tumor of striated muscle that most commonly develops in the head, neck, arms, and legs, as well as in the genitourinary tract, of children. The other descriptors are incorrect.
A high-school football player has been diagnosed as having osteosarcoma of the femur. His mother is angry because she told him not to play football. Which of the following health teaching points would you include in the teaching plan for the boy and his mother?
Football injuries do not contribute to the development of a tumor. Explanation: Trauma does not contribute to developing bone cancer; a lesion may be discovered after a traumatic injury.
The nurse realizes that the chemotherapy agents and radiation that a child is receiving are likely to irritate the bladder. What are the best measures that the nurse can take to diminish this risk?
Keep intravenous (IV) fluids running to maintain excellent hydration and frequent voids Correct Explanation: IV fluids are given before, during, and after radiation and chemotherapy drugs; bladder irritation results from the need to dilute and remove them from the body. This reduces the need for the child to drink large quantities. Administering the drug during sleep and having the child retain urine would cause irritating chemicals to be kept in contact with the bladder mucosa. No benefit is associated with providing cranberry juice.
A child with ALL is receiving methotrexate for therapy. Which nursing diagnosis below would best apply to him during therapy?
Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy Explanation: Many chemotherapy agents cause oral ulcerations that interfere with nutrition because of pain and leave a portal of infection.
The nurse preparing patients for diagnostic testing for cancer knows that the following test is used to differentiate a neuroblastoma from other tumors:
Urine catecholamines VMA, HVA Explanation: Urine catecholamine metabolites homovanillic acid (HVA) and vanillylmandelic acid (VMA) differentiate neuroblastomas from other tumors. Urinalysis provides general information abou ... (more) Urine catecholamine metabolites homovanillic acid (HVA) and vanillylmandelic acid (VMA) differentiate neuroblastomas from other tumors. Urinalysis provides general information about renal function. Serum chemistries help to evaluate the body's response to the cancer process. CBC with differential determines abnormal loss or destruction of cells that may indicate cancer or bone marrow suppression.
The nurse performing a physical assessment of a patient checks for signs of malignancies. Which of the following may indicate a soft tissue mass? Select all answers that apply.
• Cranium masses • Swelling around eyes • Drainage from ear Explanation: Masses on the cranium may indicate a soft tissue or bony mass. Drainage from the ear, asymmetry of face, jaw pain, or swelling may indicate an infection or the presence of a soft tissue mass. Pallor, bruising, petechiae, or mucous membrane bleeding may indicate leukemia. Night sweats may be present in Hodgkin disease.
What signs and symptoms has the elementary school nurse noted that create suspicion of a brain tumor in a student? Select all that apply.
• Headache on awakening • Nausea and vomiting • Clumsiness in movement Explanation: Most brain tumors in children occur in the cerebellum or brainstem, so that initial symptoms are those of increased intracranial pressure (ICP). Incoordination is also a frequent sign. Ringing in the ears and reddened sclera do not create suspicion of a brain tumor.
Parents ask why their child just diagnosed with leukemia needs a "spinal tap." Which is the best response by the nurse?
"Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system." Explanation: The cerebrospinal fluid is checked so the clinician can determine whether leukemic cells have invaded the central nervous system. It is common for a chemotherapy medication, usually methotrexate, to be administered immediately following lumbar puncture as treatment for potential infiltration. The other responses are incorrect.
Parents ask why their child just diagnosed with leukemia needs a "spinal tap." Which is the best response by the nurse?
"Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system." Explanation: The cerebrospinal fluid is checked so the clinician can determine whether leukemic cells have invaded the central nervous system. It is common for a chemotherapy medication, usually methotrexate, to be administered immediately following lumbar puncture as treatment for potential infiltration. The other responses are incorrect.
The nurse caring for a 14-year-old scheduled for magnetic resonance imaging (MRI) explains how the test works to the family. Which of the following responses accurately describes this test?
"The MRI uses radio waves and magnets to produce a computerized image of the body." Correct Explanation: The MRI uses radio waves and magnets to produce a computerized image of the body. The bone scan is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement. The ultrasound uses sound waves to create images that visualize body structures and locate masses. Radiography uses radiation to examine soft tissue and bony structures of the body.
The physician requests the nurse to calculate the child's absolute neutrophil count (ANC). The complete blood count indicates that the child's "segs" are 14%, bands are 9%, and white blood cells (WBC) are 15,000. Calculate the child's absolute neutrophil count. Record your answer using a whole number.
3450 Explanation: Bands + segs/100) x WBC = ANC 14 + 9 = 23% = 23/100 = 0.23 0.23 x 15,000 = 3,450
The nurse must calculte the absolute neutophil count for an immune suppressed child. Which is the accurate ANC based on the following laboratory results? Total white blood cell count (WBC): 3000. WBC differential: 10% segmented neutrophils, 8% neutrophil bands.
540 Explanation: The ANC is not measured directly; it must be calculated. Step 1: Determine the total percentage of neutrophils. 10% + 8% = 18% (0.18) Step 2: Multiply the WBC by the total percent of neutrophils. 3000 X 0.18 = 540 ANC
A group of students are reviewing the different classes of drugs used for cancer chemotherapy. The students demonstrate understanding of these agents when they identify which of the following as cell cycle-specific agents?
Antimetabolites Explanation: Antimetabolites are primarily cell cycle-specific agents. Alkylating agents, nitrosoureas, and nitrogen mustards are cell cycle-nonspecific agents.
The nurse is providing preoperative care for a 7-year-old boy with a brain tumor and his parents. Which intervention is priority?
Assessing the child's level of consciousness Explanation: The priority intervention is to monitor for increases in intracranial pressure because brain tumors may block cerebral fluid flow or cause edema in the brain. A change in the level of consciousness is just one of several subtle changes that can occur indicating a change in intracranial pressure. Lower priority interventions include providing a tour of the ICU to prepare the child and parents for after the surgery, and educating the child and parents about shunts.
A 4-year-old child diagnosed with Wilms tumor is admitted for surgery. Which of the following would be most important for the nurse to include in the child's preoperative plan of care?
Avoiding further abdominal palpation Correct Explanation: After the initial assessment is performed on a child with Wilms tumor, further palpation of the abdomen should be avoided because the tumor is highly vascular and soft. Therefore, excessive handling of the tumor may result in tumor seeding and metastasis. Preoperatively, the child with Wilms tumor does not have a wound; therefore, dressing changes are not necessary. Although the child may experience abdominal pain, avoiding further abdominal palpation would be the priority. Surgical removal of the tumor and affected kidney is the treatment of choice for Wilms tumor. Amputation would be more likely for a child with osteosarcoma.
A group of nursing students are studying information about childhood cancers in preparation for a class examination. They are reviewing how childhood cancers differ from adult cancers. The group demonstrates understanding of the information when they identify which of the following as an unlikely site for childhood cancer?
Bladder Explanation: The most common sites for childhood cancer include the blood, lymph, brain, bone, kidney, and muscle. Bladder is a common site for adult cancer
What is one advantage of an implanted port (central venous access device) that the nurse will explain to an adolescent?
Body appearance changes very little. Explanation: An implanted port has nothing extending through the skin and may be obvious only as a slight protrusion at the insertion site. Some tunneling from the port to a central vein is needed. Removal of the port requires a surgical procedure. Flushing of the port is necessary when used and on a regular basis.
The father of an 8-year-old boy who is receiving radiation therapy is upset that his son has to go through 6 weeks of treatments. He doesn't understand why it takes so long. In explaining the need for radiation over such a long time, which of the following should the nurse mention?
Cells are only susceptible to treatment by radiation during certain phases of the cell cycle Explanation: Radiation is not effective on cells that have a low oxygen content (a proportion of cells in every tumor), nor is it effective at the time of cell division (mitosis). Therefore, radiation schedules are designed so that therapy occurs over a period of 1 to 6 weeks and includes time intervals when cells will be in a susceptible stage.
Children who are free of acute lymphocytic anemia for 2 years following treatment are considered cured.
False Explanation: Children who are free of disease for 4 years are considered cured, and their maintenance therapy can then be stopped.
A preschooler who received chemotherapy in the pediatric oncology outpatient department 1 week ago now has a temperature of 101.5°F (38.6°C). Which is the most appropriate response by the nurse?
Have the parent bring the child to the pediatric oncology clinic as soon as possible Explanation: The preschooler is considered immune suppressed following recent chemotherapy. A fever can mean sepsis, which would require immediate investigation of blood and other body fluids to identify the organism, plus prompt treatment with an IV antibiotic. This can be accomplished only by seeing the pediatric oncologist and is likely to result in hospitalization.
A 6-month-old girl is seen with retinoblastoma. When taking a health history from her father, which symptom would you expect him to report he has noticed?
He has noticed one pupil appears white. Explanation: As the tumor grows against the retina of the eye, the red reflex is no longer visible; the pupil appears white.
A 6-month-old girl is seen with retinoblastoma. When taking a health history from her father, which symptom would you expect him to report he has noticed?
He has noticed one pupil appears white. Explanation: As the tumor grows against the retina of the eye, the red reflex is no longer visible; the pupil appears white.
A 14-year-old patient experiencing difficulty breathing is sent for a radiograph. The nurse knows that this sign may be indicative of:
Mediastinal mass Difficulty breathing or respiratory distress may indicate a mediastinal mass (which may be seen on a radiograph). Presence of a white reflection in the pupil of the eye may indicate retinoblastoma. Enlarged or tender axillary lymph nodes may indicate lymphadenopathy. Hepatomegaly or splenomegaly may be caused by an infection or tumor in the liver or abdomen
What is the priority action that the nurse should take when caring for a child newly diagnosed with Wilms' tumor (nephroblastoma)?
Protect the abdomen from manipulation. Explanation: Manipulation can release malignant cells into the abdominal cavity. Constipation may be a problem following surgical intervention. Pain is uncommon; obtaining a urine specimen is not a priority.
The nurse is assessing an adolescent with suspected osteosarcoma. Which of the following would the nurse be least likely to assess?
Severe bone pain Explanation: Osteosarcoma typically is characterized by dull bone pain that may be present for several months, eventually progressing to limp or gait changes. The affected limb may exhibit erythema and swelling, warmth, and tenderness.
The nurse is caring for a 6-year-old girl with leukemia who is having an oncological emergency. Which of the following signs and symptoms would indicate hyperleukocytosis?
Tachycardia and respiratory distress Explanation: Increased heart rate, murmur, and respiratory distress are symptoms of hyperleukocytosis (high white blood cell count) which is associated with leukemia. Increased heart rate and blood pressure are indicative of tumor lysis syndrome, which may occur with acute lymphoblastic leukemia, lymphoma, and neuroblastoma. Wheezing and diminished breath sounds are signs of superior vena cava syndrome related to non-Hodgkin's lymphoma or neuroblastoma. Respiratory distress and poor perfusion are symptoms of massive hepatomegaly which is caused by a neuroblastoma filling a large portion of the abdominal cavity.
The nurse is assessing a 4-year-old girl whose mother reports that she is not eating well, is losing weight, and has started vomiting after eating. Which risk factor from the health history suggests the child may have a Wilms tumor?
The child has Beckwith-Wiedemann syndrome. Explanation: Along with the symptoms reported by the mother, the fact that the child has Beckwith-Wiedemann syndrome suggests that the child could have a Wilms tumor. Down syndrome ... (more) Along with the symptoms reported by the mother, the fact that the child has Beckwith-Wiedemann syndrome suggests that the child could have a Wilms tumor. Down syndrome would point to leukemia or brain tumor. Schwachman syndrome would suggest leukemia. A family history of neurofibromatosis is a risk factor for brain tumor, rhabdomyosarcoma, or acute myelogenous leukemia.
A child is to receive radiation therapy this morning. A drug you would expect to see prescribed for him prior to this would be an
antiemetic. Explanation: Radiation therapy causes nausea because it destroys rapid-growing cells. Among these are the cells of the stomach lining, the reason that nausea occurs.
A young school-age child who is being treated for cancer has constipation and loss of appetite. What nursing interventions should the nurse suggest to the family? Choose all that apply.
• Add high-fiber snacks such as popcorn and apples to the diet. • Increase gross motor activities such as family walks. • Provide adequate private time in the bathroom. Explanation: Fiber in the diet promotes bowel emptying. Even with decreased appetite, popcorn and apples are likely to be accepted. A simple gross motor activity such as walking stimulates peristalsis. Adequate private bathroom time will promote evacuation in the school-age child who is sensitive about bodily functions. Suppositories are avoided to prvent damage to the rectal mucosa.
Parents bring their daughter to the health care facility for evaluation. They report that lately the child seems rather pale and really tired. Which of the following would the nurse most likely find with further assessment if the child has acute lymphoblastic leukemia (ALL)? Select all that apply.
• Bleeding from the oral mucous membranes • Headache • Painless cervical lymphadenopathy • Low-grade fever Explanation: Assessment findings associated with ALL include low-grade fever, lethargy, petechiae, bleeding from the oral mucous membranes, and easy bruising. As the spleen and liver begin to enlarge, abdominal pain, vomiting, and anorexia occur. Physical assessment reveals painless, generalized swelling of lymph nodes, especially the submaxillary or cervical nodes.
A child is diagnosed with rhabdomyosarcoma involving the neck. When assessing the child, which of the following would the nurse expect to find? Select all that apply.
• Dysphagia • Hoarseness Explanation: With rhabdomyosarcoma involving the neck, assessment findings would include hoarseness, dysphagia, and a visible and palpable mass in the neck. Proptosis would be noted if the site of the tumor is the orbit. Hearing loss and facial nerve palsy suggest middle ear involvement.
The child has been diagnosed with cancer and is being treated with chemotherapy. Which findings are common side effects of this type of treatment? Select all that apply.
• The child's mother states, "It seems like he catches every bug that comes along." • The child has no hair on his head. • The child's mother states that she often has to repeat herself because he can't hear very well. • The child reports feeling nauseated. Explanation: Common adverse effects of chemotherapeutic drugs are: immunosuppression, alopecia, hearing changes, and nausea. Another common adverse effect is microdontia, not enlarged teeth.
The nurse is assessing a 10-year-old girl with acute lymphoblastic leukemia. Which of the following would lead the nurse to suspect that the cancer has infiltrated the central nervous system?
Child complains of facial palsy and vision problems Correct Explanation: The presence of facial palsy and vision problems indicates that the central nervous system has been infiltrated by leukemia cells. The petechiae, purpura, or unusual bruising results from decreased platelet levels and may be present regardless of metastasis. Adventitious breath sounds may indicate pneumonia, and may be present whether the disease has metastasized or not. Hepatomegaly and splenomegaly result from infection, not metastasis.
Nursing students are reviewing information about childhood cancers. They demonstrate understanding of the information when they identify which of the following as the most frequent type?
Leukemia Explanation: Although Wilms' tumor, brainstem tumors, and non-Hodgkin's lymphoma can occur in children, the most frequent type of cancer in children is leukemia.
The nurse is providing care to a child and is to collect a 24-hour urine specimen for catecholamines. The nurse integrates knowledge of this testing as indicative of which of the following?
Neuroblastoma Explanation: A 24-hour urine specimen for catecholamines (homovanillic acid [HVA] and vanillylmandelic acid [VMA]) is used to help diagnose neuroblastoma because this cancer produces catecholam A 24-hour urine specimen for catecholamines (homovanillic acid [HVA] and vanillylmandelic acid [VMA]) is used to help diagnose neuroblastoma because this cancer produces catecholamines; thus, levels will be elevated. This test is not used to diagnose Hodgkin's disease, leukemia, or osteosarcoma.
The nurse is caring for a 5-year-old boy who will soon die of cancer and is experiencing dyspnea and increasing levels of pain. Which of the following would be the priority for pain management with this child?
Preventing and alleviating pain Correct Explanation: Recommendations for pain management in this setting place no limits on the dosage of analgesics but rather encourage aggressive dosing and even rapid escalation of dosages to achieve and maintain pain control. The recommendations also state that prevention and alleviation of pain is the nurse's primary goal; that children, parents, and clinicians are equal partners in pain management; and that the nurse's role includes performing and evaluating interventions. Addiction is not an issue with a dying child who is in pain. Vital signs are monitored frequently regardless of the child's pain level. Additionally, the focus of the question is on pain management of the dying child.
The nurse identifies the nursing diagnosis of risk for infection related to chemotherapy-induced immunosuppression. Which of the following would the nurse include in the teaching plan for the child and parents about reducing the child's risk? Select all that apply.
• Having the child sleep in a single bed and room • Encouraging frequent, thorough handwashing Explanation: To reduce the risk of infection, the nurse should teach the child and parents about minimizing the child's exposure to potentially infectious situations. The nurse should encourage the parents to arrange for the child to sleep in a single bed and room and, if possible, avoid close contact with other family members who may be developing upper respiratory tract infections. Thorough and frequent handwashing, especially after using the bathroom and before eating, is essential. A high-calorie, high-protein diet helps to rebuild white blood cells and should be encouraged. If possible, the child's exposure to large crowds and visitors should be limited because of the increased risk of infection from these individuals. Fresh flowers and plants should be avoided because they could harbor mold spores.
The child has been diagnosed with leukemia. Rank the following medications used to treat leukemia in order based on the stage of treatment.
Oral steroids and vincristine through an intravenous line High-dose methotrexate and 6-mercaptopurine Low doses of 6-mercaptopurine and methotrexate Chemotherapy through an intrathecal catheter Explanation: During induction, the child receives oral steroids and IV vincristine. During consolidation, the child receives high doses of methotrexate and 6-mercaptopurine. During maintenance, the child receives low doses of methotrexate and 6-mercaptopurine. During central nervous system prophylaxis, the child receives intrathecal chemotherapy.
The nurse is providing preoperative care for a 7-year-old boy with a brain tumor and his parents. Which intervention is priority?
Assessing the child's level of consciousness Correct Explanation: The priority intervention is to monitor for increases in intracranial pressure because brain tumors may block cerebral fluid flow or cause edema in the brain. A change in the ... (more) The priority intervention is to monitor for increases in intracranial pressure because brain tumors may block cerebral fluid flow or cause edema in the brain. A change in the level of consciousness is just one of several subtle changes that can occur indicating a change in intracranial pressure. Lower priority interventions include providing a tour of the ICU to prepare the child and parents for after the surgery, and educating the child and parents about shunts.
A 10-year-old who is receiving chemotherapy has received ondansetron before this therapy session. About an hour later, the child tells the nurse that his mouth feels really dry. The child has urinated several times and his skin turgor is normal. Which response by the nurse would be most appropriate?
"The drug you got to help with the nausea can cause dry mouth." Explanation: Ondansetron is associated with dry mouth. Increasing IV fluids may or may not be appropriate. The child is urinating and his skin turgor is normal so it doesn't appear that he is dehydrated and in need of extra fluid. A severe allergic reaction would more likely be manifested by itching, hives, and increasing respiratory distress. Dry mouth is not an indicator of infection.
The nurse is providing preoperative care for a 7-year-old boy with a brain tumor and his parents. Which intervention is priority?
Assessing the child's level of consciousness Explanation: The priority intervention is to monitor for increases in intracranial pressure because brain tumors may block cerebral fluid flow or cause edema in the brain. A change in the level of consciousness is just one of several subtle changes that can occur indicating a change in intracranial pressure. Lower priority interventions include providing a tour of the ICU to prepare the child and parents for after the surgery, and educating the child and parents about shunts.
What is one advantage of an implanted port (central venous access device) that the nurse will explain to an adolescent?
Body appearance changes very little. Explanation: An implanted port has nothing extending through the skin and may be obvious only as a slight protrusion at the insertion site. Some tunneling from the port to a central vein is needed. Removal of the port requires a surgical procedure. Flushing of the port is necessary when used and on a regular basis.
The nurse is assessing an 11-year-old girl diagnosed with acute myelogenous leukemia (AML) who came to the emergency department. Which of the following would alert the nurse to the need for immediate intervention?
CBC indicates hyperleukocytosis. Correct Explanation: About 25% of children with acute myelogenous leukemia present with blood counts greater than 100,000. This is called hyperleukocytosis, and it is a medical emergency requiring leukapheresis to decrease hyperviscosity by quickly decreasing the number of circulating blasts. Lymphadenopathy, headache, visual disturbance, weight loss, and muscle wasting are signs and symptoms common to both types of leukemia. Lymphadenopathy is a common manifestation associated with AML and does not require immediate intervention. Headache and vision problems are common manifestations associated with AML. They do not require immediate intervention. Weight loss and muscle wasting are common manifestations associated with AML. They do not require immediate intervention.
Nursing students are reviewing information about the normal cell cycle. They demonstrate understanding of this process when placing phases in the proper sequence. Place the phases in the sequence that demonstrates understanding by the nursing students.
Gap Cell at rest Period until DNA stabilization complete Duplication of DNA and chromosomes Doubling of cell size Cell division Explanation: The phases of the cell cycle include G or gap phase; G0 when the cell is at rest; G1, the period until DNA stabilization is complete; S(synthesis), DNA and chromosomes duplicate or ... (more) The phases of the cell cycle include G or gap phase; G0 when the cell is at rest; G1, the period until DNA stabilization is complete; S(synthesis), DNA and chromosomes duplicate or cell readies for division; G2, the cell doubles in size in preparation for dividing; and mitosis or period of cell division.
During a physical examination of a 13-year-old boy, the nurse observes a single, enlarged, rubbery-feeling cervical lymph node in the armpit. The boy also reports unexplained loss of weight and malaise. Which of the following conditions should the nurse most suspect in this client?
Hodgkin lymphoma Correct Explanation: Symptoms of Hodgkin disease usually begin with the enlargement of only one painless, enlarged, rubbery-feeling cervical lymph node. Other nodes then become involved, along with the liver, spleen, bone marrow, and, eventually, the central nervous system. The child usually reports accompanying symptoms of anorexia, malaise, night sweats, and loss of weight. Fever may be present. Non-Hodgkin's lymphomas tend to involve the lymph glands of the neck and chest most commonly, although axillary, abdominal, or inguinal nodes may be the first involved. If mediastinal lymph glands are swollen, the child may notice a cough or chest "tightness." Because mediastinal nodes press on the veins returning blood from the head, edema of the face may result. The first symptoms of ALL in children usually are those associated with decreased RBC production (anemia) such as pallor, low-grade fever, and lethargy. Children with AML have the same symptoms as those with ALL.
The nurse is assessing a 4-year-old girl whose mother reports that she is not eating well, is losing weight, and has started vomiting after eating. Which risk factor from the health history suggests the child may have a Wilms tumor?
The child has Beckwith-Wiedemann syndrome. Explanation: Along with the symptoms reported by the mother, the fact that the child has Beckwith-Wiedemann syndrome suggests that the child could have a Wilms tumor. Down syndrome would point to leukemia or brain tumor. Schwachman syndrome would suggest leukemia. A family history of neurofibromatosis is a risk factor for brain tumor, rhabdomyosarcoma, or acute myelogenous leukemia.
A child is diagnosed with rhabdomyosarcoma involving the neck. When assessing the child, which of the following would the nurse expect to find? Select all that apply.
• Dysphagia • Hoarseness Explanation: With rhabdomyosarcoma involving the neck, assessment findings would include hoarseness, dysphagia, and a visible and palpable mass in the neck. Proptosis would be noted if the site With rhabdomyosarcoma involving the neck, assessment findings would include hoarseness, dysphagia, and a visible and palpable mass in the neck. Proptosis would be noted if the site of the tumor is the orbit. Hearing loss and facial nerve palsy suggest middle ear involvement.
The nurse is teaching a group of 13-year-old boys and girls about screening and prevention of reproductive cancers. Which of the following subjects would not be included in the nurse's teaching plan? Select all that apply.
• Self examination is an effective screening method for testicular cancer. • Provide information regarding the benefits of receiving the HPV vaccine. • A papanicolaou (PAP) smear does not require parent consent in most states. • Sexually transmitted disease is a risk factor for cervical cancer. Correct Explanation: Telling the group that Testicular cancer is one of the most difficult cancers to cure would not be part of the teaching plan. It would be more accurate and appropriate for the nurse to stress that testicular cancer is one of the most curable cancers if diagnosed early. Self-examination is an excellent way to screen for the disease. Girls should know that they can take responsibility for their own sexual health by getting a PAP smear. All the children should understand that early intercourse, sexually transmitted infections (STIs), and multiple sex partners are risk factors for reproductive cancer. Information should be provided so the teen girls can discuss the benefits of receiving the human papilloma virus vaccine since many cervical cancers are attributed to human papillomavirus.
The child has been admitted to the hospital. Her absolute neutrophil count is 450 and the child has been placed in neutropenic precautions. Which of the following nursing interventions indicates that the nurse requires further education? Select all that apply.
• The child has been placed in a semiprivate room • The child is being transported to radiology for an X-ray and the nurse places gloves on the child's hands Explanation: The child in neutropenic precautions should be placed in a private room. Prior to transportation to other areas of the hospital, the nurse should place a mask on the child before she leaves her room. The nurse should monitor the child's vital signs at least every 4 hours. The nurse should carefully assess for signs and symptoms of infection at least every 8 hours. The nurse should perform hand hygiene before and after contact with each child.
A child is receiving chemotherapy and develops stomatitis. The nurse identifies a nursing diagnosis of impaired oral mucous membranes related to the effects of chemotherapy. Which of the following would the nurse include in the child's plan of care? Select all that apply.
• Apply a lip balm or petroleum jelly to prevent cracking. • Provide various soft and bland foods to minimize further irritation. • Have the child rinse the mouth with lukewarm water three times a day. Explanation: For the child with stomatitis, the nurse should provide soft foods to prevent further abrasions, have the child rinse the mouth three times a day with lukewarm water to promote comfort and healing, avoid giving the child acidic foods that would further irritate the tissue, and apply a lip balm or petroleum jelly to prevent cracking of the lips. The nurse should offer a soft toothbrush to minimize discomfort.
The nurse caring for a 14-year-old scheduled for magnetic resonance imaging (MRI) explains how the test works to the family. Which of the following responses accurately describes this test?
"The MRI uses radio waves and magnets to produce a computerized image of the body." Explanation: The MRI uses radio waves and magnets to produce a computerized image of the body. The bone scan is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement. The ultrasound uses sound waves to create images that visualize body structures and locate masses. Radiography uses radiation to examine soft tissue and bony structures of the body.
Antiemetics are ordered to control nausea and vomiting in the child undergoing chemotherapy. How can the nurse most effectively use these medications?
Administer the antiemetic before starting chemotherapy Explanation: Antiemetics are most effective when given before chemotherapy begins and then on a regular schedule to prevent nausea and vomiting throughout administration of chemotherapy. Nonpharmacologic measures can be used in conjunction with antiemetics but not in place of them.
Antiemetics are ordered to control nausea and vomiting in the child undergoing chemotherapy. How can the nurse most effectively use these medications?
Administer the antiemetic before starting chemotherapy Antiemetics are most effective when given before chemotherapy begins and then on a regular schedule to prevent nausea and vomiting throughout administration of chemotherapy. Nonpharmacologic measures can be used in conjunction with antiemetics but not in place of them.
The nurse is assessing a 14-year-old girl with a tumor. Which finding indicates Ewing sarcoma?
Palpation reveals swelling and redness on the right ribs. Explanation: Ewing sarcoma may result in swelling and erythema at the tumor site. Common sites are chest wall, pelvis, vertebrae, and long bone diaphyses. Dull bone pain in the proximal tibia is indicative of osteosarcoma. Persistent pain after an ankle injury is not indicative of Ewing sarcoma. An asymptomatic mass on the upper back suggests rhabdomyosarcoma.
The child has been diagnosed with leukemia. Rank the following medications used to treat leukemia in order based on the stage of treatment.
Oral steroids and vincristine through an intravenous line High-dose methotrexate and 6-mercaptopurine Low doses of 6-mercaptopurine and methotrexate Chemotherapy through an intrathecal catheter Explanation: During induction, the child receives oral steroids and IV vincristine. During consolidation, the child receives high doses of methotrexate and 6-mercaptopurine. During maintenance, the child receives low doses of methotrexate and 6-mercaptopurine. During central nervous system prophylaxis, the child receives intrathecal chemotherapy.
Parents ask why their child just diagnosed with leukemia needs a "spinal tap." Which is the best response by the nurse?
"Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system." Explanation: The cerebrospinal fluid is checked so the clinician can determine whether leukemic cells have invaded the central nervous system. It is common for a chemotherapy medication, usuall ... (more) The cerebrospinal fluid is checked so the clinician can determine whether leukemic cells have invaded the central nervous system. It is common for a chemotherapy medication, usually methotrexate, to be administered immediately following lumbar puncture as treatment for potential infiltration. The other responses are incorrect.
The nurse is assessing an 11-year-old girl diagnosed with acute myelogenous leukemia (AML) who came to the emergency department. Which of the following would alert the nurse to the need for immediate intervention?
CBC indicates hyperleukocytosis. Correct Explanation: About 25% of children with acute myelogenous leukemia present with blood counts greater than 100,000. This is called hyperleukocytosis, and it is a medical emergency requiring leukapheresis to decrease hyperviscosity by quickly decreasing the number of circulating blasts. Lymphadenopathy, headache, visual disturbance, weight loss, and muscle wasting are signs and symptoms common to both types of leukemia. Lymphadenopathy is a common manifestation associated with AML and does not require immediate intervention. Headache and vision problems are common manifestations associated with AML. They do not require immediate intervention. Weight loss and muscle wasting are common manifestations associated with AML. They do not require immediate intervention.
Nursing students are reviewing information about the normal cell cycle. They demonstrate understanding of this process when placing phases in the proper sequence. Place the phases in the sequence that demonstrates understanding by the nursing students.
Gap Cell at rest Period until DNA stabilization complete Duplication of DNA and chromosomes Doubling of cell size Cell division Explanation: The phases of the cell cycle include G or gap phase; G0 when the cell is at rest; G1, the period until DNA stabilization is complete; S(synthesis), DNA and chromosomes duplicate or cell readies for division; G2, the cell doubles in size in preparation for dividing; and mitosis or period of cell division.
During a physical examination of a 13-year-old boy, the nurse observes a single, enlarged, rubbery-feeling cervical lymph node in the armpit. The boy also reports unexplained loss of weight and malaise. Which of the following conditions should the nurse most suspect in this client?
Hodgkin lymphoma Explanation: Symptoms of Hodgkin disease usually begin with the enlargement of only one painless, enlarged, rubbery-feeling cervical lymph node. Other nodes then become involved, along with the liver, spleen, bone marrow, and, eventually, the central nervous system. The child usually reports accompanying symptoms of anorexia, malaise, night sweats, and loss of weight. Fever may be present. Non-Hodgkin's lymphomas tend to involve the lymph glands of the neck and chest most commonly, although axillary, abdominal, or inguinal nodes may be the first involved. If mediastinal lymph glands are swollen, the child may notice a cough or chest "tightness." Because mediastinal nodes press on the veins returning blood from the head, edema of the face may result. The first symptoms of ALL in children usually are those associated with decreased RBC production (anemia) such as pallor, low-grade fever, and lethargy. Children with AML have the same symptoms as those with ALL.
A child with ALL is beginning treatment with methotrexate in an attempt to eradicate the leukemic cells. The stage of therapy represents which of the following?
Induction stage Explanation: An induction stage is the first attempt at eradicating the leukemic cells to induce or achieve a complete remission.
The nurse realizes that the chemotherapy agents and radiation that a child is receiving are likely to irritate the bladder. What are the best measures that the nurse can take to diminish this risk?
Keep intravenous (IV) fluids running to maintain excellent hydration and frequent voids Explanation: IV fluids are given before, during, and after radiation and chemotherapy drugs; bladder irritation results from the need to dilute and remove them from the body. This reduces then IV fluids are given before, during, and after radiation and chemotherapy drugs; bladder irritation results from the need to dilute and remove them from the body. This reduces the need for the child to drink large quantities. Administering the drug during sleep and having the child retain urine would cause irritating chemicals to be kept in contact with the bladder mucosa. No benefit is associated with providing cranberry juice.
The nurse is assessing a 3-year-old boy whose mother reports that he is listless and has been having trouble swallowing. Which finding suggests the child may have a brain tumor?
Observation reveals nystagmus and head tilt Explanation: Coupled with the mother's reports, observation of nystagmus and head tilt suggest the child may have a brain tumor. Elevated blood pressure of 120/80 mm Hg may be indicative of Wilm tumor. Fever and headaches are common symptoms of acute lymphoblastic leukemia. A cough and labored breathing points to rhabdomyosarcoma near the child's airway.
The nurse is assessing a 3-year-old boy whose mother reports that he is listless and has been having trouble swallowing. Which finding suggests the child may have a brain tumor?
Observation reveals nystagmus and head tilt Coupled with the mother's reports, observation of nystagmus and head tilt suggest the child may have a brain tumor. Elevated blood pressure of 120/80 mm Hg may be indicative of Wilm tumor. Fever and headaches are common symptoms of acute lymphoblastic leukemia. A cough and labored breathing points to rhabdomyosarcoma near the child's airway.
The nurse preparing patients for diagnostic testing for cancer knows that the following test is used to differentiate a neuroblastoma from other tumors:
Urine catecholamines VMA, HVA Explanation: Urine catecholamine metabolites homovanillic acid (HVA) and vanillylmandelic acid (VMA) differentiate neuroblastomas from other tumors. Urinalysis provides general information about renal function. Serum chemistries help to evaluate the body's response to the cancer process. CBC with differential determines abnormal loss or destruction of cells that may indicate cancer or bone marrow suppression.
The nurse is assessing a 2-year-old girl whose parents noticed that one of her pupils appeared to be white. Which assessments should the nurse expect to find if the girl has retinoblastoma? Select all that apply.
• Parents report that the child has headaches. • Observation confirms cat's eye reflex in pupil. • Assessment discloses hyphema in one eye. • History reveals strabismus. Explanation: Observation revealing a thick, yellow discharge is typical of infectious conjunctivitis, not retinoblastoma. Headaches and hyphema, a collection of blood in the anterior chamber of the eye, are associated with retinoblastoma as is leukocoria, "cat's eye reflex." Health history reveals associated symptoms, including stabismus.
