Chapter 24

The nurse is preparing a child for diagnostic testing to diagnose disseminated intravascular coagulation (DIC). Which results would the nurse identify as indicating this condition?

Increased D-Dimer assay

The nurse has received morning report on a group of pediatric clients. Which pediatric client will the nurse see first?

a child with hemophilia reporting knee pain and edema Rationale: The child with hemophilia should be quickly evaluated when reporting joint pain as this could indicate bleeding. A child with sickle cell anemia requesting a cool compress is experiencing a psychosocial need. A child experiencing a purpural rash and arthralgia (joint pain) is exhibiting signs of Henoch-Schonlein purpura. Lethargy can be a symptom of thalassemia major.

The nurse is meeting with a parent and child at the pediatric clinic. Which statement made by the parent during the history would alert the nurse that there might be a possible malignancy in the child?

fever with no response to repeated antibiotics

A child diagnosed with idiopathic thrombocytopenia purpura (ITP) is scheduled to receive an infusion of intravenous immunoglobulin (IVIG), due to low platelet counts. Prior to the infusion, the nurse administers acetaminophen to the child. The nurse would explain to the parents that acetaminophen is administered to obtain which expected outcome?

to decrease fever produced from the medication

The nurse is preparing a presentation for a local parent group about nutritional measures to prevent anemia. The group of parents have children between the ages of 4 and 8. The nurse would recommend a daily iron intake of which amount?

10mg Rationale: The recommended daily dietary iron intake for children 1 to 10 years of age is 10 mg. The recommended daily dietary iron intake for children 0 to 6 months of age is 6 mg. The recommended daily dietary iron intake for boys 11 to 18 years of age is 12 mg. The recommended daily dietary iron intake for girls 11 to 18 years of age is 15 mg.

The nurse is reviewing the results of a clotting study for a healthy 6-year-old. What would the nurse document as a normal prothrombin finding?

11.0 to 13.0 seconds rationale: The nurse would identify a prothrombin time of 11.0 to 13.0 seconds as normal for a healthy child. A result of 21.0 to 35.0 seconds would be the expected range for partial thromboplastin time and activated partial thromboplastin time. Findings of 6.0 to 9.0 seconds and 16.0 to 18.0 seconds are outside the normal range.

A client with cancer is diagnosed with typhlitis. Which emergency intervention would the nurse perform?

Administer broad-spectrum antibiotics intravenously Rationale: Typhlitis (neutropenic enterocolitis) is an inflammatory process of the gastrointestinal tract that occurs with the induction phase of leukemia chemotherapy. The recommended interventions for treatment are to administer broad-spectrum antibiotics or antifungals intravenously, provide supportive care to manage symptoms, and provide IV nutrition. The client should be kept NPO. The nurse should assess for any signs of bowel perforation or shock. Administering diuretics would not be needed and may cause harm. Monitoring sodium levels as well as other electrolytes would be necessary to evaluate IV nutrition.

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 Rationale: Live vaccines (viral or bacterial) should not be administered to an immunosuppressed 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.

The child is prescribed liquid ferrous sulfate. The nurse should encourage the child to take which action immediately after each dose to best eliminate possible side effects?

Brush his or her teeth

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 Rationale: 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, what should the nurse mention?

Cells are only susceptible to treatment by radiation during certain phases of the cell cycle Rationale: 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 child with hemophilia A has had repeated episodes of hemarthrosis. Which assessment finding is most important to consider?

Decreased range of motion Rationale: Repeated bleeding into a joint causes cartilage erosion and joint space narrowing, decreased range of motion, and proximal muscle weakening; disabling arthropathy may follow.

A client with severe chronic anemia is receiving ongoing transfusion therapy. The nurse frequently assesses the client for what major complication of this therapy?

Development of toxic iron overload

A nurse caring for an 8-year-old with a bleeding disorder documents the following nursing diagnosis: ineffective tissue perfusion related to intravascular thrombosis and hemorrhage. This diagnosis is most appropriate for a client with:

Disseminated intravascular coagulation Rationale: Disseminated intravascular coagulation (DIC) is an acquired coagulopathy that, paradoxically, is characterized by both thrombosis and hemorrhage. The goal is for the child to maintain adequate tissue perfusion of all body systems affected by DIC and regain adequate laboratory values for hemostasis. Hemophilia and von Willebrand disorders are genetic and symptoms are caused by a deficiency in a factor needed for clotting. Iron-deficiency anemia occurs when there is not enough iron for adequate hemoglobin capacity in the red blood cells.

The nurse explains to the teenager that which alterations may occur when steroids are added to the cancer therapy regimen?

Facial changes Rationale: 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. Reference:

The nurse identifies the nursing diagnosis of Risk for infection related to chemotherapy-induced immunosuppression. What 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 Rationale: 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.

When caring for a 7-year-old client diagnosed with sickle cell anemia, which clinical manifestation will the nurse report to the health care provider first?

Hyperactive bowel sounds Rationale: The nurse would first report an unexpected manifestation because this could indicate a complication or a different disease. Hyperactive bowel sounds are not expected in the pediatric client with sickle cell anemia. These clients are expected to have an absence of bowel sounds. Sickle cell disease causes chronic anemia, with a hemoglobin level of 6 to 9 g/dL (60 to 90 g/L) with a normal level in a child at 11 to 13 g/dL (110 to 130 g/L). 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), swelling of the hands and feet (dactylitis), and increased respirations.

A child with cancer has developed neutropenia and is in isolation with neutropenic precautions. What nursing assessment takes priority for this child?

Infection symptoms Rationale: The neutrophils are the primary means of fighting bacterial infection. When the neutrophil count is very low, the child has the potential to have an overwhelming bacterial infection. The child is at the greatest risk when the neutrophil count is less than 500/µL (0.50 ×109/L). The nurse's priority would be to assess for signs and symptoms of infection. A bacterial infection can be life-threatening for this child. This child would be placed in neutropenic precautions. This is a form of isolation where the child is protected from health care workers and outside visitors. Among other precautions, no plants or raw fruits or vegetables would be allowed in the room, and the child should have no rectal examinations or medications and not experience a urinary catheterization. To prevent an infection, the nurse would administer broad spectrum antibiotics. The vital signs should be assessed every 4 hours, and alterations could indicate more problems than just infection. Mucositis occurs when there is an ulcerated oral mucosa. It should be assessed but is not the priority. Bleeding would be more related to low platelet count and not neutrophils.

A 14-year-old adolescent with Hodgkin disease is experiencing difficulty breathing and is sent for a radiograph. Which finding should the nurse expect to see on the x-ray report?

Mediastinal mass Rationale: Difficulty breathing or respiratory distress may indicate a mediastinal mass (which may be seen on a radiograph) in the client with Hodgkin disease. Hepatomegaly or splenomegaly may occur when there is advanced disease. Lymphadenopathy is present in the cervical and supraclavicular nodes. These could be palpated and do not require an x-ray to diagnose. Presence of a white reflection in the pupil of the eye may indicate retinoblastoma.

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. Rationale: 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 Wilms 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 completing the health history of a 6-month-old infant with retinoblastoma with the child's parents. Which symptom should the nurse expect that the parents have observed?

One pupil appears white. Rationale: On examination, the child's pupil of the affected eye appears white because the red reflex is absent. Some might describe this symptom as a "cat's eye." Ear tugging, eye protrusion, and keeping the eyes closed are not manifestations of retinoblastoma.

A child is undergoing a series of diagnostic tests for a suspected malignancy. Which diagnostic test result is only present in Hodgkin disease?

Reed-Sternberg cells Rationale: With Hodgkin disease, lymphocytes proliferate in the lymph glands, and special Reed-Sternberg cells (large, multinucleated cells that are probably nonfunctioning monocyte-macrophage cells) develop. Although these lymphocytes are capable of DNA synthesis and mitotic division, they are abnormal because they lack both B- and T-lymphocyte surface markers and cannot produce immunoglobulins as do usual B-lymphocytes. There will be elevated lymphocytes, but this is present in leukemias as well. T-lymphocyte surface markers are lacking in Hodgkin disease. Megakaryocyte cells are normal cells in the bone marrow and produce platelets.

A 9-month-old infant with iron-deficiency anemia is given ferrous sulfate therapy. Which assessment would best help the nurse determine that the infant is actually taking it daily?

The stools will appear black Rationale: Oral iron supplements are dark in color because the iron is pigmented. As a result of digestion of this pigment, the stools of an infant taking iron will be dark to black. Taking iron supplements will cause constipation, not diarrhea. After treatment with iron, the reticulocyte count should be increased, not decreased. Children with iron deficiency are tired and many times irritable. With correction of the deficiency, the infant should be less irritable and have more energy.

The nurse is explaining the procedure of bone marrow aspiration to a 6-year-old child with leukemia. What explanation would be best to give to the child?

You may feel pressure on your hip during the procedure." Rationale: The bone marrow aspiration is performed on the iliac crest if the child is older and on the femur if the child is an infant. Bone marrow aspiration requires hard pressure to allow the needle to puncture the bone. A lidocaine/prilocaine cream is applied to the skin anywhere from 1 to 3 hours prior to the procedure to help numb the site where the needle will be inserted. Bone marrow aspirations and biopsies are usually performed with conscious sedation. If the child is an infant or there are special circumstances the procedure may be performed under anesthesia. The child is placed on the side for the procedure so the health care provider has better access to the iliac crest. The child will need to rest after the procedure to prevent bleeding, but is not required to lay flat on the back. Children who have had a lumbar puncture may need to lie on the back and are at risk for a headache.

Wilms tumor is suspected in a 5-year-old child. Which action would be avoided?

abdominal palpation Rationale: if Wilms tumor is suspected, the abdomen should not be palpated. Palpating the abdomen may cause the tumor capsule to rupture, resulting in tumor spillage. Tumor spillage can change the tumor from stage I to stage II or III, depending on the amount of spillage that occurs.

After teaching the parents of a child diagnosed with sickle cell disease, the nurse determines that the teaching was successful when the parents state that they will contact the primary health care provider if the child develops which signs or symptoms? Select all that apply.

chest pain severe dizziness sudden change in vision Rationale: The parents should contact the primary health care provider if the child develops a fever, dizziness or severe headaches, severe stomach pain or swelling, sudden changes in vision, weakness, or loss of consciousness. There is no need to notify the primary health care provider if the child develops constipation or irritability.

A child receiving chemotherapy is experiencing significant reduction in red blood cells secondary to myelosuppression. Which agent would the nurse most likely expect to be ordered?

epoetin alfa Rationale: Epoetin alfa is a colony-stimulating factor used to stimulate production of red blood cells. Filgrastim is a colony-stimulating factor used to stimulate production of granulocytes. Sargramostim is a colony-stimulating factor used to stimulate production of granulocytes. Gamma interferon is used to stimulate macrophage production to fight bacteria and fungus.

A child with cancer is dying and in hospice care. When developing the plan of care, which intervention should the nurse include as the primary focus?

keeping the child pain-free Rationale: Children die from cancer. They may die at home or in the hospital, and hospice care can be provided in either setting. Children with terminal cancer often experience a great deal of pain, particularly when death is imminent. The primary goal of caring for a dying child is the prevention and alleviation of pain. The nurse would work with the parents to determine the pharmacologic and nonpharmacologic methods which work best. Many times, dyspnea and agitation can occur as a result of pain. These symptoms are reduced with pain management. Any care to the child, even in hospice care, should be developmentally appropriate. Emotional support is a necessity, both for the child and the parents, but pain relief is the priority.

A 5-year-old child is at the pediatric clinic for a well-child visit. Which symptom alerts the health care provider that this child might have acute lymphoblastic leukemia (ALL)?

lethargy, bruises, and lymphadenopathy Rationale: Although all of these symptoms could be related to leukemia, the most likely are lethargy, bruises, and lymphadenopathy. Joint pain and swelling could also be juvenile arthritis or another disorder. Anorexia and weight loss are fairly nonspecific, as is abdominal pain, nausea, and vomiting. With ALL, because the bone marrow overproduces lymphocytes and therefore is unable to continue normal production of other blood components, the first symptoms of ALL in children usually are those associated with decreased RBC production (anemia) such as pallor, low-grade fever, and lethargy. A low thrombocyte (platelet) count will lead to petechiae and bleeding from oral mucous membranes and cause easy bruising on arms and legs. As the spleen and liver begin to enlarge from infiltration of abnormal cells, abdominal pain, vomiting, and anorexia occur. As abnormal lymphocytes invade the bone periosteum, the child experiences bone and joint pain. Central nervous system (CNS) invasion leads to symptoms such as headache or unsteady gait. On physical assessment, painless, generalized swelling of lymph nodes is revealed.

The nurse develops a meal plan for a child with iron-deficiency anemia. Which meal would the nurse teach the parent has the highest amount of iron?

red meat, eggs, oatmeal, and dried fruit Rationale: ron-deficiency anemia occurs when the blood does not have enough iron to produce hemoglobin. The anemia can be corrected via iron supplementation, nutrition, and even blood transfusion if the anemia is severe. Foods that have the highest sources of iron include red meat, tuna, eggs, tofu, enriched grains, dried beans and peas, dried fruits, green leafy vegetables and iron-fortified breakfast cereals. The nurse should teach the meal containing red meat, eggs, oatmeal and dried fruit has the highest amount of iron. Chicken has less iron than red meat, and corn has only a small amount. All the fruits listed have iron, but when dried the iron levels increase. Pork has limited amount of iron, and white rice contains almost no iron. Brown rice and whole grains contain higher iron amounts.

The nurse is caring for a 6-year-old girl with leukemia who is having an oncologic emergency. Which signs and symptoms would indicate hyperleukocytosis?

tachycardia and respiratory distress Rationale: 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.

A child with cancer is scheduled for a stem cell transplant. The parents ask the nurse why this procedure is being done. What is the nurse's best answer?

to allow higher doses of chemotherapy Rationale: Transplantation of stem cells from the bone marrow of a well person to a child with cancer has become a frequently used treatment. The procedure allows higher doses of chemotherapy and radiation to be used because, in the event of severe bone marrow depression, the child can have healthy marrow restored. Immune cells in the transplanted marrow may actually help to kill remaining cancer cells in the child's circulation. Stem cells to do not prevent further metastasis or infections while on chemotherapy. Stem cells do not suppress the child's immune system; rather, chemotherapy given prior to stem cell transplant is used to suppress the child's immune response.

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 Rationale: 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 nurse is developing a plan of care for a child who is to have a transfusion. Which would the nurse expect to administer because it is the most common form of transfusion?

Packed red blood cells Rationale: Various forms of blood are available, including whole blood, packed red blood cells (RBCs), washed RBCs (as much "foreign" matter is removed as possible to reduce the possibility of blood reaction), plasma, plasma factors, platelets, white blood cells (WBCs), and albumin. Packed RBCs represent the most common form of transfusion used with children because they help minimize the risk of fluid overload.

A 5-year-old boy is diagnosed with congenital aplastic anemia. Which symptoms should be considered when developing the plan of care? Select all that apply.

Pallor Fatigue Easy bruising Cyanosis

A 13-year-old, diagnosed with beta-thalassemia major is seen in the pediatric clinic. The nurse completes an assessment and notes that the client is below the 10th percentile in height for age. What assumption can the nurse make based on this information?

This finding is a common manifestation of the client's diagnosis.

A mother contacts the oncology nurse concerned about the redness and tenderness of her child's skin following radiation treatments. What is the nurse's best response?

Use mild soap and nonscented moisturizer. rationale: Skin reactions, such as erythema and tenderness, are typical local effects. Maintaining good skin hygiene and use of mild soaps or moisturizers (nonfragrant) may help preserve skin integrity. Keeping skin clean and dry is helpful, but the skin needs a mild moisturizer to preserve skin integrity. Covering with an occlusive dressing is not helpful, as the skin needs hydration. Telling the mother there is nothing that can be done is inaccurate.

The nurse treating clients with hemophilia knows that if bleeding is not treated effectively, which body part is at greatest risk for the development of chronic, disabling disease?

joints

The nurse is assessing a child and notices pinpoint hemorrhages appearing on several different areas of the body. The hemorrhages do not blanch on pressure. The nurse documents this finding as:

petechiae.

A 3-year-old child is hospitalized with a diagnosis of sickle cell anemia and is experiencing a pain crisis. Using the FACES scale, the nurse assesses the child's pain to be a 10 on a scale of 1 to 10. The child is receiving intravenous fluids and oxygen at 2 L/min via nasal cannula. The parent is at the bedside holding the child's hand and has a concerned look. What is the nurse's priority in caring for the child?

Implement strategies to address the child's pain. Rationale: In this case, the nurse's priority is to address the child's pain. The child is already receiving IV fluids and oxygen. That, in combination with analgesia, will assist in resolving the crisis. Asking the parent if he or she has questions, asking the health care provider to meet with the parent, and providing distraction for the child are all appropriate interventions, but the priority is to address the child's pain.

An adolescent receiving chemotherapy has lost all hair and is sad about self-image. Which action should the nurse take to support this adolescent and involve the client in decision making?

Encourage the adolescent to select hats or wigs to fit one's personality.

The nurse is assessing a school-aged child with sickle-cell anemia. Which assessment finding is consistent with this child's diagnosis?

Slightly yellow sclera Rationale: In sickle-cell anemia, eye scleras become icteric or yellowed from the release of bilirubin from the destruction of the sickled cells. Mandibular and long bone growth and depigmentation are not manifestations of this health problem.

A nurse is providing dietary interventions for a 5-year-old with an iron deficiency. Which response indicates a need for further teaching?

"Red meat is a good option; he loves the hamburgers from the drive-thru." Rationale: While iron from red meat is the easiest for the body to absorb, the nurse must limit fast food consumption from the drive-thru as it is also high in fat, fillers, and sodium. The other statements are correct.

The nurse will use a special needle to start intravenous (IV) fluids through which central venous access device?

An implanted port

A child develops treatment-related thrombocytopenia. When preparing the plan of care for the child, which would the nurse include? Select all that apply.

Applying pressure to a puncture site for a full 5 minutes Limiting the use of adhesive tape on the child's skin Administering medications orally or intravenously

A nurse is teaching a school-aged child with iron-deficiency anemia and her parents about dietary measures to increase iron intake. The nurse determines that the teaching was successful when they state which food is high in iron? Select all that apply.

Eggs Fortified cereal Green leafy vegetables

When providing care for a child immediately after a bone marrow aspiration, which nursing action is priority?

Monitor the site dressing and vital signs. Rationale: Monitoring vital signs and the dressing for signs of bleeding is a priority after bone marrow aspiration. Although providing pain medication, educating on handwashing, and allowing for therapeutic play are all important, these should only be performed after first stabilizing the child.

A child with iron-deficiency anemia is prescribed ferrous fumarate, 3 mg/kg/day in two divided doses. What does this prescription indicate to the nurse?

The child has mild to moderate iron deficiency. Rationale: The recommended dosage for iron supplementation for a child with mild to moderate iron deficiency is 3 mg/kg/day of ferrous fumarate. A prophylactic dose is 1 to 2 mg/kg/day of up to a maximum of 15 mg elemental iron per day. Severe iron deficiency requires 4 to 6 mg/kg/day of elemental iron in three divided doses. Transfusion of packed red blood cells is reserved for the most severe cases. Prior to the transfusion of packed red blood cells, the nurse would follow specific blood bank guidelines.

A 14-year-old girl who is a vegetarian has recently developed anemia. Blood smear results show large, fragile, immature erythrocytes. She claims to take an iron supplement regularly and is surprised to learn that she is anemic, as she is otherwise healthy. The nurse recognizes that the likely cause of this type of anemia is:

Vitamin B12 deficiency.

The nurse is examining a child who was diagnosed with acute lymphoblastic leukemia (ALL) 6 months ago. The child exhibits pallor, ecchymoses, and petechiae. The nurse interprets these findings as indicating that the cancer has invaded which part of the body?

bone marrow

The nurse is reviewing the laboratory test results of a child with thalassemia. Which results would the nurse expect to find with the hemoglobin electrophoresis? Select all that apply

hemoglobin A2 hemoglobin F Rationale: In thalassemia, the hemoglobin electrophoresis would reveal the presence of hemoglobin F and A2 only. Hemoglobin S would be found with sickle cell disease.

Children with acute lymphoblastic leukemia (ALL) may need periodic lumbar punctures. The nurse would teach the parent that this is done to assess for:

leukemic cells. Rationale: Acute lymphoblastic leukemia (ALL) is a rapidly progressive cancer affecting the undifferentiated or immature cells. It is the most common form of cancer in children. Throughout the course of the disease and treatment the child will be tested regularly for complete blood counts, bone marrow aspirations, lumbar punctures, and testing for renal and liver function. Lumbar punctures are performed to determine if leukemic cells have infiltrated the central nervous system. The white blood cells, temperature, and other symptoms would be indicative of meningitis and septicemia. The platelet count would be assessed for the possibility of bleeding.

The nurse is evaluating the complete blood count of a 7-year-old child with a suspected hematological disorder. Which finding is associated with an elevated mean corpuscular volume (MCV)?

macrocytic red blood cells (RBCs) Rationale: When the MCV is elevated, the RBCs are larger and referred to as macrocytic. The WBC count does not affect the MCV. The platelet count and Hgb are within normal ranges for a 7-year-old child.

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:

neuroblastoma. Rationale: 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 disease, leukemia, or osteosarcoma.

A 12-year-old child is suspected of having Hodgkin lymphoma. When preparing the child and family for diagnostic testing, which test would the nurse describe as being used to confirm the diagnosis?

Lymph node biopsy

After teaching a group of students about hemophilia, the instructor determines that the students have understood the information when they identify hemophilia A as involving a problem with:

factor VIII Rationale: n hemophilia A, the problem is with factor VIII, and in hemophilia B the problem lies with factor IX. Platelets are problematic in idiopathic thrombocytopenic purpura (ITP). Plasmin is involved in the pathophysiologic events of disseminated intravascular coagulation.

The nurse is working with a child who is in sickle cell crisis. Treatment and nursing care for this child include which actions? Select all that apply.

Administering oxygen Administering analgesics Maintaining fluid intake

A child diagnosed with hemophilia presents with warm, swollen, painful joints. Which action will the nurse take first?

Prepare to administer factor replacement medication Rationale: Many clients with hemophilia have repeated episodes of hemarthrosis or bleeding into the joints, and develop functional impairment of the joints, despite careful treatment. To assist in limiting impairment, the nurse would prepare to administer factor replacement medications, such as plasma, recombinant clotting factor VIII, or a clotting promotor medication. The nurse would document the finding, notify the health care provider, and assess the client for additional symptoms after limiting the amount of blood loss.

The parents of a child diagnosed with rhabdomyosarcoma ask the nurse to explain what this means. What is the nurse's best response?

"The tumor is in the muscle." Rationale: A rhabdomyosarcoma is a tumor of striated muscle. A nephroblastoma (Wilms tumor) is a malignant tumor that rises from the metanephric mesoderm cells of the upper pole of the kidney. Retinoblastoma is a malignant tumor of the retina of the eye. Ewing sarcoma occurs in the bone.

A 3-year old child is brought to the emergency department by the parents. Assessment reveals bruising and bleeding from the nose and mouth. The nurse suspects which condition?

von Willebrand disease (vWD)

The nurse is caring for a 6-year-old boy with non-Hodgkin lymphoma who is being treated with monoclonal antibodies. What recommendation would the nurse include in the child's plan of care?

Monitoring for allergic reactions or anaphylaxis. rationale: The nurse would monitor for infusion-related reactions and anaphylaxis if monoclonal antibodies were administered and would have epinephrine, antihistamines, and steroids available at the bedside for treatment if a reaction occurred. Assessing the level of hydration due to vomiting would be necessary if tumor necrosis factor was administered. The flu-like symptoms produced by interferons also require hydration maintenance. Monitoring for complaints of bone pain is appropriate when administering colony-stimulating factors such as filgrastim or sargramostim. Assessing for signs of capillary leak syndrome within 2 to 12 hours of the start of treatment is necessary when interleukins are used.

A 3-year-old child presents with bruising and mucous membrane bleeding from the nose and mouth. The nurse knows that these symptoms are indicative of:

von Willebrand disease. Rationale: von Willebrand disease occurs because there is a deficiency of the von Willebrand factor. This factor is responsible for binding factor VIII, protecting this "glue" that attaches platelets to the site of injury from breakdown. The primary clinical manifestations of von Willebrand disease are bruising and mucous membrane bleeding from the nose and mouth. Bleeding may be mild or can become severe and lead to anemia and shock. Deep bleeding into joints and muscles is rare. This is typically associated with hemophilia. A child does not bleed with iron-deficiency anemia. The child with DIC would be bleeding from every orifice.

After teaching the parents of a child diagnosed with pernicious anemia about the disorder and treatment, the nurse determines that the teaching was successful when the parents state:

"He'll need to have those vitamin shots for the rest of his life." Rationale: Monthly injections of vitamin B12 are required for life. Although diet is important, diet alone will not cure the anemia. Iron used to treat iron-deficiency anemia can lead to constipation. Bone marrow transplant is used to treat aplastic anemia.

A 6-year-old child has been found to have a stage II brain tumor. The parent asks the nurse to explain what "stage II" means. Which information would the nurse provide?

The cancer has spread in the brain itself but the chance of complete surgical removal is good. rationale: Knowing the stage of a tumor helps the health care team design an effective treatment program, establish an accurate prognosis, and evaluate the progress or regression of the disease. In general, stage I refers to a tumor that has not extended into the surrounding tissue so can be completely removed surgically; stage II means there is some local spread but the chance for complete surgical removal is good. Stage III typically means cancer cells have spread to local lymph nodes; stage IV designates tumors that have spread systemically (metastasis).

A child is diagnosed with iron-deficiency anemia. Which diagnostic test results would the nurse expect to be altered?

serum ferritin

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." Rationale: 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 boy has anemia and iron supplements that will be administered by his parents at home. Which statements by the child's parents indicate that further education is required? Select all that apply.

"I can give the iron mixed with chocolate milk." "He may develop diarrhea."

The parents of a 6-year-old child with idiopathic thrombocytopenic purpura (ITP) ask the nurse, "What causes this disease?" Which response by the nurse would be most appropriate?

"ITP is primarily an autoimmune disease in that the immune system attacks and destroys the body's own platelets, for an unknown reason."

In discussing the causes of iron-deficiency anemia in children with a group of nurses, the following statements are made. Which of these statements is a misconception related to iron-deficiency anemia?

"Milk is a perfect food, and babies should be able to have all the milk they want."

A child is to receive oral iron therapy in liquid form three times per day. After teaching the parents about administering the iron, which statement indicates a need for additional teaching?

"Our child can drink the medicine from a medicine cup." Rationale: Liquid iron can stain the teeth; therefore, the parents should give the liquid iron through a straw or syringe, placing it toward the back of the child's mouth. Iron turns stools dark. To maximize absorption, it is best to give the iron with water or juice between meals.

Parents of a 10-year-old have just been informed that their child has stage III cancer. They ask the nurse what this means. What is the nurse's best response?

"The cancer cells have spread to the lymph nodes." Rationale: Stage III typically means cancer cells have spread to local lymph nodes. Stage IV designates tumors that have spread systemically to other organs. Stage I refers to a tumor that has not extended into the surrounding tissue. Stage II means there is some local spread, but the chance for complete surgical removal is good.

The parents of a child diagnosed with cerebral astrocytoma ask the nurse about their child's prognosis. Which response by the nurse would be most appropriate?

"The prognosis is favorable with complete surgical resection and the child usually experiences minimal neurologic deficits post-operatively."

A child is to receive an oral corticosteroid as part of the treatment regimen for leukemia. After teaching the child and family about this drug, the nurse determines the need for additional teaching when they state:

"We should administer the drug on an empty stomach." Rationale: Corticosteroids are commonly administered with food to decrease the risk for gastrointestinal upset. Corticosteroids can disrupt glucose balance, so urine should be checked for glucose. A moon face is an adverse effect of corticosteroids. Corticosteroids need to be tapered gradually to reduce the risk of adrenal insufficiency.

A nurse is reviewing the laboratory test results of a 3-year-old child. Which absolute neutrophil count would the nurse identify as indicating neutropenia?

1.0 Rationale: The normal absolute neutrophil count (ANC) ranges from 1.5 to 8.0 (1500 to 8000/mm3). An ANC less than 1.5 (1500/mm3) in children over age 1 indicates neutropenia.

A nurse is assessing an 8-year-old child brought to the emergency department by his mother. The child has a history of sickle cell anemia and reports acute back pain and joint pain. His mucous membranes are dry; skin turgor is poor. Capillary refill is slowed and nail beds are pale. The child is diagnosed with sickle cell crisis. Which nursing diagnosis would the nurse identify as the priority?

Acute pain related to effects of sickling

Which site is most frequently used to perform a bone marrow aspiration?

Iliac crest

Which nursing interventions would be appropriate for the plan of care designed for a child diagnosed with hemophilia who is experiencing an episode of active bleeding? Select all that apply.

Administer ibuprofen as prescribed for pain Applying splints to extremities Schedule regular active range-of-motion exercises

The nurse is admitting to an examination room a child with the diagnosis of "probable acute lymphoblastic leukemia (ALL)." What will confirm this diagnosis?

Bone marrow aspiration Rationale: 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 caring for a child with leukemia. The parent states a variety of symptoms. Which symptoms does the nurse identify as directly related to the child's cancer? Select all that apply.

Bruising Anorexia Sore throat Lymphadenopathy

The nurse is assessing an 11-year-old child diagnosed with acute myeloid leukemia (AML) who came to the emergency department. What would alert the nurse to the need for immediate intervention?

Complete blood count (CBC) indicates hyperleukocytosis.

The nurse is educating the parents of a 16-year-old boy who has just been diagnosed with Hodgkin disease. Which discussion is most appropriate at this time?

Describing the two ways of staging the disease.

Which diagnosis would be most appropriate for an infant with a large retinoblastoma after surgery?

Disturbed sensory perception related to enucleation

When providing care for a toddler with hemophilia who is being prepped for an elective procedure, which nursing action is priority?

Ensure all side rails are padded.

The pediatric nurse examines the radiographs of a client that indicate lesions on the bone. This finding is indicative of:

Ewing sarcoma Rationale: Radiographs that show lesions on the bone may indicate tumors (e.g., Ewing sarcoma, osteosarcoma) or metastasis of tumors. Osteosarcoma is the most common type of bone malignancy in children. It occurs primarily in the long bones. Ewing sarcoma is a highly malignant bone cancer. It occurs in the pelvis, chest wall, vertebrae, and midshaft of the long bones. Neuroblastomas are seen in children younger than 5 years old and arise from immature nerve cells and the adrenal glands. Hodgkin disease develops from the immune system. Non-Hodgkin lymphoma is a blood cancer.

A child receiving radiation therapy has a nursing diagnosis of Impaired skin integrity related to the effects of radiation therapy as manifested by erythema and dryness of the skin. Which would the nurse include in the child's plan of care? Select all that apply.

Expose the skin to air frequently. Avoid application of creams and lotions. Use mild soap to clean the skin.

While administering a blood transfusion to a child with a hematologic disorder, the nurse notes the child develops urticaria and wheezing. Which collaborative interventions will the nurse begin? Select all that apply.

Give an antihistamine. Apply oxygen as needed. Discontinue the transfusion.

The nurse is caring for a 4-year-old boy following surgical removal of a stage I neuroblastoma. Which intervention is most appropriate for this child?

Giving medications as ordered via the least invasive route.

A child with hemophilia A is scheduled for surgery. Which precautions would the nurse institute with this client?

Handle the child gently when transferring to a stretcher. Rationale: Hemophilia is a group of X-linked recessive disorders that prevent clot formation. The best care for the child is to prevent any bruising or bleeding so gentle handling when moving the child from the stretcher is necessary. Because the child is having surgery, infusion of clotting agents will be necessary. Analgesia will be needed postoperatively as will surgical dressings. IM injections are contraindicated because of potential bleeding. Brushing the teeth is part of normal daily hygiene.

A child with leukemia is receiving methotrexate for therapy. Which nursing diagnosis should the nurse use to best guide this child's care at this time?

Impaired oral mucous membrane related to effects of chemotherapy Rationale: Mucositis or ulcers of the gum line and mucous membranes of the mouth is a frequent effect of antimetabolic drugs. This is the diagnosis that would have the highest priority for the client's care at this time. Methotrexate does not impair mobility, impact aldosterone secretion, or cause adverse effects to the central nervous system.

A 4-month-old infant is found to be anemic. Which is the most likely cause of anemia in this child?

Inadequate intake of dietary iron in the mother during late gestation

A nurse is teaching the parents of a child with sickle cell disease about factors that predispose the child to a sickle cell crisis. The nurse determines that the teaching was successful when the parents identify what as a factor?

Infection rationale: Factors that may precipitate a sickle cell crisis include: fever, infection, dehydration, hot or humid environment, cold air or water temperature, high altitude, or excessive physical activity. Respiratory distress and pallor are general signs and symptoms of a sickle cell crisis.

What 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 Rationale: 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.

The nurse is providing postoperative care to a school-age child after a splenectomy and notes the following: temperature 102.1ºF (39ºC), heart rate 120 bpm, respiratory rate 28 breaths/minute, blood pressure 78/36 mm Hg, and oxygen saturation 90%. Which nursing action is priority?

Place the child in a supine position.

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 Rationale: Frequent, gentle oral hygiene will keep the vulnerable oral mucosa clean and will prevent secondary infection. Offering only cool, clear liquids will limit nutrition. 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.

A mother asks the nurse why her infant who was born at 34 weeks' gestation is being prescribed ferrous sulfate. Which response by the nurse is most appropriate?

Preterm infants are at risk for iron-deficiency anemia." Rationale: Infants born prematurely are at risk for iron-deficiency anemia because iron stores are built during the last few weeks of gestation. Although some infants with pyloric stenosis may require an iron supplement, such as ferrous sulfate, not all infants will. Infants with excessive diarrhea may develop iron-deficiency anemia, and ferrous sulfate helps improve red blood cell formation, but this does not explain why a preterm infant is being prescribed an iron supplement.

The nurse is caring for a child with idiopathic thrombocytopenic purpura with a platelet count of 24,000/mm3. Which health care provider prescription will the nurse question?

Provide ibuprofen as needed for pain.

A child with acute lymphoblastic leukemia (ALL) is receiving methotrexate for therapy. Which nursing diagnosis would best apply during therapy?

Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy

The nurse caring for a 14-year-old scheduled for magnetic resonance imaging (MRI) explains to a family how the test works. Which response accurately describes this test?

The MRI uses radio waves and magnets to produce a computerized image of the body." Rationale: 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 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.

Which symptom would lead the nurse to suspect that a child is developing a common side effect of vincristine?

The child says the fingertips feel numb.

In caring for a child with sickle cell disease, the highest priority goal is:

The child's fluid intake will improve. rationale: The highest priority goals for this child are maintaining comfort and relieving pain. The child is prone to dehydration because of the kidneys' inability to concentrate urine, so increasing fluid intake is the next highest priority. Other goals include improving physical mobility, maintaining skin integrity, reducing the caregiver's anxiety, and increasing the caregiver's knowledge about the causes of crisis episodes — but these goals are not the highest priority.

What are important considerations when the nurse is planning care for the family of a child with cancer? Select all that apply.

prognosis of cancer family's coping strategies prevention and alleviation of pain monitoring for side effects of treatment stage of grief of child, parents, and siblings

While inspecting the skin of a child, the nurse notes blotchy areas of hemorrhage. When notifying the health care provider, the nurse would identify the client's skin as having:

ecchymoses. rationale: Blotchy areas of hemorrhage in the skin are ecchymoses and suggest a vascular disorder. Petechiae are small reddish purplish spots (macules) appearing on the skin. Purpura is purplish or reddish-brown discoloration easily visible through the epidermis; it includes petechiae, ecchymoses, and hematomas. A hematoma is a localized collection of blood creating an elevated ecchymosis.

A child is sent to pediatric intensive care following surgery for a brain tumor. Which prescription would the nurse question?

elevate head of bed 90 degrees

The oncology nurse is alert for clients displaying signs and symptoms of disseminated intravascular coagulation (DIC). Which symptom would alert the nurse to this emergency condition?

uncontrolled bleeding Rationale: DIC is a complex condition that is secondary to other problems such as sepsis. It is life-threatening. Symptoms of DIC include uncontrolled bleeding, petechiae, ecchymosis, purpuric rash, prolonged prothrombin time and partial thromboplastin time, an increased D-dimer assay, decreased antithrombin III levels, below-normal fibrinogen levels, and increased fibrin-degradation products. The platelet count is decreased in DIC. In moderate to severe cases it is less than 50,000/mm3 (50 ×109/L). The symptom the nurse would see first is uncontrolled bleeding. The remainder are laboratory results that would be used to make the diagnosis.

The nurse is caring for a 6-year-old boy with an abdominal neuroblastoma prior to having a magnetic resonance imaging (MRI) scan without contrast done. Which intervention would the nurse expect to perform?

Administering a sedative as ordered to keep the child still. Rationale: The nurse would expect to administer a sedative as ordered to keep the child still because the machine makes a loud thumping noise that could frighten the child. The child must lie without moving while the MRI is being done. Encouraging fluid intake to increase radionuclide uptake is necessary for a bone scan. Advising the physician that the child is allergic to shellfish is an intervention for a computed tomograph (CT) scan with contrast. If the child did not have an IV prior to the MRI and contrast was going to be used, then an IV would need to be inserted for the contrast after the noncontrast MRI was finished. Applying EMLA to an injection site prior to inserting an IV would be appropriate for both the CT and bone scans.

The parent of a child with Down syndrome calls the nurse and reports 3 weeks of a lack of energy, limping, and weight loss in the young child. What is the most appropriate response by the nurse?

"Bring your child to the primary health care provider to be examined." Rationale: Symptoms could indicate acute lymphoblastic leukemia (ALL). Compared with other children, children with Down syndrome have 15 times the risk of developing ALL. The nurse would recommend the child come in for further assessment to determine what, if any, treatment is needed for this child. Stating the child needs to be seen within the week if symptoms continue is doing nothing for the child at this time. The child's symptoms are not appropriate for acetaminophen; this choice is also a "do nothing" option. It is appropriate to limit the child's play to conserve energy and provide frequent snacks; however, it is most important for the child to be assessed.

The nurse is caring for a toddler taking ferrous sulfate for severe iron-deficiency anemia. Which report by the parent is most concerning?

"I mix ferrous sulfate with milk in a bottle." Rationale: Ferrous sulfate may not be absorbed if taken with milk or tea, and if the parent mixes the medicine with milk in a bottle, there is also concern that if the child does not drink the entire amount of medication. Ferrous sulfate may be taken after meals to prevent gastrointestinal irritation. Dark stools are a common side effect of ferrous sulfate. Parents should be encouraged to brush the child's teeth thoroughly to prevent teeth staining.

A 9-year-old child with leukemia is scheduled to undergo an allogenic hematopoietic stem cell transplant. When teaching the child and parents, what information would the nurse include?

"We'll need to have a match to a donor." Rationale: An allogenic hematopoietic stem cell transplantation (HSCT) refers to transplantation using stem cells from another individual that are harvested from the bone marrow, peripheral blood, or umbilical cord blood. With this type of transplant, human leukocyte antibody (HLA) matching must occur. Therefore, the lesser the degree of HLA matching in the donor, the higher the risk for graft rejection and graft-versus-host disease (GVHD). Regardless of the type of transplant, a period of purging of abnormal cells in the child is necessary and accomplished through high-dose chemotherapy or irradiation. The procedure is accomplished by intravenously infusing hematopoietic stem cells into the child.

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 Rationale: 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 nurse is caring for an 18-month-old client with suspected iron-deficiency anemia. The nurse will expect to prepare the client for which laboratory tests first?

Complete blood count and iron level Rationale: The nurse would expect the client to undergo a complete blood count, hemoglobin, hematocrit, reticulocyte, iron, ferritin, and free erythrocyte protoporphyrin levels to confirm the diagnosis. Laboratory evaluation will reveal decreased hemoglobin and hematocrit, decreased reticulocyte count, microcytosis and hypochromia, decreased serum iron and ferritin levels, and increase FEP level. The other findings do not point to iron-deficiency anemia. A white blood cell is used to diagnosis infection. A thrombocyte level is used to assess platelet counts. Glycosylated hemoglobin levels are used to assess glucose levels over the past 2 to 3 months.

The nurse cares for adolescents with cancer. Which recommended psychosocial interventions will the nurse use to help the adolescents cope with their disease? Select all 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 an adolescent's condition. Rationale: Adolescents need as normal a life as possible to experience things other peers engage in. The nurse should encourage usual activities and plans for the future and control the amount of information outsiders know about the adolescent's condition. Relationships with other children with cancer should be encouraged as well as an early return to school. Children should attend school as long as their white blood cells are not dangerously low. They can participate in activities if their platelets are adequate to prevent any bleeding from accidents while playing sports. The nurse should be a friend as well as an advisor to the adolescents.

The nurse is caring for a child who had a stem cell transplant and is being monitored for engraftment. Which nursing action is priority?

Ensure neutropenic precautions are in place. Rationale: With stem cell transplants, children are at greatest risk for infection and sepsis. The nurse should ensure neutropenic precautions are used to reduce the change of infection. Monitoring laboratory values, reminding the parent to contact the school, and encouraging therapeutic play are important, but preventing infection in the immunocompromised child is a priority.

The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with sickle cell anemia. The nurses in the group make the following statements. Which statement is most accurate regarding sickle cell anemia?

If the trait is inherited from both parents the child will have the disease. Rationale: 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 black clients. Either sex can have the trait and disease.

Which nursing diagnosis would be most appropriate for a child with idiopathic thrombocytopenic purpura?

Ineffective tissue perfusion related to poor platelet formation Rationale: Idiopathic thrombocytopenic purpura (ITP) results from an immune response following a viral infection that produces antiplatelet antibodies. These antibodies destroy the platelets which cause petechiae, purpura, and excessive bleeding. ITP does not affect the kidneys. Breathing difficulties would not occur with decreased white blood cells. It occurs when there is decreased red blood cells. The child who develops ITP has no different immune system than other children who are healthy.

Which mechanism is central to cancers in children?

cellular growth Rationale: Certain pediatric malignancies clearly occur at times of peak physical growth and cellular maturation. This coincidence suggests that cellular growth and development are central to the mechanism of cancer in children. By contrast, environmental exposures are a primary component of carcinogenesis in adults. Genetics and race are not commonly identified as related to pediatric cancers.

The nurse is planning care for a child with idiopathic thrombocytopenic purpura. Which client education should be included?

Not to pick or irritate the nose Rationale: Idiopathic thrombocytopenic purpura (ITP) occurs as an immune response following a viral infection. It produces antiplatelet antibodies that destroy platelets. This leads to the classic symptoms of petechiae, purpura, and excessive bruising. Without adequate platelets, children bleed easily from lesions. If the child "picks" the nose, an area could be opened and bleeding could occur. Folic acid will have no effect on the disease process. The lesions are not itchy and are open or draining, so cold water washing and soothing lotions are not required.

Which nursing diagnosis should the nurse identify as being the most appropriate for a child with idiopathic thrombocytopenic purpura?

Risk for bleeding related to insufficient platelet formation Rationale: diopathic thrombocytopenic purpura is the result of a decrease in the number of circulating platelets in the presence of adequate megakaryocytes, which are precursors to platelets. Because bleeding can occur with this disease process, the diagnosis most appropriate for the client at this time is risk for bleeding related to insufficient platelet formation. Reduced numbers of platelets would not increase the client's risk for infection. Reduced numbers of platelets does not increase the client's risk for renal impairment. Reduced risk of platelets will not lead to an ineffective breathing pattern.

The nurse is caring for a 17-year-old girl in the terminal phase of osteosarcoma. Which action demonstrates integration of the recommendations of the American Academy of Pediatrics (AAP) Committee on Bioethics?

Telling the child exactly what to expect of further treatments. Rationale: The committee recommends telling the child exactly what to expect of further treatments and procedures, explaining the prognosis in a developmentally appropriate way to ensure the child's understanding, and endeavoring to gain the child's candid opinion of the proposed care plan. It also recommends that decision-making for older children and adolescents should include the assent of the child or adolescent.

A nurse is conducting a class to a group of parents on sickle cell anemia. Which statement by a parent indicates teaching has been effective?

The sickle shape of red blood cells decreases oxygen to tissues. Rationale: The sickle shape of the red blood cells impedes the flow of blood through the vessels, thus causing hypoxia to the tissues. Sickle cell anemia is a hereditary disease but it is autosomal recessive, meaning it requires two genes in order for the disease to be transmitted. Sickle cell anemia is common in people of African, Mediterranean, and Indian descent. Hydration is important to controlling sickle cell anemia. Dehydration is a trigger for sickle cell crisis.

A nurse is providing care for a child with disseminated intravascular coagulation (DIC). What would alert the nurse to possible neurologic compromise?

Widely fluctuating blood pressure Rationale: A key aspect of the nurse's role is to assess the child for signs and symptoms of impaired tissue perfusion in the various body systems that may be affected by DIC. Unstable or abnormal blood pressure (such as wide BP fluctuations) or unequal pupil size may suggest neurologic compromise. Hematuria would suggest renal compromise. Petechiae would be indicative of bleeding into the skin.

Which lab values will the nurse expect to observe in a child with a hemolytic blood transfusion reaction? Select all that apply.

bilirubin 10 mg/dl (171 µmol/L) hemoglobin 8 mg/dL (80 g/L) red blood cells 3 million/mm3

The nurse is providing care for a 13-year-old child diagnosed with iron-deficiency anemia. The client's current hemoglobin level is 11 g/dL (110 g/L). Which intervention will the nurse anticipate including in the client's care?

giving ferrous sulfate with orange juice between meals

The nurse is administering meperidine as ordered for pain management for a 10-year-old boy in sickle cell crisis. The nurse would be alert for:

seizures Rationale: Repeated use of meperidine for pain management during sickle cell crisis increases the risk of seizures when used in children with sickle cell anemia. Behavioral addiction is rarely a concern in the child with sickle cell anemia if the narcotic is used for the alleviation of severe pain. Priapism is a complication of sickle cell anemia unrelated to meperidine administration. Leg ulcers are a complication of sickle cell anemia unrelated to meperidine administration.

The nurse is teaching the parents of a 15-year-old boy who is being treated for acute myeloid 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 Rationale: 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/pain when swallowing) are reasons to seek medical care, but are not as grave as the risk of infection.

A nurse is preparing a teaching plan for a child with hemophilia and his parents. Which information would the nurse be least likely to include to manage a bleeding episode?

Apply heat to the site of bleeding. Rationale: Ice or cold compresses, not heat, would be applied to the site of bleeding. Direct pressure is applied until the bleeding stops. The injured part is elevated unless elevating would contribute to further injury. Factor VIII replacement is given to replace the missing clotting factor.

Individuals with hemophilia B have a deficiency in factor IX, which can cause excessive blood loss. What is another name for this clotting factor?

Christmas factor Rationale: Factor IX is also known as plasma thromboplastin component or Christmas factor. Its function is to activate factor X. Factor X is the Stuart factor. Stuart factor's function is to activate factor II in the clotting cascade. Factor VIII is the antihemophilic factor. It is a platelet cofactor and also helps activate factor X. Factor VII is proconvertin. It is considered a stable factor and also acts to activate factor X.

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 Rationale: 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.

The health care provider prescribed an alkylating agent for a child's chemotherapy. Which best describes an action produced by these types of agents?

They are cell cycle-nonspecific, destroying both resting and dividing cells. Rationale: Alkylating agents are cell cycle-nonspecific, destroying both resting and dividing cells. During alkylation, the hydrogen atoms of some molecules within the cell are replaced by an alkyl group. This group interferes with DNA replication and RNA transcription. Interferons are the classification of drugs that are synthesized by bacterial and fungal agents. Antimetabolites are active in the S phase and act similarly to normal cellular metabolites. They alter the cell's function to destroy the cell's ability to replicate.