Chapter 26: Oncological Disorders

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? A The infant always keeps her eyes tightly closed. B He has noticed one pupil appears white. C. His daughter tugs and pulls at one ear. D. His daughter's eye appears to be protruding.

ANS: B Rationale: As the tumor grows against the retina of the eye, the red reflex is no longer visible; the pupil appears white

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? A Tell the parent to administer acetaminophen every 4 hours until the fever dissipates. B Ask whether any family members or other close associates are ill. C Have the parent bring the child to the pediatric oncology clinic as soon as possible. D Instruct the parent to immediately obtain and give the antibiotic that the oncologist will order.

ANS: C Rationale: 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 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? A "We'll need to have a match to a donor." B "The risk for rejection is much less with this type of transplant." C "You won't need to receive the high doses of chemotherapy before the transplant." D "You'll need to have an incision in your hip area to instill the cells."

ANS: A 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.

Antiemetics are ordered to control nausea and vomiting in the child undergoing chemotherapy. How can the nurse most effectively use these medications? A Administer the antiemetic before starting chemotherapy B Provide the antiemetic as needed (PRN) when nausea and vomiting are reported C Use the antiemetic after it is clear that nonpharmacologic methods are not effective D Start the antiemetic on a scheduled basis when the chemotherapy begins to cause nausea

ANS: A Rationale: 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.

3. 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? A Calling the doctor if the child gets a sore throat B Keeping a written copy of the treatment plan C Writing down phone numbers and appointments D Using acetaminophen if the child needs an analgesic

ANS: A 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.

An adolescent is recovering from surgery, radiation, and chemotherapy following a diagnosis of Ewing sarcoma. Which statement by the family indicates that reteaching is needed? A. "Our child is looking forward to playing football again." B. "We will remind our child to care for the skin following radiation." C. "Our child's friends shaved their heads in solidarity to show their support." D. "We will watch for signs of infection and report it to our health care provider."

ANS: A Rationale: Caution adolescents to continue to be careful about activities that cause stress on an extremity that has received radiation (for example, football or weight lifting) because it may not be as strong as usual afterward. The family will need reteaching because they say their child is looking forward to playing football again. Skin care, supportive friends, and reporting infections are all good foNr UhiRs SreIcoNvGer-y

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: A "We should administer the drug on an empty stomach." B "We should check our son's urine for glucose." C "He might develop a rounded face from this drug." D. "We will need to gradually decrease the dosage."

ANS: A 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 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? A Epoetin alfa B Filgrastim C Sargramostim D Gamma interferon

ANS: A 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.

The nurse is preparing to post a sign above the crib of an infant with a Wilms tumor. Which statement should the nurse post immediately? A. "Do not palpate abdomen." B. "No intramuscular injections." C. "No milk or milk products allowed." D. "No blood sampling in lower extremities."

ANS: A Rationale: It is important that the child's abdomen not be palpated any more than is necessary for diagnosis because handling appears to aid metastasis. Place a sign reading "No Abdominal Palpation" over the child's crib to help prevent this. Intramuscular injections, milk products, or blood sampling in the lower extremities are not contraindicated for this health problem.

A nurse is communicating with a family about palliative care. Which of the following would be the best approach to take? A. Ask the family what they know, what they wish to know and be prepared to repeat the information you give to them several times B. Give the family as much information as possible to promote better decision-making C. Provide information during a crisis when the parent's senses are heightened and memory is improved D. Avoid pushing the family by asking too many questions.

ANS: A Rationale: It is important to ask what the family knows, what they are ready to hear, and be prepared to repeat the information over the course of time. An essential component of communication is to realize that it is a dynamic ongoing process and that too much information can be delivered at one time. It is important to ask what the family knows, what they are ready to hear, and be prepared to repeat the information over the course of time. In times of crisis or stress, concentration and understanding may be impaired due to overwhelming feelings of loss and helplessness.

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 time and his skin turgor is normal. Which response by the nurse would be most appropriate? A "The drug you got to help with the nausea can cause dry mouth." B "Let me increase your intravenous fluids." C "You might be having a severe allergic reaction. Are you itchy?" D "This indicates an infection. We need to start antibiotics."

ANS: A Rationale: 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 assessing a 10-year-old girl with acute lymphoblastic leukemia. What information would lead the nurse to suspect that the cancer has infiltrated the central nervous system? A Child reports of facial palsy and vision problems B Observing petechiae, purpura, or unusual bruising C Noting adventitious breath sounds during auscultation D Palpation of abdomen reveals enlarged

ANS: A Rationale: 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.

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. A. Having the child sleep in a single bed and room B. Encouraging frequent, thorough handwashing C. Providing a low-carbohydrate, low-protein diet D. Encouraging frequent close contact with numerous visitors E. Cheering up the environment with fresh flowers and plants

ANS: A, B 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.

A child receiving chemotherapy wants to have a large birthday party and invite all the classmates. When the parent asks the nurse about this, what is the nurse's best response? A. "That will be a good way to cheer your child up!" B. "It is better to avoid large groups right now." C. "What about taking your child to a movie instead?" D. "We can have the party here in the hospital play room."

ANS: B Rationale: A child receiving chemotherapy is particularly susceptible to contracting an infection and thus should be kept away from people with known infections. Therefore, having the child avoid large groups right now is best. Although it would possibly cheer up the client, it is not best for the client's health. Going to a movie would not be a good idea because it could lead to exposure to someone who is ill. A party in the hospital play room is a possibility for the children in the hospital, but it would not be possible to invite the child's entire class.

A 6-year-old is dealing with the death of a sibling. Which action should the nurse suggest to the family to best support the child with the grieving process? A. Having the child stay with a family friend instead of attending the funeral B. Assisting the child in drawing a picture to be placed in the sibling's casket C. Having the sibling stand in the receiving line with the parents at the funeral home D. Discouraging the child from interacting with family and friends while they express their sympathy

ANS: B Rationale: It is difficult for a 6-year-old child to understand the death of a sibling. Research supports having the presence of the sibling at the funeral and encouraging a token of love such as a drawing or note. Allowing the child to interact with others who provide comfort helps the child in this difficult time.

A nurse is providing care to a toddler with nephroblastoma and is being evaluated. Which nursing action would be most important? A. Restricting the child's visitors B. Placing a "no abdominal palpation" sign above the child's bed C. Ensuring that the child be allowed nothing by mouth D. Preparing the child for chemotherapy E. Preventing weight-bearing activities

ANS: B Rationale: Nephroblastoma (Wilms' tumor) metastasizes rapidly, so it is important that the child's abdomen not be palpated any more than necessary for diagnosis, because handling appears to aid metastasis. There is no need to restrict the child's visitors. Ensuring nothing by mouth would be appropriate prior to surgery. Preventing weight-bearing activities would be appropriate for a child with Ewing's sarcoma.

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. What instructions would the nurse include in the child's plan of care? Select all that apply. A Vigorously rub the child's gums with gauze to clean them. B Provide various soft and bland foods to minimize further irritation. C Have the child rinse the mouth with lukewarm water three times a day. D Give the child acidic foods (e.g., orange juice) to cleanse the mouth. Apply a lip balm or petroleum jelly to prevent cracking.

ANS: B, C, E Rationale: 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.

A 16-year-old child suffering from alopecia related to chemotherapy treatment is refusing to let friends visit. Which action by the nurse is most appropriate? A Respect the child's wishes and document refusal B Have the parents explain the importance of letting friends visit C Provide opportunities for the child to discuss his or her body image changes D Allow friends to visit because socialization is important for adolescents

ANS: C Rationale: Being able to discuss body image changes is a pathway toward providing insight on adaptive measures to minimize the appearance of hair loss. The nurse should respect the child's wishes not to have visitors, but the nurse should recognize that this may be a result of altered body image.

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? A Administer chemotherapy during sleep periods, including naps and overnight B Have the child wait to void until the bladder becomes full C Keep intravenous (IV) fluids running to maintain excellent hydration and frequent voids D Promote drinking of cranberry juice, making it an attractive oral fluid option

ANS: C Rationale: 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 high-school football player has been diagnosed as having osteosarcoma of the femur. The parents are angry because they told the adolescent not to play football. Which health teaching points would the nurse include in the teaching plan for the adolescent and parents? A Osteosarcoma often follows trauma, such as a football injury. B You can expect some discoloration of the leg following chemotherapy. C Football injuries do not contribute to the development of a tumor. D Tumor growth is related to your dislike of milk.

ANS: C Rationale: Osteosarcoma is the most malignant form of bone cancer. It is caused from the embryonic mecenchymal tissue that forms in the bones. A football injury may predispose more scrutiny of a lesion but it will not be the cause of the cancer, nor will the dislike of milk. Osteosarcoma may be treated with chemotherapy and radiation. It may also involve an amputation. The parents who state they are angry at their adolescent for playing football is more likely projecting their fears of the diagnosis and the future for their adolescent.