PEDs Chapt 28 Nursing Care of the Child with a Neoplastic Disorder
The nurse is assessing a 16-year-old boy who has had long-term corticosteroid therapy. Which of the following findings, along with the use of the corticosteroids, would indicate Cushing disease? a) Observing delayed dentition b) History of rapid weight gain c) Observing a round, child-like face d) Observing high weight to height ratio
History of rapid weight gain Explanation: A history of rapid weight gain and long-term corticosteroid therapy suggests this child may have Cushing disease, which could be confirmed using an adrenal suppression test. A round, child-like face is common to both Cushing and growth hormone deficiency. Observing high weight to height ratio and delayed dentition are findings with growth hormone deficiency.
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? a) Delayed intensive-therapy phase b) Induction phase c) Consolidation phase d) Sanctuary phase
Induction phase Correct Explanation: An induction phase 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? a) Administer chemotherapy during sleep periods, including naps and overnight b) Keep intravenous (IV) fluids running to maintain excellent hydration and frequent voids c) Have the child wait to void until the bladder becomes full d) Promote drinking of cranberry juice, making it an attractive oral fluid option
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.
The nurse is assessing a 4-year-old girl whose mother complains that she is not eating well, is losing weight, and has started vomiting after eating. Which of the following risk factors from the health history would suggest the child may have a Wilm tumor? a) The child has Down syndrome b) The child has Schwachman syndrome c) There is a family history of neurofibromatosis d) The child has Beckwith-Wiedemann syndrome
The child has Beckwith-Wiedemann syndrome Correct 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 Wilm 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.
Which intervention is best to use with the 6-year-old who has developed stomatitis as a side effect of chemotherapy? a) Limit foods to cool, clear liquids b) Use lidocaine rinses c) Have the child freely choose desired foods and beverages d) Practice frequent, gentle oral hygiene
Practice frequent, gentle oral hygiene 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.
What is the priority action that the nurse should take when caring for a child newly diagnosed with Wilms' tumor (nephroblastoma)? a) Protact the abdomen from manipulation. b) Assess for constipation. c) Obtain a catheterized urine specimen. d) Control acute pain.
Protact 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.
Parents ask why their child just diagnosed with leukemia needs a "spinal tap." Which is the best response by the nurse? a) "Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system." b) "The spinal tap will help relieve pressure and headache for your child." c) "It will help rule out a second malignancy." d) "A sample of cerebrospinal fluid is needed to check for possible central nervous system infection."
"Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system." Correct 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 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? a) "Has your baby been rubbing either eye?" b) "Most parents mention a red color." c) "I will report this to the pediatrician." d) "A plugged tear duct would not be unusual."
"I will report this to the pediatrician." Correct 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.
What is the best response by the nurse to the parents of a child with leukemia who express guilt because they did not take immediate action when their child seemed to develop one respiratory infection after another? a) "Young children develop minor illness easily and often. Stop being hard on yourselves." b) "Don't feel bad. Children get lots of colds." c) "Keep in mind that the signs of leukemia are often subtle and difficult to recognize." d) "You need to focus on the present treatment now and not worry about the past."
"Keep in mind that the signs of leukemia are often subtle and difficult to recognize." Correct Explanation: Pointing out that the signs and symptoms of leukemia are often difficult to recognize indicates to the parents that they were not neglectful, while also providing information about the disease. The other responses minimize the parents' feelings or tell them how they should feel and are not therapeutic.
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? a) "The MRI is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement." b) "The MRI uses radio waves and magnets to produce a computerized image of the body." c) "The MRI uses sound waves to create images that visualize body structures and locate masses." d) "The MRI uses radiation to examine soft tissue and bony structures of the body."
"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.
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 which of the following? a) "We should administer the drug on an empty stomach." b) "We will need to gradually decrease the dosage." c) "We should check our son's urine for glucose." d) "He might develop a rounded face from this drug."
"We should administer the drug on an empty stomach." Correct Explanation: 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.
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? a) Wheezing and diminished breath sounds b) Tachycardia and respiratory distress c) Respiratory distress and poor perfusion d) Bradycardia and distinct S1 and S2 sounds
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 child has been diagnosed with leukemia. Rank the following medications used to treat leukemia in order based on the stage of treatment. The child is receiving chemotherapy through an intrathecal catheter. The child is receiving vincristine through an intravenous line and oral steroids. The child is receiving low doses of mercaptopurine and methotrexate. The child is receiving high doses of mercaptopurine and methotrexate.
The child is receiving vincristine through an intravenous line and oral steroids. The child is receiving high doses of mercaptopurine and methotrexate. The child is receiving low doses of mercaptopurine and methotrexate. The child is receiving 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 mercaptopurine. During maintenance, the child receives low doses of methotrexate and mercaptopurine. During central nervous system prophylaxis, the child receives intrathecal chemotherapy.
When explaining the procedure of bone marrow aspiration to a child with leukemia, what would be the best explanation? a) "You will have to lie on your back and hold your breath." b) "You won't feel any pain at all, because you will be asleep." c) "You will feel pressure on your hip from the needle." d) "You will need to lie still afterward to prevent a headache."
"You will feel pressure on your hip from the needle." Correct 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 and round to the hundredths place. ______ BSA
0.99 Explanation: Square root of (height [cm] x weight [kg] divided by 3,600) = BSA. The child is 130 cm tall and weighs 27 kg: 130 x 27 = 3,510; 3,510/3,600 = 0.975; and the square root of 0.975 is 0.9874. The BSA would be 0.987, when rounded to the hundredths place = 0.99.
The physician requests the nurse to calculate the child's 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. _____ ANC
3450 Correct Explanation: Bands + segs/100) x WBC = ANC 14 + 9 = 23% = 23/100 = 0.23 0.23 x 15,000 = 3,450
Children with ALL may need periodic lumbar punctures. You would teach the mother this is done to assess for a) early meningitis. b) leukemic cells. c) platelets. d) early development of septicemia.
leukemic cells. Correct Explanation: Leukemic cells in cerebrospinal fluid must be identified because, if present, they require additional therapy.
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? a) CBC indicates hyperleukocytosis. b) Palpation reveals lymphadenopathy in the axillae. c) Observation discloses weight loss and muscle wasting. d) Child complains of headache and vision problems.
CBC indicates hyperleukocytosis. 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.
A nursing student compares and contrasts childhood and adult cancers. Which statement does so accurately? a) Adult cancers are more responsive to treatment than are those in children. b) Little is known regarding cancer prevention in adults, although much prevention information is available for children. c) Environmental and lifestyle influences in children are strong, unlike those in adults. d) Children's cancers, unlike those of adults, often are detected accidentally, not through screening.
Children's cancers, unlike those of adults, often are detected accidentally, not through screening. Correct 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.
Which of the following diagnoses would be most appropriate for an infant with a large retinoblastoma after surgery? a) Disturbed sensory perception related to enucleation b) Pain related to retinal removal c) Anticipatory grieving related to change in body image d) Fear related to loss of normal vision
Disturbed sensory perception related to enucleation Explanation: The primary therapy for a large retinoblastoma is removal (enucleation) of the affected eye.
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) Gamma interferon d) Sargramostim
Epoetin alfa Correct Explanation: 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 explains to the teenager that which alterations may occur when steroids are added to the cancer therapy regimen? a) Facial changes b) Nighttime itching c) Loss of appetite d) Urinary incontinence
Facial changes Correct 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.
Children who are free of acute lymphocytic anemia for 2 years following treatment are considered cured. a) False b) True
False Correct Explanation: Children who are free of disease for 4 years are considered cured, and their maintenance therapy can then be stopped.
The nurse is teaching an 11-year-old boy and his family how to manage his diabetes. Which of the following does not focus on glucose management? a) Promoting higher levels of exercise than previously maintained b) Encouraging the child to maintain the proper injection schedule c) Instructing the child to rotate injection sites to decrease scar formation d) Teaching that 50% of daily calories should be carbohydrates
Instructing the child to rotate injection sites to decrease scar formation Explanation: Instructing child to rotate injection sites to decrease scar formation is important, but does not focus on managing glucose levels. Teaching the child and family to eat a balanced diet, encouraging the child to maintain the proper injection schedule, and promoting a higher level of exercise all focus on regulating glucose control.
How can the nurse most simply describe for distressed parents a rhabdomyosarcoma that has been found in their 5-year-old? a) Indicate that the more commonly used name is Hodgkin's disease b) Explain that it develops in nerves outside the brain and spinal cord c) Describe it as a bone tumor d) Call it a tumor of muscle tissue
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.
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
Calling the doctor if the child gets a sore throat Correct 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 nurse is caring for a 4-year-old boy following surgical removal of a stage I neuroblastoma. Which of the following interventions will be most appropriate for this child? a) Applying aloe vera lotion to irradiated areas of skin b) Giving medications as ordered via least invasive route c) Maintaining isolation as prescribed to avoid infection d) Administering antiemetics as prescribed for nausea
Giving medications as ordered via least invasive route Explanation: Giving medications as ordered using the least invasive route is a postsurgery intervention focused on providing atraumatic care and is appropriate for this child. Since the child has a stage I tumor, it can be treated by surgical removal, and does not require chemotherapy or radiation therapy. Applying aloe vera lotion is good skin care following radiation therapy. Administering antiemetics and maintaining isolation are interventions used to treat side effects of chemotherapy.
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 a) antineoplastic. b) analgesic. c) antipyretic. d) antiemetic.
antiemetic. Correct 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.
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 lymphocytic leukemia? Select all that apply. a) Painless cervical lymphadenopathy b) Headache c) Low-grade fever d) Chest pain e) Bleeding from the oral mucous membranes
• Bleeding from the oral mucous membranes • Headache • Painless cervical lymphadenopathy • Low-grade fever Explanation: Assessment findings associated with acute lymphcytic leukemia 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 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. a) Provide various soft and bland foods to minimize further irritation. b) Have the child rinse the mouth with lukewarm water three times a day. c) Give the child acidic foods (eg, orange juice) to cleanse the mouth. d) Vigorously rub the child's gums with gauze to clean them. e) 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. • Apply a lip balm or petroleum jelly to prevent cracking. Correct 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 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 of the following symptoms should the parents seek medical care immediately? a) Difficulty or pain when swallowing b) A temperature of 101°F (38.3° C) or greater
A temperature of 101°F (38.3° C) or greater 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.
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? a) Acute lymphocytic (lymphoblastic) leukemia b) Osteogenic sarcoma c) Neuroblastoma d) Non-Hodgkin's lymphoma
Acute lymphocytic (lymphoblastic) leukemia Correct 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%
The school nurse notes that a child diagnosed with diabetes mellitus is experiencing an insulin reaction and is unable to eat or drink. Which of the following actions would be the most appropriate for the school nurse to do? a) Request that someone call 911 b) Administer subcutaneous glucagon c) Anticipate that the child will need intravenous glucose d) Dissolve a piece of candy in the child's mouth
Administer subcutaneous glucagon Correct Explanation: If the child having an insulin reaction cannot take a sugar source orally, glucagon should be administered subcutaneously to bring about a prompt increase in the blood glucose level. This treatment prevents the long delay while waiting for a physician to administer IV glucose or for an ambulance to reach 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) Provide the antiemetic as needed (PRN) when nausea and vomiting are reported b) Start the antiemetic on a scheduled basis when the chemotherapy begins to cause nausea c) Administer the antiemetic before starting chemotherapy d) Use the antiemetic after it is clear that nonpharmacologic methods are not effective
Administer the antiemetic before starting chemotherapy Correct 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.
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 of the following interventions would the nurse expect to perform? a) Encouraging fluid intake to increase radionuclide uptake b) Administering a sedative as ordered to keep the child still c) Applying EMLA to the injection site prior to inserting the IV d) Advising the physician that the child is allergic to shellfish
Administering a sedative as ordered to keep the child still Explanation: 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 toddler with a cancer diagnosis is seen for a well-child checkup. Which health maintenance activity will the nurse exclude? a) Assessing dietary intake by addressing "picky eating" and "food jags" b) Plotting height and weight on a growth chart c) Administering the measles, mumps, rubella (MMR) vaccine d) Teaching the importance of taking water safety measures
Administering the measles, mumps, rubella (MMR) vaccine Correct 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.
The nurse will use a special needle to start intravenous (IV) fluids through which central venous access device? a) A peripherally inserted central catheter b) An implanted port c) A multilumen catheter d) A tunneled central catheter
An implanted port Correct Explanation: An implanted port requires a special (Huber) needle placed through the skin into the port, which is implanted surgically under the skin and over a bony prominence. The peripherally inserted central catheter (PICC) and tunneled catheters (Broviac, Hickman, Groshong) do not require a special needle for access. A multilumen catheter has more than one lumen but is not a port.
What is one advantage of an implanted port (central venous access device) that the nurse will explain to an adolescent? a) Body appearance changes very little. b) Flushing of the device is not necessary. c) No tunneling is needed when the port is inserted. d) No special procedure is necessary for removal.
Body appearance changes very little. Correct 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 admitting to an examination room a child with the diagnosis of "probable acute lymphoblastic leukemia." What will confirm this diagnosis? a) History of leukemia in twin b) Lethargy, bruising, and pallor c) Bone marrow aspiration d) Complete white blood count
Bone marrow aspiration Correct 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 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? a) Observing petechiae, purpura, or unusual bruising b) Child complains of facial palsy and vision problems c) Noting adventitious breath sounds during auscultation d) Palpation of abdomen reveals enlarged liver and spleen
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.
As a nurse, you know that which of the following is caused by excessive levels of circulating cortisol: a) Cushing syndrome b) Addison disease c) Turner syndrome d) Graves disease
Cushing syndrome Correct Explanation: CS is a characteristic cluster of signs and symptoms resulting from excessive levels of circulating cortisol. Addison disease is caused by autoimmune destruction of the adrenal cortex, which results in dysfunction of steroidogenesis. Grave disease is the most common form of hyperthyroidism. Turner syndrome is deletion of the entire X chromosome.
The pediatric nurse examines the radiographs of a patient that show that there are lesions on the bone. This finding is indicative of: a) Neuroblastoma b) Hodgkin disease c) Ewing sarcoma d) Non-Hodgkin lymphoma
Ewing sarcoma Correct 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.
A nurse is giving instructions to the father of a boy who is receiving chemotherapy including methotrexate regarding how best to care for the boy during this period of treatment. Which of the following should she mention to him? a) Give him aspirin to help manage pain b) Give the boy folic acid supplements c) Be sure that the boy receives only live-virus vaccines d) Keep him away from people with known infections
Keep him away from people with known infections Correct Explanation: Caution parents, while children are receiving chemotherapy, not to give them aspirin for pain as, in addition to increasing the child's susceptibility to Reye syndrome, aspirin may interfere with blood coagulation, a problem that may already be present because of lowered thrombocyte levels. A parent who wants to give a child vitamins should check with the primary health care provider to be certain the vitamin preparation will not interfere with a chemotherapeutic agent. Administration of a vitamin that contains folic acid, for example, could interfere with the effectiveness of methotrexate, a folic acid antagonist. A child receiving chemotherapy is particularly susceptible to contracting an infection so should be kept away from people with known infections. Caution parents that live-virus vaccines should not be given during chemotherapy as, if the child's immune mechanism is deficient, these vaccines could cause widespread viral disease.
The nurse is caring for a 4-year-old boy during a growth hormone stimulation test. Which of the following is a priority task for the care of this child? a) Providing a wet washcloth to suck on b) Monitoring blood glucose levels c) Educating family about side effects d) Monitoring intake and output
Monitoring blood glucose levels Correct Explanation: Monitoring blood glucose levels during this study is the priority task along with observing for signs of hypoglycemia since insulin is given during the test to stimulate release of growth hormone. Providing a wet washcloth would be more appropriate for a child who is on therapeutic fluid restriction, such as with syndrome of inappropriate antidiuretic hormone. Monitoring intake and output would not be necessary for this test but would be appropriate for a child with diabetes insipidus. While it is important to educate the family about this test, it is not the priority task.
A child with ALL is receiving methotrexate for therapy. Which nursing diagnosis below would best apply to him during therapy? a) Excess fluid volume related to effect of methotrexate on aldosterone secretion b) Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy c) Risk for impaired mobility related to depressant effects of methotrexate d) Risk for self-directed violence related to effect of methotrexate on central nervous system
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.
A nurse is assessing a child with cancer and suspects that the child has developed sepsis based on which of the following? Select all that apply. a) Increased blood urea nitrogen (BUN) b) Hyperkalemia c) Absolute neutrophil count (ANC) less than 500 d) Respiratory alkalosis e) Thrombocytosis
• Absolute neutrophil count (ANC) less than 500 • Increased blood urea nitrogen (BUN) • Hyperkalemia Explanation: Findings associated with sepsis include ANC less than 500, increased BUN, increased potassium, decreased platelets, and metabolic acidosis.
The nurse caring for a patient with leukemia documents the following signs that are clinical or diagnostic features of the disease (select all answers that apply): a) Lymphadenopathy b) Bruising c) Sore throat d) Increased hemoglobin e) Anorexia f) Increased platelet count
• Bruising • Anorexia • Sore throat • Lymphadenopathy Explanation: Clinical and diagnostic features of leukemia include fatigue, weakness, pallor, fever, bruising, bleeding (e.g., petechiae or purpura), weight loss, anorexia, swollen gums, sore throat, recurrent infections, flu-like symptoms, abdominal pain, nausea, vomiting, bone pain, lymphadenopathy, splenomegaly, hepatosplenomegaly, elevated leukocyte count (mm3), decreased hemoglobin (g/dL), and decreased platelets.
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) a) Self examination is an effective screening method for testicular cancer b) Sexually transmitted disease is a risk factor for cervical cancer c) Testicular cancer is one of the most difficult cancers to cure d) Provide information regarding the benefits of receiving the HPV vaccine e) A papanicolaou (PAP) smear does not require parent consent in most states
• Self examination is an effective screening method for testicular cancer • A papanicolaou (PAP) smear does not require parent consent in most states • Sexually transmitted disease is a risk factor for cervical cancer • Provide information regarding the benefits of receiving the HPV vaccine Explanation: Answer b 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.
A 9-year-old child with leukemia is scheduled to undergo an allogenic hematopoietic stem cell transplant. When teaching the child and parents, which of the following would the nurse include? a) "The risk for rejection is much less with this type of transplant." b) "You'll need to have an incision in your hip area to instill the cells." c) "We'll need to have a match to a donor." d) "You won't need to receive the high doses of chemotherapy before the transplant."
"We'll need to have a match to a donor." Correct Explanation: 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.
The nurse is providing preoperative care for a 7-year-old boy with a brain tumor and his parents. Which of the following is the priority intervention? a) Assessing the child's level of consciousness b) Having him talk to a child who has had this surgery c) Educating the child and parents about shunts d) Providing a tour of the intensive care unit
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? a) Preparing the child for amputation b) Avoiding further abdominal palpation c) Administering analgesics for pain d) Performing dressing changes to the affected area
Avoiding further abdominal palpation 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? a) Bladder b) Brain c) Blood d) Kidney
Bladder Correct 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.
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? a) Insurance companies typically allow only a short radiation treatment per week, to contain costs b) It is difficult to locate where the cancer cells are in the body, so the entire body must be irradiated c) Cells are only susceptible to treatment by radiation during certain phases of the cell cycle d) Radiation therapy is very weak, and therefore it takes a long time to achieve therapeutic doses
Cells are only susceptible to treatment by radiation during certain phases of the cell cycle Correct 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.
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. Doubling of cell size Cell at rest Gap Duplication of DNA and chromosomes Cell division Period until DNA stabilization complete
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.
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) Ask whether any family members or other close associates are ill b) Tell the parent to administer acetaminophen every 4 hours until the fever dissipates c) Instruct the parent to immediately obtain and give the antibiotic that the oncologist will order d) Have the parent bring the child to the pediatric oncology clinic as soon as possible
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.
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) His daughter tugs and pulls at one ear. b) His daughter's eye appears to be protruding. c) He has noticed one pupil appears white. d) The infant always keeps her eyes tightly closed.
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.
Which of the following is a well-defined risk management technique that the nurse can teach children and parents to prevent cancer? a) Incorporate more preservative-free foods into the diet b) Eliminate aerosol sprays from the living area c) Avoid artificial colors, flavors, and fragrances in foods, cosmetics, and household items d) Limit sun exposure throughout childhood and adolescence
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.
The nurse is caring for a 6-year-old boy with non-Hodgkin lymphoma who is being treated with monoclonal antibodies. Which of the following would the nurse include in the child's plan of care? a) Monitoring for complaints of bone pain b) Assessing the child's hydration status secondary to vomiting c) Monitoring for allergic reactions or anaphylaxis d) Assessing for signs of capillary leak syndrome
Monitoring for allergic reactions or anaphylaxis Correct Explanation: 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 require hydration maintenance also. 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.
The nurse is assessing a 14-year-old girl with a tumor. Which of the following findings would indicate Ewing's sarcoma? a) Child complains of persistent pain from minor ankle injury b) Palpation reveals swelling and redness on the right ribs c) Child complains of dull bone pain just below her knee d) Palpation discloses asymptomatic mass on the upper back
Palpation reveals swelling and redness on the right ribs Correct 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's sarcoma. An asymptomatic mass on the upper back suggests rhabdomyosarcoma.
A nurse is caring for a 12-year-old girl who is recovering from surgery for removal of a brain tumor. Which of the following interventions should the nurse implement to avoid increasing intracranial pressure? a) Place a sterile towel under wet dressings b) Regulate the rate of IV fluid infusions carefully c) Apply saline eye drops, as prescribed d) Sponge the client's face
Regulate the rate of IV fluid infusions carefully Correct Explanation: Be certain to regulate the rate of IV fluid infusions carefully because an increase in the infusion rate has the potential to increase intracranial pressure. The other answers refer to other interventions, unrelated to intracranial pressure.
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. a) Encouraging frequent, thorough handwashing b) Cheering up the environment with fresh flowers and plants c) Encouraging frequent close contact with numerous visitors d) Having the child sleep in a single bed and room e) Providing a low-carbohydrate, low-protein diet
• Encouraging frequent, thorough handwashing • Having the child sleep in a single bed and room Correct 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.
