Ch. 24- Nursing Care of the Child With an Alteration in Cellular Regulation/Hematologic or Neoplastic Disorder

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? A. bone marrow B. lymph nodes C, liver D. bloodstream

A. bone marrow A child with cancer often appears pale and thin, with symptoms of lethargy and generalized malaise. The presence of pallor, ecchymoses, and petechiae may indicate that the cancer has invaded the bone marrow and is interrupting the normal production of red blood cells and platelets, as in leukemia.

The nurse has received morning report on a group of pediatric clients. Which pediatric client will the nurse see first? A. a child with hemophilia reporting knee pain and edema B. a child reporting lethargy with a history of thalassemia major C. a child with sickle cell anemia requesting a cool compress D. a child experiencing a palpable purpural rash and arthralgia

A. a child with hemophilia reporting knee pain and edema - 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.

A pediatric nurse is conducting a class for a group of nursing students about children with cancer. The nurse determines that the teaching was successful when the class identifies which as reflecting typical signs of pediatric cancers? Select all that apply. A. pain related to compression, infiltration, or obstruction caused by the tumor B. Alterations caused by tumor metabolism or cell death C. changes in bowel or bladder habits with rectal bleeding D. unusual lump or nonhealing wound E. secretion of a substance by the tumor that interferes with normal organ function

A. pain related to compression, infiltration, or obstruction caused by the tumor B. Alterations caused by tumor metabolism or cell death E. secretion of a substance by the tumor that interferes with normal organ function Childhood cancer symptoms are compression, infiltration, or obstruction caused by the tumor; changes in blood cell production such as decreased hemoglobin, hematocrit, white blood count, or platelets; secretion of a substance by the tumor that interferes with normal organ functioning; and metabolic, electrolyte, hormonal, or immunologic alterations caused by tumor metabolism or cell death.

The nurse is admitting to an examination room a child with the diagnosis of "probable acute lymphoblastic leukemia (ALL)." What will confirm this diagnosis? A. History of leukemia in twin B. Bone marrow aspiration C. Lethargy, bruising, and pallor D. Complete white blood count

B. Bone marrow aspiration 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.

Which nursing diagnosis would be most appropriate for a child with idiopathic thrombocytopenic purpura? A. Ineffective breathing pattern related to decreased white blood count B. Ineffective tissue perfusion related to poor platelet formation C. Risk for altered urinary elimination related to kidney impairment D. Risk for infection related to abnormal immune system

B. Ineffective tissue perfusion related to poor platelet formation 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.

To prevent further sickle cell crisis, the nurse would advise the parents of a child with sickle cell anemia to: A. prevent the child from drinking an excess amount of fluids per day. B. administer an iron supplement daily. C. notify a health care provider if the child develops an upper respiratory infection. D. encourage the child to participate in school activities, such as long-distance running.

C. notify a health care provider if the child develops an upper respiratory infection. Infections caused by the Streptococcus pneumoniae can be lethal to a child with sickle cell, because they can cause overwhelming sepsis or meningitis. By 2 months of age the child should be started on Penicillin V as prophylaxis against pneumococcal infections. The child should receive the 7 valent pneumococcal series in infancy. After 2 years of age the child should receive the 23 valent pneumococcal vaccine. He or she should also be immunized against meningitis. Participating in strenuous activities such as running and limiting the amount of fluids leads to a reduction of oxygen and dehydration. This can lead to the increased sickling of cells. The anemia of sickle cell disease is not the result of iron deficiency. It is the result of the abnormal shape of the red blood cell. Administering iron will not correct the anemia.

When planning the care for a child with leukemia who is receiving methotrexate, the nurse would assess the child closely for which possible effect? A. mucositis B. weight gain C. paresthesias of the fingers D. cushingoid facial appearance

A. mucositis Mucositis, or ulcers of the gum line and mucous membranes of the mouth, is a frequent side effect of methotrexate. Cushingoid facial appearance and weight gain are associated with the use of prednisone. Paresthesias are associated with vincristine.

The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with sickle cell disease. The nurses in the group make the following statements. Which statement is most accurate regarding this condition? A. "The disease is most often seen in individuals of Asian decent." B. "Males are much more likely to have the disease than females." C. "The trait or the disease is seen in one generation and skips the next generation." D. "If the trait is inherited from both parents the child will have the disease."

D. "If the trait is inherited from both parents the child will have the disease." 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.

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

A. "She has been down, but playing in soccer camp will cheer her up." Following a sickle cell crisis, the child should avoid extremely strenuous activities that may cause oxygen depletion. Fluids are encouraged, pain management will be needed, and the child's legs may be elevated to relieve discomfort, so these are all statements that indicate an understanding of caring for the child who has had a sickle cell crisis.

An 8-month-old girl appears pale, irritable, and anorexic. On blood testing, the red blood cells are hypochromic and microcytic. The hemoglobin level is less than 5 g/100 mL, and the serum iron level is high. Which symptom should the nurse most expect as a result of excessive iron deposits? A. An enlarged spleen B. An enlarged heart C. An enlarged thyroid gland D. Enlarged lymph nodes

A. An enlarged spleen The child with thalassemia major may have both an enlarged spleen and liver due to excessive iron deposits, fibrotic scarring in the liver, and the spleen's increased attempts to destroy defective RBCs.

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: A. seizures. B. leg ulcers. C. priapism. D. behavioral addiction.

A. seizures. - 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 opioid 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 caring for a 14-year-old client scheduled for magnetic resonance imaging (MRI). The nurse explains the test to the child and family. Which information would be mostappropriate to include in the explanation? A. "The MRI uses radiation to examine soft tissue and bony structures of the body." B. "The MRI uses radio waves and magnets to produce a computerized image of the body." C. "The MRI is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement." D. "The MRI uses sound waves to create images that visualize body structures and locate masses."

B. "The MRI uses radio waves and magnets to produce a computerized image of the body." 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 with cancer has developed neutropenia and is in isolation with neutropenic precautions. What nursing assessment takes priority for this child? A. vital signs B. infection symptoms C. mucositis D. bleeding

B. infection symptoms 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.

The nurse is providing preoperative care for a 7-year-old boy with a brain tumor, as well as his parents. Which intervention is a priority? A. Providing a tour of the intensive care unit. B. Having the child talk to another child who has had this surgery. C. Assessing the child's level of consciousness. D. Educating the child and parents about shunts.

C. Assessing the child's level of consciousness. 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.

Parents ask why their child just diagnosed with leukemia needs a "spinal tap." Which is the bestresponse by the nurse? A. "It will help rule out a second malignancy." B. "The spinal tap will help relieve pressure and headache for your child." C. "A sample of cerebrospinal fluid is needed to check for possible central nervous system infection." D. "Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system."

D. "Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system." 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.

A nurse is providing dietary interventions for a 5-year-old with an iron deficiency. Which response indicates a need for further teaching? A. "I must encourage a variety of iron-rich foods that he likes." B. "There are many iron fortified cereals that he likes." C. "He will enjoy tuna casserole and eggs." D. "Red meat is a good option; he loves the hamburgers from the drive-thru."

D. "Red meat is a good option; he loves the hamburgers from the drive-thru." 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.

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

D. "We should administer the drug on an empty stomach." 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 10-year-old boy with hemophilia. He asks the nurse for suggestions about appropriate physical activities. Which activity would the nurse most likely recommend? A. Football B. Soccer C. Wrestling D. Baseball

D. Baseball Children with hemophilia should stay active. Good physical activities would be swimming, baseball, basketball, and bicycling (with a helmet). He would still need to be careful about falls and sliding into base. Intense contact sports like football, wrestling, and soccer should be avoided.

A nursing student compares and contrasts childhood and adult cancers. Which statement does so accurately? A. Environmental and lifestyle influences in children are strong, unlike those in adults. B. Adult cancers are more responsive to treatment than are those in children. C. Little is known regarding cancer prevention in adults, although much prevention information is available for children. D. Children's cancers, unlike those of adults, often are detected accidentally, not through screening.

D. Children's cancers, unlike those of adults, often are detected accidentally, not through screening. 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.

When developing the postoperative plan of care for a child with sickle cell anemia who has undergone a splenectomy, which would the nurse identify as the priority? A. Deficient fluid volume B. Impaired skin integrity C. Risk for delayed growth and development D. Risk for infection

D. Risk for infection Removal of the spleen places the child at significant risk for infection. Although the child's skin integrity is disrupted due to the surgery, this is not the priority nursing diagnosis. Loss of fluids occurs during surgery and adequate hydration is important to prevent a sickle cell crisis, but this diagnosis is not the priority in the postoperative period. Although the child is at risk for delayed growth and development, the priority postoperatively is to prevent infection.

Children with acute lymphoblastic leukemia (ALL) may need periodic lumbar punctures. The nurse would teach the parent that this is done to assess for: A. early meningitis. B. early development of septicemia. C. platelets. D. leukemic cells.

D. leukemic cells. 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.

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? A. Apply heat to the site of bleeding. B. Administer factor VIII replacement. C. Elevate the injured area such as a leg or arm. D. Apply direct pressure to the area.

A. Apply heat to the site of bleeding. 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.

The nurse is planning care for a child with idiopathic thrombocytopenic purpura. Which client education should be included? A. To apply a soothing cream to lesions B. Not to pick or irritate the nose C. What foods are high in folic acid D. To use mainly cold water to wash

B. Not to pick or irritate the nose 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.

The nurse is caring for a child with leukemia. Which nursing intervention would be the highest priority for this child? A. providing age-appropriate activities B. following guidelines for reverse isolation C. grouping nursing care D. encouraging the child to share feelings

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

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)? A. lethargy, bruises, and lymphadenopathy B. abdominal pain, nausea, and vomiting C. joint pain and swelling D. anorexia and weight loss

A. lethargy, bruises, and lymphadenopathy 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.

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? A. "Your infant may have been having excessive diarrhea." B. "Infants with pyloric stenosis require ferrous sulfate." C. "Preterm infants are at risk for iron-deficiency anemia." D. "Ferrous sulfate helps improve red blood cell formation."

C. "Preterm infants are at risk for iron-deficiency anemia." 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 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? A. Remain in an upright position for at least 15 minutes B. Not eat or drink for one hour C. Brush his or her teeth D. Drink a glass of milk

C. Brush his or her teeth To prevent staining of the teeth, the child should brush the teeth after administration of iron preparations such as ferrous sulfate. There is no need to remain upright, drink milk or to refrain from eating or drinking for one hour.

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

C. Calling the doctor if the child gets a sore throat 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.