Ch 53 PrepU: Child with Malignancy

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

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.

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 and biopsy are diagnostic. An abnormal white blood count and symptoms of lethargy, bruising, and pallor only create suspicion of leukemia; a twin may or may not be affected.

The nurse is preparing a discharge teaching plan for the parents of an 8-year-old girl with leukemia. Which instruction would be the priority?

Calling the doctor if the child gets a sore throat 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 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 parent contacts the oncology clinic nurse with concerns about mucositis following chemotherapy. Which are appropriate interventions for the nurse to include? Select all that apply.

Serve soft foods rather than hard or crunchy foods. Encourage rinsing the mouth with lukewarm water. Have the child drink fluids as often as possible to remain hydrated. Use a soft toothbrush and swish with an antibiotic mouthwash.

The nurse is preparing clients for diagnostic testing for cancer. Which test is used to differentiate a neuroblastoma from other tumors?

Urine catecholamine metabolites, homovanillic acid (HVA), and vanillylmandelic acid (VMA) Neuroblastomas produce catecholamines. Urine catecholamine metabolites, homovanillic acid (HVA), and vanillylmandelic acid (VMA) differentiate neuroblastomas from other tumors. This exam is done by collecting a 24-hour urine specimen. Urinalysis provides general information about renal function. Serum chemistries help to evaluate the body's response to the cancer process. CBC with differential determines abnormal loss or destruction of cells that may indicate cancer or bone marrow suppression.

Which care is most important to be completed for a child experiencing daily external beam radiation therapy?

cleansing the skin with mild soaps and moisturizers for daily hygiene The nurse is correct to care for the skin when providing care to a child with external beam radiation therapy. During this procedure, it is common to have skin irritation. Careful assessment and good skin hygiene through use of a mild soap or nonfragrant moisturizer may help preserve skin integrity. An antiemetic, not clear liquids, is prescribed prior to the radiation treatment if the child experiences radiation sickness. Crackers are commonly offered as well. External beam radiation does not require a port. The radiation site markings are not removed during radiation treatment.

The nurse performing a physical assessment of a client checks for signs of malignancies. Which findings may indicate a soft tissue mass? Select all that apply.

cranium masses, swelling around the eyes, drainage from ear

A child diagnosed with a malignancy is receiving long-term corticosteroid therapy as part of the chemotherapy regimen. The nurse would be especially alert for the development of which effect?

cushingoid faces Although other effects such as vomiting, constipation, and mucositis are possible with chemotherapy, children receiving long-term corticosteroid therapy (e.g. dexamethasone or prednisone) develop a typical "moon face," red cheeks, and a stocky build. Like the loss of hair, a Cushingoid appearance can be devastating to children or parents, the final insult in light of all the other things happening to them.

A nurse is reviewing the medical record of a child receiving chemotherapy and notes that the child is receiving an alkylating agent. Which medication falls into the medication classification as a potential agent? Select all that apply.

cyclophosphamide and chlorambucil Cyclophosphamide and chlorambucil are alkylating agents. Methotrexate is an antimetabolite. Vincristine is a plant alkaloid. Dactinomycin is an antibiotic.

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 Abnormal duration of symptoms that have lingered or increased over an unusually long period (e.g., a fever that has not responded to antibiotics) and has lasted longer than expected for recovery from acute illness could be a sign of a malignancy. Frequent stomach aches could stem from a variety of issues, such as irritable bowel syndrome. Recurrent headaches while reading may relate to visual changes. Swollen cervical lymph nodes with pharyngitis are typically viral or bacterial in nature.

The nurse is caring for a client newly diagnosed with cancer. The husband states, "I understand that something happens when cells reproduce causing a malignancy, but where does it go wrong?" The nurse is most correct to identify the stages of the normal cell cycle as which? Place the phases in the correct sequence.

gap cell at rest period until dna stabilization is complete duplication of dna and chromosomes double of cell size cell division

A pediatric nurse is providing a session on risk factors for childhood cancers. Which risk factor does the nurse include in this teaching session? Select all that apply.

-viral triggers -genetic predisposition for certain cancers -genetic markers that fail to suppress cancer -absence of tumor suppressor cells that allow abnormal growth -accumulation of mutations in the cell that transform to neoplasm Oncogenic (cancer-causing) viruses such as HPV may be directly responsible for tumor growth. According to this viral theory, oncogenic viruses have the ability to change the structure of DNA or RNA in cells. C-type RNA viruses, for example, have been implicated in leukemia. As more and more evidence is compiled on the nature of genes, specific markers in tumors that apparently fail to suppress, or stimulate, cancer-causing genes are being identified; almost all childhood cancers have such markers or a genetic trigger or predisposition to cancer. Somatic mutation theory postulates that an accumulation of mutations in the cell is what ultimately results in the transformation to a neoplastic state. In some children, because of their genetics, tumor suppressor cells may not be present, allowing abnormal growth stimulated by viruses to continue. Environmental factors do not seem to be a factor in children. In adults, tumors may grow because normal cell growth has been altered by environmental exposures, such as chronic exposure to chemical irritants or cigarette smoke. In contrast, in children tumors most frequently occur in organs unexposed to the environment such as leukemia of the bone marrow.

The nurse is planning a discussion group for parents with children who have cancer. How would the nurse describe a difference between cancer in children and adults?

Childhood cancers usually affect the tissues, not the organs, as in adults. Metastasis often is present when the childhood cancer is diagnosed. Childhood cancers, unlike adult cancers, are very responsive to treatment. Unfortunately, little is known about cancer prevention in children.

A nursing student compares and contrasts childhood and adult cancers. Which statement does so accurately?

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 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 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.

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." 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.

Parents tell the nurse who is admitting their infant for a well-child exam that they recently saw a "white glow" in their child's left pupil. What is the nurse's best response?

"I will report this to the pediatrician." 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.

A 9-year-old child with leukemia is scheduled to undergo an allogeneic 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." An allogeneic 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 child is receiving chemotherapy. The chemotherapy is scheduled to begin at 1000. To prevent nausea and vomiting, the child is prescribed ondansetron. At what time will the nurse administer the medication?

0930 Chemotherapeutic agents frequently have nausea and vomiting as a side effect of the treatment. Ondansetron is a common antiemetic agent, which blocks central and peripheral serotonin receptor sites to prevent chemotherapy-induced nausea. Ondansetron should be given 30 minutes before beginning chemotherapy.

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

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 parent calls the pediatric oncology clinic about the child having headaches after chemotherapy. What is the nurse's best advice?

Administer acetaminophen as needed. Caution parents, while children are receiving chemotherapy, not to give them nonsteroidal anti-inflammatory drugs because they may interfere with blood coagulation, a problem that may already be present because of lowered thrombocyte levels. Instead, suggest they use acetaminophen to relieve a headache. Ice packs are used to prevent hair loss and do not help with headaches. Hydrocodone is not needed for a headache.

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 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.

A group of nursing students are reviewing the various drug classes used for cancer chemotherapy. The students demonstrate an understanding of these classes when they identify which agent as an example of a nitrosourea?

Carmustine is an example of a nitrosourea

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. A positive body image is important, especially to an adolescent. It is important for the nurse to acknowledge the adolescent's feelings of sadness over the body changes caused by the illness. To help the adolescent have some power over the illness, the nurse should encourage the adolescent to choose wigs, hats, or scarves that fit his or her personality or even meet a goal of doing something the adolescent would not have dared to before. This could be a wig of different hair color or a big floppy hat with sequins. Whatever the choice, this gives the adolescent a feeling of being in control of the situation and able to make the decisions. Nurses should support the adolescent's choice of clothing. Most likely the adolescent will choose clothing for comfort. Loose clothing disguises weight loss or scarring while promoting self-esteem. Referring the adolescent to a support group or the help of a Child Life specialist are good interventions. Both will help the adolescent work through the feelings of loss, but neither gives the adolescent the ability to make decisions about outward appearance.

Which intervention is best to use with the 6-year-old who has developed stomatitis as a side effect of chemotherapy?

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.

The nurse is administering a chemotherapy agent with side effect of bladder irritation. What is the best measure the nurse can take to diminish this risk?

Keep intravenous (IV) fluids running to maintain excellent hydration and frequent voids. 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 and have a strict hourly voiding schedule. Reporting symptoms after they occur is not preventing the irritation. No benefit is associated with providing cranberry juice.

The pediatric nurse is explaining to a new graduate nurse the differences in planning well-child maintenance for a child with cancer. Which statement by the new nurse demonstrates understanding of the teaching?

No routine live vaccines are administered while on chemotherapy. Children with cancer need much of the same well-child maintenance care that all children do, with one exception. While they are undergoing chemotherapy, which causes a decreased immune response, they should not receive "routine" vaccines, especially live vaccines. The siblings in the home can receive all nonlive vaccines, and the entire family (including the child undergoing treatment) is encouraged to receive a yearly flu vaccine. Growth and development are monitored during well-child visits, but it is not necessarily true that growth and development may be stunted. It is always a good idea to eliminate second-hand smoke for all children, not just for children with cancer. Childhood cancers do not seem to be related to environmental contaminants.

What is the priority action the nurse should take when caring for a child newly diagnosed with Wilms tumor (nephroblastoma)?

Protect the abdomen from manipulation. Manipulation can release malignant cells into the abdominal cavity. Constipation may be a problem following surgical intervention. Pain is uncommon; obtaining a urine specimen is not a priority.

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

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

Reed-Sternberg cells 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 5-year-old client has been diagnosed with leukemia and is currently on chemotherapy and radiation. The child is having difficulty due to mucositis. Which is the most appropriate nursing diagnosis for this child?

Risk for imbalanced nutrition, less than body requirements, related to inflammation Mucositis is inflammation of the oral mucosa, which puts this child at risk for risk for imbalanced nutrition. The client may have pain due to neoplastic process in the bone, but that is not mentioned in the scenario. The client may have lost hair, but that is not mentioned. The client's family coping is also not mentioned.

The nurse is assessing a 13-year-old girl with a family history of kidney cancer who has come to the clinic complaining of abdominal pain, nausea, and vomiting. Which finding would the nurse identify as least likely indicative of cancer in a child?

The child also reports rectal bleeding and diarrhea. Rectal bleeding and diarrhea are symptoms of rectal cancer in adults and are not typical of children with cancer. The child reporting that a bone broke without any trauma, the nurse observing asymmetric swelling in the abdomen, or palpation revealing a mass in the abdomen are findings in children with cancer.

A school nurse is teaching a group of parents about signs and symptoms of cancer in children. Which symptom is an early sign of a brain tumor?

headache, vision changes, and vomiting Children with any form of brain tumor develop symptoms of increased intracranial pressure: headache, vision changes, vomiting, an enlarging head circumference, or papilledema. Lethargy, projectile vomiting, and coma are late signs. Epistaxis is not usually related to a brain tumor. A growing tumor produces specific localized signs, such as nystagmus (constant horizontal movement of the eye) or visual field defects. As tumor growth continues, symptoms of ataxia, personality change (e.g., emotional lability, irritability), and seizures may occur. These would be later symptoms.

A child is scheduled for chemotherapy as treatment for leukemia. As the nurse is collaborating with another colleague, the discussion turns to the client's first phase of chemotherapy. This phase is known as:

induction A chemotherapy program is aimed at first achieving a complete remission or absence of leukemia cells (induction phase); second, preventing leukemia cells from invading or growing in the CNS (sanctuary or consolidation phase); third, administering delayed intensive therapy; and fourth, maintaining the original remission (maintenance phase).

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. 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.