Chapter 43: Hematological or Immunological Pediatric

Which of the following confirms a diagnosis of Hodgkin disease in a 15-year-old? 1. Reed-Sternberg cells in the lymph nodes. 2. Blast cells in the blood. 3. Lymphocytes in the bone marrow. 4. VMA in the urine.

1 1. A lymph node biopsy is done to con- firm a histological diagnosis and staging of Hodgkin disease. The presence of Reed-Sternberg cells is characteristic of the disease. 2. Blast cells are usually seen with leukemia. 3. A bone marrow aspiration is usually done to diagnose the type of leukemia. 4. This test is done to diagnose neuroblastoma.

Which of the following analgesics is most effective for a child with sickle cell pain crisis? 1. Demerol. 2. Aspirin. 3. Morphine. 4. Excedrin.

3 1. Demerol should not be used as it may potentiate seizures. 2. Aspirin should not be used in children because of the risk for Reye syndrome. 3. Morphine is the drug of choice for a child with sickle cell crises. Usually the child is started on oral doses of Tylenol with codeine. When that is not sufficient to alleviate pain, stronger narcotics are prescribed such as morphine. 4. Excedrin contains aspirin.

A nurse is caring for a child with von Willebrand disease. The nurse is aware that which of the following is a (are) clinical manifestation(s) of von Willebrand disease? Select all that apply. 1. Bleeding of the mucous membranes. 2. The child bruises easily. 3. Excessive menstruation. 4. The child has frequent nosebleeds. 5. Elevated creatinine levels. 6. The child has a factor IX deficiency.

1, 2, 3, 4. 1. Von Willebrand disease is a hereditary bleeding disorder characterized by defi- ciency of or defect in a protein. The dis- order causes adherence of platelets to damaged endothelium and a mild defi- ciency of factor VIII. One of the mani- festations of this disease is bleeding of the mucous membranes. 2. Bruising is a common manifestation of this disease. 3. Excessive menstruation may be a mani- festation of this disease. 4. Frequent nosebleeds are a common manifestation of this disease. 5. There is no increase in creatinine in this disease. 6. Von Willebrand disease is a mild factor VIII deficiency, not a factor IX deficiency.

Which of the following measures should the nurse implement to help with the nausea and vomiting from chemotherapy? Select all that apply. 1. Give an antiemetic 30 minutes prior to the start of therapy. 2. Continue the antiemetic as ordered until 24 hours after the chemotherapy is complete. 3. Remove food that has a lot of odor. 4. Keep the child on a nothing-by-mouth status. 5. Wait until the nausea begins to start the antiemetic.

1, 2, 3. 1. The first dose should be given 30 minutes prior to the start of the therapy. 2. Antiemetic should be administered around the clock until 24 hours after the chemotherapy is completed. 3. It is also helpful to remove foods with odor so the smell of the food does not make the child nauseated. 4. The child should be allowed to take food and fluids as tolerated. 5. Antiemetics are most beneficial if given before the onset of nausea and vomiting.

Which of the following can be manifestations of leukemia in a child? Select all that apply. 1. Leg pain. 2. Fever. 3. Excessive weight gain. 4. Bruising. 5. Enlarged lymph nodes.

1, 2, 4, 5. 1. The proliferation of cells in the bone marrow can cause leg pain. 2. Fever is a result of the neutropenia. 3. There is usually a decrease in weight, because the child will feel sick and not as hungry. 4. A decrease in platelets causes the bruising. 5. The lymph nodes are enlarged from the infiltration of leukemic cells.

Which of the following can lead to a possible diagnosis of human immunodeficiency virus (HIV) in a child? Select all that apply. 1. Repeated respiratory infections. 2. Intermittent diarrhea. 3. Excessive weight gain. 4. Irregular heartbeat. 5. Poor weight gain.

1, 2, 5. 1. Symptoms of human immunodefi- ciency virus include frequent respira- tory infections. The symptoms present based on the underlying cellular immunodeficiency-related disease. 2. Symptoms of human immunodefi- ciency virus include intermittent diarrhea. The symptoms present based on the underlying cellular immunodeficiency-related disease. 3. Symptoms of human immunodeficiency virus include poor weight gain. The symptoms present based on the underlying cellular immunodeficiency-related disease. 4. Irregular heart rate is not associated with human immunodeficiency virus. 5. Symptoms of human immunodefi- ciency virus include poor weight gain.

The nurse is caring for a child with leukemia. The nurse should be aware that children being treated for leukemia may experience which of the following complications? Select all that apply. 1. Anemia. 2. Infection. 3. Bleeding tendencies. 4. Bone deformities. 5. Polycythemia.

1, 2. 1. Anemia is caused by decreased pro- duction of red blood cells. 2. Infection risk in leukemia is secondary to the neutropenia. 3. Bleeding tendencies are from decreased platelet production. 4. There are no bone deformities with leukemia, but there is bone pain from the proliferation of cells in the bone marrow. 5. Polycythemia is an increase in red blood cells.

Which of the following factors need(s) to be included in a teaching plan for a child with sickle cell anemia? Select all that apply. 1. The child needs to be taken to a physician when sick. 2. The parent should make sure the child sleeps in an air-conditioned room. 3. Emotional stress should be avoided. 4. It is important to keep the child well hydrated. 5. It is important to make sure the child gets adequate nutrition.

1, 3, 4, 5. 1. Seek medical attention for illness to prevent the child from going into a crisis. 2. A cold environment causes vasoconstriction, which needs to be prevented to get good tissue perfusion. 3. Stress can cause a depressed immune system, making the child more suscepti- ble to infection and crisis. Parents and children are advised to avoid stress. 4. The child needs good hydration and nutrition to maintain good health. 5. The child needs good hydration and nutrition to maintain good health.

The nurse is caring for a child who is receiving a transfusion of packed red blood cells. The nurse is aware that if the child had a hemolytic reaction to the blood, the signs and symptoms would include which of the following? Select all that apply. 1. Fever. 2. Rash. 3. Oliguria. 4. Hypotension. 5. Chills.

1, 3, 4. 1. Hemolytic reactions include fever, pain at insertion site, hypotension, renal failure, tachycardia, oliguria, and shock. 2. Febrile reactions are fever and chills. Allergic reactions include hives, itching, and respiratory distress. 3. Hemolytic reactions include fever, pain at insertion site, hypotension, renal failure, tachycardia, oliguria, and shock. 4. Hemolytic reactions include fever, pain at insertion site, hypotension, renal failure, tachycardia, oliguria, and shock. 5. Febrile reactions are fever and rash. Allergic reactions include rash, hives, and respiratory distress.

The nurse is caring for a child who is receiving extensive radiation as part of the treatment for Hodgkin disease. Which intervention should be implemented? 1. Administer pain medication prior to the child's going to radiation therapy. 2. Assess the child for neuropathy since this is a common side effect. 3. Provide adequate rest, as the child may experience excessive malaise and lack of energy. 4. Encourage the child to eat a low-protein diet while on radiation therapy.

1. It should not be necessary to give pain medication, as radiation therapy should not be painful. 2. Neuropathy is not a normal side effect of radiation therapy. 3. The most common side effect is extensive malaise, which may be from damage to the thyroid gland, causing hypothyroidism. 4. No diet restriction is required for the radiation therapy. Continue with nutri- tional supplements as needed to maintain adequate nutrition.

When caring for a child with lymphoma, the nurse needs to be aware of which of the following? 1. The same staging system is used for lymphoma and Hodgkin disease. 2. The aggressive chemotherapy with central nervous system prophylaxis will give the child a good prognosis. 3. All children with lymphoma need a bone marrow transplant for a good prognosis. 4. Despite high-dose chemotherapy, the prognosis is very poor for most children with a diagnosis of lymphoma.

2 1. The clinical staging system used in Hodgkin disease is of little value in lymphoma. Other systems have been developed. 2. The use of aggressive combination chemotherapy has a major impact on the survival rates for children with a diagnosis of lymphoma. Because there is usually bone marrow involvement, there is a need for central nervous system prophylaxis. 3. Not all children receive a bone marrow transplant. 4. Usually there is a good prognosis for lymphoma with aggressive chemotherapy.

A nurse is caring for a 5-year-old with sickle cell vaso-occlusive crisis. Which of the following orders should the nurse question? Select all that apply. 1. Position the child for comfort. 2. Apply hot packs to painful areas. 3. Give Demerol 25 mg intravenously every 4 hours as needed for pain. 4. Restrict oral fluids. 5. Apply oxygen per nasal cannula to keep oxygen saturations above 94%.

3, 4. 1. Medical treatment of sickle cell crises is directed toward preventing hypoxia. Tissue hypoxia is very painful, so placing the child in a position of comfort is important. 2. Hot packs help relieve pain because they cause vasodilation, which allows increased blood flow and decreased hypoxia. 3. Tissue hypoxia is very painful. Narcotics such as morphine are usually given for pain when the child is in a crisis. Demerol should be avoided because of the risk of Demerol-induced seizures. 4. The child should receive hydration because when the child is in crisis, the abnormal S-shaped red blood cells clump, causing tissue hypoxia and pain. 5. Providing oxygen when the oxygen satura- tion decreases helps treat the hypoxia.

The nurse is taking care of a child with sickle cell disease. The nurse is aware that which of the following problems is (are) associated with sickle cell disease? Select all that apply. 1. Polycythemia. 2. Hemarthrosis. 3. Aplastic crisis. 4. Thrombocytopenia. 5. Splenic sequestration. 6. Vaso-occlusive crisis.

3, 5, 6. 1. Polycythemia is seen in children with chronic hypoxia, such as cyanotic heart disease. 2. Hemarthrosis is commonly seen in children with hemophilia. 3. Aplastic crisis is associated with sickle cell anemia. 4. Thrombocytopenia is associated with idiopathic thrombocytopenia purpura. 5. Splenic sequestration is associated with sickle cell anemia. 6. Vaso-occlusive crisis is the most com- mon problem in children with sickle cell disease.

The parent of a 4-year-old brings the child to the clinic and tells the nurse the child's abdomen is distended. After a complete examination, a diagnosis of Wilms tumor is sus- pected. Which of the following is most important when doing a physical examination on this child? 1. Avoid palpation of the abdomen. 2. Assess the urine for the presence of blood. 3. Monitor vital signs, especially the blood pressure. 4. Obtain an accurate height and weight.

1 1. Palpating the abdomen of the child in whom a diagnosis of Wilms tumor is suspected should be avoided, because manipulation of the abdomen may cause seeding of the tumor. 2. Hematuria is a clinical manifestation. 3. Because the kidney is involved, hypertension should be assessed. 4. Height and weight are always important to obtain, as they can be used to calculate doses of medications and chemotherapy.

The nurse is caring for a child being treated for ALL. Laboratory results indicate that the child has a white blood cell count of 5000/mm3 with 5% polys and 3% bands. Which of the following analyses is most appropriate? 1. The absolute neutrophil count is 400/mm3, and the child is neutropenic. 2. The absolute neutrophil count is 800/mm3, and the child is neutropenic. 3. The absolute neutrophil count is 4000/mm3, and the child is not neutropenic 4. The absolute neutrophil count is 5800/mm3, and the child is not neutropenic.

1 1. The calculated absolute neutrophil count is 400/mm3 (0.08 × 5000) and is neutropenic as it is less than 500/mm3. 2. The absolute neutrophil count is incor- rectly calculated. The child would not be neutropenic with a count of 800/mm3. 3. The absolute neutrophil count is incor- rectly calculated. The child would not be neutropenic with a count of 4000/mm3. 4. The absolute neutrophil count is incor- rectly calculated. The child would not be neutropenic if the count were 5800/mm3.

School-age children with cancer often have a body image disturbance related to hair loss, moon face, or debilitation. Which of the following interventions is most appropriate? 1. Encourage them to wear a wig similar to their own hairstyle. 2. Emphasize the benefits of the therapy they are receiving. 3. Have them play only with other children with cancer. 4. Use diversional techniques to avoid discussing changes in the body because of the chemotherapy.

1 1. Wearing a wig is a good way for the child to keep personal identity despite the loss of hair. 2. Just discussing the benefits of the therapy will not help the child with self-image. 3. Having the child play only with other children with cancer could make the child feel even worse because of the inability to interact with friends. The child needs to find acceptance as appearance begins to change. 4. Diverting the child's attention would be avoiding the truth and would not be dealing with the issues.

Which of the following activities should a nurse suggest for a client diagnosed with hemophilia? Select all that apply. 1. Swimming. 2. Golf. 3. Hiking. 4. Fishing. 5. Soccer.

1, 2, 3, 4. 1. Children with hemophilia should be encouraged to take part in noncontact activities that allow for social, psycho- logical, and physical growth, such as swimming. 2. Children with hemophilia should be encouraged to take part in noncontact activities that allow for social, psycho- logical, and physical growth, such as golf. 3. Children with hemophilia should be encouraged to take part in noncontact activities that allow for social, psycho- logical, and physical growth, such as hiking. 4. Children with hemophilia should be encouraged to take part in noncontact activities that allow for social, psycholog- ical, and physical growth, such as fishing. 5. Contact sports like soccer should be discouraged.

A nurse is caring for a 15-year-old who has just been diagnosed with non-Hodgkin lymphoma. Which of the following should the nurse include in teaching the parents about this lymphoma? Select all that apply. 1. The malignancy originates in the lymphoid system. 2. The presence of Reed-Sternberg cells in the biopsy is considered diagnostic. 3. Mediastinal involvement is typical. 4. The disease is diffuse rather than nodular. 5. Treatment includes chemotherapy and radiation.

1, 3, 4, 5. 1. Non-Hodgkin disease originates in the lymphoid system. 2. Reed-Sternberg cells are diagnostic for Hodgkin disease. 3. Mediastinal involvement is typical. 4. The disease is diffuse rather than nodular. 5. Treatment includes chemotherapy and radiation.

A child has completed treatment for leukemia and comes to the clinic with the parents for a checkup. The parents express to the nurse that they are glad their child has been cured of cancer and is safe from getting cancer later in life. Which of the following should the nurse consider in responding? 1. Childhood cancer usually instills immunity to all other cancers. 2. Children surviving one cancer are at higher risk for a second cancer. 3. The child may have a remission of the leukemia but is immune to all other cancers. 4. As long as the child continues to take steroids, there will be no other cancers.

2 1. There is no immunity to recurrent cancers with remission of the leukemia. 2. The most devastating late effect of leukemia treatment is development of secondary malignancy. 3. After the child is in remission, the child may relapse, but there is no immunity to other malignancy. 4. The child will not receive steroid treatment after completing therapy.

Which of the following describe(s) idiopathic thrombocytopenia purpura (ITP)? Select all that apply. 1. ITP is a congenital hematological disorder. 2. ITP causes excessive destruction of platelets. 3. Children with ITP have normal bone marrow. 4. Platelets are small in ITP. 5. Purpura is observed in ITP.

2, 3, 5. 1. ITP is an acquired hematological condition that is characterized by excessive destruc- tion of platelets, purpura, and normal bone marrow along with an increase in large, yellow platelets. 2. ITP is characterized by excessive destruction of platelets. 3. The bone marrow is normal in children with ITP. 4. Platelets are large, not small. 5. ITP is characterized by purpuras, which are areas of hemorrhage under the skin.

Which of the following is a (are) reason(s) to do a lumbar puncture on a child with a diagnosis of leukemia? Select all that apply. 1. Rule out meningitis. 2. Assess the central nervous system for infiltration. 3. Give intrathecal chemotherapy. 4. Determine increased intracranial pressure. 5. Stage the leukemia.

2, 3. 1. There is no need to do a spinal tap to rule out meningitis unless the patient has symptoms of meningitis. 2. A lumbar puncture is done to assess the central nervous system by obtain- ing a specimen that can determine the presence of leukemic cells. 3. Chemotherapy can also be given with a spinal tap. 4. There should not be an indication to determine increased intracranial pressure. 5. Leukemia is not staged.

The nurse receives a call from a parent of a child with leukemia in remission. The parent says the child has been exposed to chickenpox. The child has never had chickenpox. Which of the following responses is most appropriate for the nurse? 1. "You need to monitor the child's temperature frequently and call back if the temperature is greater than 101°F (38.3°C)." 2. "At this time there is no need to be concerned." 3. "You need to bring the child to the clinic for a chickenpox immunoglobulin vaccine." 4. "Your child will need to be isolated for the next 2 weeks."

3 1. The temperature should always be moni- tored, but the child has been exposed to chickenpox. The child needs to be protected from getting the disease as it can be life threatening. 2. Chickenpox exposure is a real concern for a child who is immunocompromised, and action needs to be taken. 3. The child should receive varicella zoster immune globulin within 96 hours of the exposure. 4. Starting isolation at this time does not protect the child.

Where is the primary site of origin of the tumor in children who have neuroblastoma? 1. Bone. 2. Kidney. 3. Abdomen. 4. Liver.

3 1. Tumor involvement in the bone is usually osteosarcoma. 2. Tumors that are located in the kidney are most often a Wilms tumor. 3. Neuroblastoma tumors originate from embryonic neural crest cells that nor- mally give rise to the adrenal medulla and the sympathetic nervous system. The majority of the tumors arise from the adrenal gland or from the retroperitoneal sympathetic chain. Therefore, the primary site is within the abdomen. 4. In most tumors in children, there is liver involvement when there is metastasis to the liver.

Which intervention should be implemented after a bone marrow aspiration? 1. Ask the child to remain in a supine position. 2. Place the child in an upright position for 4 hours. 3. Keep the child nothing by mouth for 6 hours. 4. Administer analgesics as needed for pain.

4 1. There is no need to have the client remain supine after a bone marrow aspiration is done. 2. The child can assume any position after a bone marrow aspiration. 3. The child usually receives conscious sedation during the procedure and will have nothing by mouth prior to the procedure. Oral fluids can be resumed after the procedure is completed. 4. Children may experience minor discomfort after the procedure, and analgesics should be given as needed.

Which of the following measures should the nurse teach the parent of a child with hemophilia to do first if the child sustains an injury to a joint causing bleeding? 1. Give the child a dose of Tylenol. 2. Immobilize the joint, and elevate the extremity. 3. Apply heat to the area. 4. Administer factor per the home-care protocol.

4 1. Tylenol helps with the pain but does not stop the bleeding. 2. Elevating and immobilizing the extremity are good interventions as they decrease blood flow. Factor should be administered first, however. 3. Cold, not heat, should be applied to promote vasoconstriction. 4. Administration of factor should be the first intervention if home-care transfusions have been initiated.

Which of the following best describes the action of chemotherapeutic agents used in the treatment of cancer in children? 1. Suppress the function of normal lymphocytes in the immune system. 2. Are alkylating agents and are cell-specific. 3. Cause a replication of DNA and are cell-specific. 4. Interrupt cell cycle, thereby causing cell death.

1 1. All chemotherapy is immunosuppres- sive as most childhood cancers affect the immune system. 2. Not all chemotherapy drugs are alkylating agents. 3. There is no replication of DNA with chemotherapy. Chemotherapy drugs such as the antimetabolites usually inhibit syn- thesis of DNA or RNA. 4. There is no interruption of the cell cycle.

A child diagnosed with leukemia is receiving allopurinol as part of the treatment plan. The parents ask why their child is receiving this medication. What information about the medication should the nurse provide? 1. Helps reduce the uric acid level caused by cell destruction. 2. Used to make the chemotherapy work better. 3. Given to reduce the nausea and vomiting associated with chemotherapy. 4. Helps decrease pain in the bone marrow.

1 1. Allopurinol reduces serum uric acid. When there is lysis of cells from chemotherapy, there will be an in- crease in serum uric acid. 2. There is no specific medication that makes chemotherapy work better. 3. Allopurinol is not an antiemetic. 4. Allopurinol is not an analgesic.

Which of the following measures should be implemented for a child with von Willebrand disease who has a nosebleed? 1. Apply pressure to the nose for at least 10 minutes. 2. Have the child lie supine and quiet. 3. Avoid packing of the nostrils. 4. Encourage the child to swallow frequently.

1 1. Applying pressure to the nose may stop the bleeding. In von Willebrand disease, there is an increased tendency to bleed from mucous membranes, to nosebleeds commonly from the anterior part of the nasal septum. 2. The child should sit up and lean forward to avoid aspiration of blood. 3. Packing the nose with cotton may be used to stop bleeding, but be careful when the cotton is removed as it may dislodge the clot. 4. Swallowing will cause the child to swallow the blood, which then can cause vomiting.

The nurse is caring for a child with a diagnosis of ALL who is receiving chemother- apy. The nurse notes that the child's platelet count is 20,000/mm3. Based on this laboratory finding, what information should the nurse provide to the child and parents? 1. A soft toothbrush should be used for mouth care. 2. Isolation precautions should be started immediately. 3. The child's vital signs, including blood pressure, should be monitored every 4 hours. 4. All visitors should be discouraged from coming to see the family.

1 1. Because the platelet count is de- creased, there is a significant risk of bleeding, especially in soft tissue. The use of the soft toothbrush should help prevent bleeding of the gums. 2. A low platelet count does not indicate a need to start isolation. 3. There is always a need to monitor the child frequently, but the low platelet count puts the child at risk for bleeding. 4. In caring for children, always screen visitors, but there is no need to restrict visitation unless something is found on the screening.

A nurse educator is providing a teaching session for the nursing staff. Which of the following individuals is at greatest risk for developing beta-thalassemia (Cooley anemia)? 1. A child of Mediterranean descent. 2. A child of Mexican descent. 3. A child whose mother has chronic anemia. 4. A child who has a low intake of iron.

1 1. Beta-thalassemia is an inherited reces- sive disorder that is found primarily in individuals of Mediterranean descent. The disease has also been reported in Asian and African populations. 2. It is not found often in the Mexican population. 3. This is a hereditary disease that causes chronic anemia. The mother should have had thalassemia for this answer to be correct. 4. This disorder has nothing to do with iron deficiency.

Which of the following is correct regarding prognostic factors for determining survival for a child newly diagnosed with ALL? 1. The initial white blood cell count on diagnosis. 2. The race of the child. 3. The amount of time needed to initiate treatment. 4. The allergy history of the child.

1 1. Children with a normal or low white blood cell count who do not have non-T, non-B acute lymphoblastic leukemia, and who are CALLA-positive have a much better prognosis than those with high cell counts or other cell types. 2. Race is not a factor in prognosis of leukemia. 3. The child should begin treatment as soon as diagnosed, but time in initiating treat- ment does not have an effect on prognosis. 4. A history of allergies has no connection to prognosis in acute lymphoblastic leukemia.

The nurse is caring for a child with sickle cell anemia who is scheduled to have an exchange transfusion. What information should the nurse teach the family? 1. The procedure is done to prevent further sickling during a vaso-occlusive crisis. 2. The procedure reduces side effects from blood transfusions. 3. The procedure is a routine treatment for sickle cell crisis. 4. Once the child's spleen is removed, it is necessary to do exchange transfusions.

1 1. Exchange transfusion reduces the number of circulating sickle cells and slows down the cycle of hypoxia, thrombosis, and tissue ischemia. 2. Exchange transfusion does not decrease risk of a transfusion reaction. Every time a transfusion is done, the child continues to be at risk for a reaction. 3. This is not a routine procedure and is performed only when the number of sickle cells is elevated and the child is at high risk for thrombosis. 4. After a splenectomy, transfusions still need to be done depending on the client's hemoglobin level.

The parent of a teen with a diagnosis of Hodgkin disease asks what the child's prognosis will be with treatment. What information should the nurse give to the parent and child? 1. Clinical staging of Hodgkin disease will determine the treatment; long-term survival for all stages of Hodgkin disease is excellent. 2. There is a considerably better prognosis if the client is diagnosed early and is between the ages of 5 and 11 years. 3. The prognosis for Hodgkin disease depends on the type of chemotherapy. 4. The only way to obtain a good prognosis is by chemotherapy and bone marrow transplant.

1 1. Long-term survival for all stages of Hodgkin disease is excellent. Early- stage disease can have a survival rate greater than 90%, with advanced stages having rates between 65% and 75%. 2. Hodgkin disease mostly affects adolescents. 3. The treatment consists of chemotherapy and often radiation therapy and does not predict prognosis. 4. Bone marrow transplant is not always necessary with the treatment of Hodgkin disease and will most likely worsen the prognosis.

A child with hemophilia A fell and injured a knee while playing outside. The knee is swollen and painful. Which of the following measures should be taken to stop the bleeding? Select all that apply. 1. The extremity should be immobilized. 2. The extremity should be elevated. 3. Warm moist compresses should be applied to decrease pain. 4. Passive range-of-motion exercises should be administered to the extremity. 5. Factor VIII should be administered.

1, 2, 5. 1. Measures are needed to induce vasocon- striction and stop the bleeding, includ- ing immobilization of the extremity. 2. Measures are needed to induce vasocon- striction and stop the bleeding. Treatment should include elevating the extremity. 3. Measures are needed to induce vasocon- striction and stop the bleeding. Treatment should include an application of cold compression. 4. Measures are needed to induce vasocon- striction and stop the bleeding. Treatment should include factor replacement. 5. Hemophilia A is a deficiency in factor VIII, which causes delay in clotting when there is a bleed.

Which test provides a definitive diagnosis of aplastic anemia? 1. Complete blood count with differential. 2. Bone marrow aspiration. 3. Serum IgG levels. 4. Basic metabolic panel.

2 1. A complete blood count with differential indicates pancytopenia but does not reveal what is occurring in the bone marrow. 2. Definitive diagnosis is determined from bone marrow aspiration, which demonstrates the conversion of red bone marrow to yellow, fatty marrow. 3. Serum IgG levels do not diagnose aplastic anemia, which does not seem to have an immune cause. 4. A basic metabolic panel tests for meta- bolic disorders.

A nurse instructs the parent of a child with sickle cell anemia about factors that might precipitate a pain crisis in the child. Which of the following factors identified by the parent as being able to cause a pain crisis indicates a need for further instruction? 1. Infection. 2. Overhydration. 3. Stress at school. 4. Cold environment.

2 1. An infection can cause a child to go into crisis. 2. Overhydration does not cause a crisis. 3. Emotional stress can cause a child to go into crisis. 4. A cold environment causes vasoconstriction, which could lead to crisis.

Which of the following is the best method to prevent the spread of infection to an immunosuppressed child? 1. Administer antibiotics prophylactically to the child. 2. Have people wash their hands prior to contact with the child. 3. Assign the same nurses to care for the child each day. 4. Limit visitors to family members only.

2 1. Antibiotics should be used only if the child has a bacterial infection. 2. Hand-washing is the best method to prevent the spread of germs and protect the child from infection. 3. All nurses should use the same techniques in caring for the child. Assigning the same nurses may not be possible. 4. Visitors should be screened for infection and communicable diseases, but visitors should not be limited to family members only.

A 10-year-old with severe factor VIII deficiency falls, injures an elbow, and is brought to the ER. The nurse should prepare which of the following? 1. An IM injection of factor VIII. 2. An IV infusion of factor VIII. 3. An injection of desmopressin. 4. An IV infusion of platelets.

2 1. Factor VIII is not given intramuscularly. 2. The child is treated with an IV infu- sion of factor VIII to replace the miss- ing factor and help stop the bleeding. 3. Desmopressin is given to stimulate factor VIII production, and it is given intravenously. 4. Platelets are not affected in hemophilia.

The nurse is caring for a 10-year-old with leukemia who is receiving chemotherapy. The child is on neutropenic precautions. Friends of the child come to the desk and ask for a vase for flowers. Which of the following is the best response? 1. "I will get you a special vase that we use on this unit." 2. "The flowers from your garden are beautiful but should not be placed in the room at this time." 3. "As soon as I can wash a vase, I will put the flowers in it and bring it to the room." 4. "Get rid of the flowers immediately. You could harm the child."

2 1. Flowers should not be kept in the room of the client who is neutropenic. There are no special vases that are used with these clients that can protect them from infection. 2. A neutropenic client should not have flowers in the room because the flowers may harbor Aspergillus or Pseudomonas aeruginosa. Neutropenic children are susceptible to infection. Precautions need to be taken so the child does not come in contact with any potential sources of infection. Fresh fruits and vegetables can also harbor molds and should be avoided. Telling the friend that the flowers are beautiful but that the child cannot have them is a tactful way not to offend the friend. 3. Washing the vase will not change the reason for not having the flowers around the child. 4. This could scare the visitors and make them feel guilty that they might harm the child in some way.

The parent of a child with hemophilia is asking the nurse what caused the hemophilia. Which is the nurse's best response? 1. It is an X-linked dominant disorder. 2. It is an X-linked recessive disorder. 3. It is an autosomal dominant disorder. 4. It is an autosomal recessive disorder.

2 1. Hemophilia is transmitted as an X-linked recessive disorder. About 60% of children have a family history of hemophilia. The usual transmission is by a female with the trait and an unaffected male. 2. Hemophilia is transmitted as an X-linked recessive disorder. About 60% of children have a family history of hemophilia. The usual transmission is by a female with the trait and an unaffected male. 3. Hemophilia is transmitted as an X-linked recessive disorder. About 60% of children have a family history of hemophilia. The usual transmission is by a female with the trait and an unaffected male. 4. Hemophilia is transmitted as an X-linked recessive disorder. About 60% of children have a family history of hemophilia. The usual transmission is by a female with the trait and an unaffected male.

Which of the following should the nurse expect to administer to a child with ITP and a platelet count of 5000/mm3? 1. Platelets. 2. Intravenous immunoglobulin. 3. Packed red blood cells. 4. White blood cells.

2 1. In ITP, destruction of platelets is caused from what is believed to be an immune response, so giving additional platelets would only result in new platelets being destroyed. 2. Intravenous immunoglobulin is given because the cause of platelet destruc- tion is believed to be an autoimmune response to disease-related antigens. Treatment is usually supportive. Activity is restricted at the onset because of the low platelet count and risk for injury that could cause bleeding. 3. Red blood cells are not an effective treatment for ITP. 4. White blood cells are not an effective treatment for ITP. White blood cell infusion is rarely done with any disease process.

The nurse is caring for a child with sickle cell disease who is scheduled to have a splenectomy. What information should the nurse explain to the parents regarding the reason for a splenectomy? 1. To decrease potential for infection. 2. To prevent splenic sequestration. 3. To prevent sickling of red blood cells. 4. To prevent sickle cell crisis.

2 1. The cells involved with sickle cell anemia are red blood cells, so a decrease in infection would not be correct. 2. Splenic sequestration is a life- threatening situation in children with sickle cell anemia. Once a child is considered to be at high risk of splenic sequestration or has had this in the past, the spleen will be removed. 3. Removal of the spleen will not prevent sickling, as it will not change the disease condition. 4. The child will still have sickle cell disease and can still have sickle cell crises.

The parent of a 2-year-old who is HIV+ questions the nurse about placing the child in day care. Which of the following is the best response? 1. The child should not go to day care until older, because there is a high risk for transmission of the disease. 2. The child can be admitted to day care without restrictions and should be allowed to participate in all activities. 3. The child can go to day care but should avoid physical activity. 4. The child may go to day care, but the parent must inform all the parents at the day care that the child is HIV+.

2 1. The child can attend day care. The risk of transmission remains the same at any age. 2. The child can attend day care without any limitations but should not attend with a fever. 3. There is no need to restrict the child's activity. 4. There is no law that requires notification of the child's condition.

What are the clinical manifestations of non-Hodgkin lymphoma? 1. Basically the same as those in Hodgkin disease. 2. Depends on the anatomical site and extent of involvement. 3. Those that affect the abdomen, as non-Hodgkin lymphoma is a fast-growing cancer in very young children. 4. Changes that occur in the lower extremities.

2 1. The clinical manifestations are different from those of Hodgkin disease, as the en- larged lymph nodes usually occur in the cervical area. 2. The clinical manifestations include symptoms of involvement. Rarely is a single sign or symptom diagnostic. Metastasis to the bone marrow or central nervous system may produce manifestations of leukemia. 3. The manifestations are not just limited to the abdomen, and NHL is not usually seen in young children. 4. There is not just lower extremity involve- ment with NHL.

The nurse is caring for a child diagnosed with thalassemia major who is receiving the first chelation therapy. What information should the nurse teach the parent regarding the therapy? 1. Decreases the risk of bleeding. 2. Eliminates excess iron. 3. Prevents further sickling of the red blood cells. 4. Provides an iron supplement.

2 1. There are no bleeding tendencies in thalassemia major (beta-thalassemia or Cooley anemia), and chelation does not affect clotting. 2. Chelation therapy is used to rid the body of excess iron stores that result from frequent blood transfusions. 3. There is no sickling of red blood cells in thalassemia, and chelation therapy has no direct effect on red blood cells. 4. Chelation does not provide an iron supplement.

A 5-year-old is admitted to the hospital with complaints of leg pain and fever. On physical examination, the child is pale and has bruising over various areas of the body. The physician suspects that the child has ALL. The nurse informs the parent that the diagnosis will be confirmed by which of the following? 1. Lumbar puncture. 2. White blood cell count. 3. Bone marrow aspirate. 4. Bone scan.

3 1. A lumbar puncture is done to look for blast cells in the spinal fluid, which indi- cate central nervous system disease. It is also done to administer intrathecal chemotherapy, as the chemotherapy that will be given does not pass through the blood-brain barrier. 2. An altered white blood cell count occurs as a result of the disease, but it does not make the diagnosis, as many diseases can alter the white blood cell count. 3. The diagnostic test that confirms leukemia is microscopic examination of the bone marrow aspirate. 4. Bone scans do not confirm the diagnosis of a disease that occurs in the bone marrow.

The parent of a child diagnosed with Wilms tumor asks the nurse what the treatment plan will be. The nurse explains the usual protocol for this condition. Which information should the nurse give to the parent? 1. The child will have chemotherapy and, after that has been completed, radiation. 2. The child will need to have surgery to remove the tumor. 3. The child will go to surgery for removal of the tumor and the kidney and will then start chemotherapy. 4. The child will need radiation and later surgery to remove the tumor.

3 1. Chemotherapy is started after tumor removal, and radiation is done depending on stage and histological pattern. 2. Combination therapy of surgery and chemotherapy is the therapeutic manage- ment. 3. Combination therapy of surgery and chemotherapy is the primary thera- peutic management. Radiation is done depending on clinical stage and histological pattern. 4. Radiation should be done after surgery and chemotherapy, depending on stage and histological pattern.

A teen is seen in clinic for a possible diagnosis of Hodgkin disease. The nurse is aware that which of the following symptoms should make the physicians suspect Hodgkin disease? 1. Fever, fatigue, and pain in the joints. 2. Anorexia with weight loss. 3. Enlarged, painless, and movable lymph nodes in the cervical area. 4. Enlarged liver with jaundice.

3 1. Fever and pain may be some of the symp- toms, but they can be from other forms of cancer. Joint pain is not a symptom of Hodgkin disease. 2. Anorexia with weight loss can be a symptom of many other conditions. 3. Enlarged, painless, and movable lymph nodes in the cervical area are the most common presenting manifestations of Hodgkin disease. 4. Enlarged liver with jaundice is not a pre- senting symptom with Hodgkin disease.

Which of the following should be done to protect the central nervous system from the invasion of malignant cells in a child newly diagnosed with leukemia? 1. Cranial and spinal radiation. 2. Intravenous steroid therapy. 3. Intrathecal chemotherapy. 4. High-dose intravenous chemotherapy.

3 1. Radiation should be done as part of ther- apy if there is metastasis. 2. Steroids are given as part of the treatment protocol but do not need to be given in- travenously. Steroids do not pass through the blood-brain barrier. 3. Giving chemotherapy via lumbar punc- ture allows the drugs to get to the brain and helps prevent metastasis of the disease. 4. Chemotherapy that is given intravenously will not pass through the blood-brain barrier.

An 18-month-old male is brought to the clinic by his mother. His height is in the 50th percentile, and weight is in the 80th percentile. The child is pale. The physical examination is normal, but his hematocrit level is 20%. Which of the following questions should assist the nurse in making a diagnosis? Select all that apply. 1. "How many bowel movements a day does your child have?" 2. "How much did your baby weigh at birth?" 3. "What does your child eat every day?" 4. "Has the child been given any new medications?" 5. "How much milk does your child drink per day?"

3, 5. 1. Because the child has a low hematocrit level, the child most likely has anemia. Iron-deficiency anemia is the most common nutritional anemia. The number of bowel movements the child has is important information but not necessary to make the diagnosis of iron-deficiency anemia. 2. Knowing birth weight can help determine if the child is following his or her own curve on the growth chart. 3. A diet history is necessary to determine the nutritional status of the child and whether the child is getting sufficient sources of iron. 4. Knowing if the child is taking any new med- ication is good but is not necessary to make the diagnosis of iron-deficiency anemia. 5. By asking how much milk the child con- sumes, the nurse can determine whether the child is filling up on milk and then not wanting to take food.

Which of the following is the most common opportunistic infection in children infected with human immunodeficiency virus (HIV)? 1. CMV. 2. Encephalitis. 3. Meningitis. 4. Pneumocystic pneumonia.

4 1. CMV infection is one common character- istic of human immunodeficiency virus infections, but it is not the most common. 2. Encephalitis is not a specific opportunistic infection noted in human immunodefi- ciency virus-infected children. 3. Meningitis is not a specific opportunistic infection noted in human immunodefi- ciency virus-infected children. 4. Pneumocystis carinii pneumonia is the most common opportunistic infection that can occur in human immunodefi- ciency virus-infected children, and such children are treated prophylacti- cally for this.

The nurse is instructing the parent of a child with HIV about immunizations. Which of the following should the nurse tell the parent? 1. Hepatitis B vaccine will not be given to this child. 2. Members of the family should be cautioned not to receive the varicella vaccine. 3. The child will need to have a Western blot test done prior to all immunizations. 4. Pneumococcal and influenza vaccines are recommended.

4 1. Hepatitis B vaccine is administered according to the immunization schedule. 2. The varicella vaccine is avoided in the child who is human immunodeficiency virus infected. 3. A Western blot test is not done and is not necessary. 4. Immunizations against childhood illnesses are recommended for chil- dren exposed to or infected with human immunodeficiency virus. Pneumococcal and influenza vaccines are recommended.

The nurse is discharging a child who has just received chemotherapy for neuroblastoma. Which of the following statements made by the child's parent indicates a need for additional teaching? 1. "I will inspect the skin often for any lesions." 2. "I will do mouth care daily and monitor for any mouth sores." 3. "I will wash my hands before caring for my child." 4. "I will take a rectal temperature daily and report a temperature greater than 101°F (38.3°C) immediately to the physician."

4 1. Inspecting the skin is a good measure to monitor for infection and should be done. 2. Mouth care is essential and should be done daily to help prevent infection. Chemotherapy puts the child at risk for mucositis. 3. Washing the hands is one of the most important measures to prevent infection. 4. Monitoring the child's temperature and reporting it to the physician are important, but the temperature should not be taken rectally. The risk of injury to the mucous membranes is high. Rectal abscesses can occur in the damaged rectal tissue. The best method of taking the temperature is axillary, especially if the child has mouth sores.

A child with leukemia is receiving chemotherapy and is complaining of nausea. The nurse has been giving the scheduled antiemetic. Which of the following should the nurse do when the child is nauseated? 1. Encourage low-protein foods. 2. Encourage low-caloric foods. 3. Offer the child's favorite foods. 4. Offer cool, clear liquids.

4 1. It is better to provide high-protein nutritional supplements if the child can tolerate them. 2. It is better to provide high-caloric nutritional supplements. 3. Offering the child's favorite foods when the child is nauseated can create a later association with being sick; then the child may not want that food when not ill. 4. Cool, clear liquids are better tolerated. Milk-based products cause secretions to be thick and can cause vomiting.

Which of the following will be abnormal in a child with the diagnosis of hemophilia? 1. Platelet count. 2. Hemoglobin level. 3. White blood cell count. 4. Partial thromboplastin time.

4 1. Platelet function is normal in hemophilia. 2. There is no change in hemoglobin with a diagnosis of hemophilia. The hemoglobin will drop with bleeding. 3. The white blood cell count does not change with hemophilia. 4. The abnormal laboratory results in hemophilia are related to decreased clotting function. Partial thromboplastin time is prolonged.

Prednisone is given to children who are being treated for leukemia. Why is this medication given as part of the treatment plan? 1. Enhances protein metabolism. 2. Enhances sodium excretion. 3. Increases absorption of the chemotherapy. 4. Destroys abnormal lymphocytes.

4 1. Prednisone does not enhance protein metabolism. 2. Prednisone may cause retention of sodium. 3. There is no drug that increases absorption of chemotherapy. 4. Prednisone is used in many of the treatment protocols for leukemia because there is abnormal lymphocyte production. Prednisone is thought to destroy abnormal lymphocytes.

The nurse expects which of the following clinical manifestations in a child diagnosed with SCID? 1. Prolonged bleeding. 2. Failure to thrive. 3. Fatigue and malaise. 4. Susceptibility to infection.

4 1. Prolonged bleeding indicates abnormalities of the clotting system. 2. Failure to thrive is a consequence of a present illness. 3. Fatigue and malaise result from decreases in red blood cells. 4. SCID is characterized by an absence of cell-mediated immunity, with the most common clinical manifestation being in- fection in children from age 3 months. These children do not usually recover from these infections.

Which of the following laboratory tests will be ordered to determine the presence of the human immunodeficiency virus antigen in an infant whose parent is HIV+? 1. CD4 cell count. 2. Western blot. 3. IgG levels. 4. p24 antigen assay.

4 1. The CD4 cell count indicates how well the immune system is working. 2. A Western blot test confirms the presence of human immunodeficiency virus antibodies. 3. An IgG level samples the immune system. 4. Detection of human immunodeficiency virus in infants is confirmed by a p24 antigen assay, viral culture of human immunodeficiency virus, or poly- merase chain reaction.

A nurse is doing discharge education with a parent who has a child with beta-thalassemia (Cooley anemia). The nurse informs the parent that the child is at risk for which of the following conditions? 1. Hypertrophy of the thyroid. 2. Polycythemia vera. 3. Thrombocytopenia. 4. Chronic hypoxia and iron overload.

4 1. The thyroid is not involved in beta- thalassemia. 2. Polycythemia vera refers to excessive red blood cell production, which can result in thrombosis. 3. There is no increase in platelets in beta- thalassemia. 4. In beta-thalassemia there is increased destruction of red blood cells, causing anemia. This results in chronic anemia and hypoxia. The children are treated with multiple blood transfusions, which can cause iron overload and damage to major organs.

A child diagnosed with HIV is prescribed a combination of antiretroviral drugs to delay ______________________.

Drug resistance. A combination of antiretroviral medications is prescribed for a child who is HIV positive to delay develoment of drug resisitance. HIV drugs work on different stages of the HIV life cycle to prevent reproduction of new virus particles.