Chapter 44: Cancer

A nurse caring for a child receiving chemotherapy notes that the childs urine specific gravity is 1.010. Which action by the nurse is the most appropriate? a. Document the findings in the childs chart. b. Increase the rate of the IV fluids per protocol. c. Notify the provider about the laboratory results. d. Prepare to administer an alkalizing agent.

ANS: A Children on chemotherapy should remain well hydrated to ensure the medications and any toxic by-products are flushed out. The urine specific gravity should remain at 1.012 or below. The nurse needs to take no further action after documenting the findings. The IV rate should be increased if the specific gravity is above that level. The provider does not need to be notified specifically about this normal finding. An alkalizing agent is not needed.

An adolescent with osteosarcoma is scheduled for a leg amputation in 2 days. The nurses approach should include which action? a. Answering questions with straightforward honesty b. Avoiding discussing the seriousness of the condition c. Explaining that, although the amputation is difficult, it will cure the cancer d. Assisting the adolescent in accepting the amputation as better than a long course of chemotherapy

ANS: A Honesty is essential to gain the childs cooperation and trust. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared for the surgery so he or she has time to reflect on the diagnosis and subsequent treatment. This allows questions to be answered. To accept the need for radical surgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will not guarantee a cure. Chemotherapy is an integral part of the therapy with surgery. The child should be informed of the need for chemotherapy and its side effects before surgery.

A 4-year-old child is several days postoperative after a resection of a brain tumor. The nurse finds the child irritable and lethargic, and notes that she has vomited. Which medication does the nurse anticipate administering? a. Dexamethasone (Decadron) b. Fosphenytoin (Cerebyx) c. Odansetron (Zofran) d. Phenytoin (Dilantin)

ANS: A This child has manifestations of increased intracranial pressure, a possible outcome after brain surgery. The nurse prepares to administer a corticosteroid to decrease the edema. Fosphenytoin and phenytoin are for seizures. Odansetron is for nausea.

A child has the following laboratory values: WBC, 7.2 mm3; bands, 4%; and neutrophils, 60%. Based on these values, which action by the nurse is the most appropriate? a. Continue monitoring the child for infection. b. Place the child on protective isolation. c. Obtain two sets of blood cultures. d. Restrict visitors to the child.

ANS: A This childs absolute neutrophil count is 4,608; therefore, the child is not neutropenic. The nurse should continue to monitor. The other actions are not necessary.

Prior to administering IV chemotherapy, which action by the nurse is most important? a. Ensure the IV has a good blood return. b. Provide diversionary activities. c. Take and record a set of vital signs. d. Weigh the child.

ANS: A To prevent extravasation of IV chemotherapy it is important to make sure the line flushes easily and has a good blood return. This is a critical action to maintain patient safety. The other actions may also be utilized, but would not take priority over ensuring patient safety.

A student is learning about the process of hematopoiesis and how it is affected by leukemia. Which information does the student discover? (Select all that apply.) a. Blast cells multiply faster than mature cells. b. Leukemia disrupts normal hematopoiesis. c. Lymphoid cells differentiate into B and T cells. d. Myeloid cells crowd out normal cells in bone marrow. e. Pancytopenia occurs from proliferation of mast cells.

ANS: A, B, C Blast, or immature, cells have an increased rate of proliferation and multiply at the expense of normal cells. Leukemia does disrupt normal hematopoiesis (production and development of blood cells). Lymphoid cells differentiate into B and T cells. Myeloid cells differentiate into red blood cells, monocytes, granulocytes, and platelets; they do not reproduce and crowd out normal cells in the marrow. Pancytopenia occurs when large numbers of blast cells reproduce and crowd out normal marrow components.

The staff nurse is educating nursing students on the long-term effects of childhood chemotherapy. Which problems does the nurse include in the educational session? (Select all that apply.) a. Cardiac dysfunction b. Hearing loss c. Increased risk of multiple-gestation pregnancies d. Learning disabilities e. Peripheral neuropathy

ANS: A, B, D, E The list of long-term effects of chemotherapy is lengthy and includes cardiac dysfunction, hearing loss, learning disabilities, and peripheral neuropathy, among others. Sterility, not an increased risk for multiple- gestation pregnancies, is also an effect.

The student nurse studying childhood cancers understands that neoplasms are caused by which factors? (Select all that apply.) a. Chromosomal/genetic abnormalities b. External stimuli or environment c. Maternal nutrition during gestation d. Substance abuse during pregnancy e. Viruses that alter the immune system

ANS: A, B, E Neoplasms are caused by one or a combination of the following: chromosomal or genetic abnormalities, external stimuli or the environment, and/or viruses that alter the immune system. Nutritional deficits and substance abuse by the mother can certainly lead to developmental and other health problems, but do not lead to childhood cancers.

A child is getting induction therapy for Burkitt lymphoma. The nurse finds the child lethargic and complaining of side and back pain. The childs morning laboratory results indicate a serum calcium level of 7.2 mg/dL. What actions by the nurse are the most appropriate at this time? (Select all that apply.) a. Administer a dose of pain medication. b. Assess Chvostek and Trousseau signs. c. Call the rapid response team. d. Encourage an increased oral intake. e. Prepare to administer allopurinol (Aloprim).

ANS: A, B, E This child is manifesting signs of tumor lysis syndrome. The child is at risk due to the rapid destruction of cancer cells (induction therapy) and from the childs type of cancer (Burkitt lymphoma). Lethargy, flank pain, and hypocalcemia are common findings in this condition. The nurse should administer pain medication, assess for physical manifestations of hypocalcemia (Chvostek and Trousseau signs), and prepare to administer allopurinol. Adequate hydration is important as well, but because the child is lethargic, IV fluids should be given, not oral fluids. The rapid response team is not needed at this point.

The nurse is explaining types of solid tumors to a group of students. Which information does the nurse include? (Select all that apply.) a. A sarcoma is found in bone or muscle. b. Carcinoma means any cancerous tumor. c. Epithelial cells give rise to carcinomas. d. Lymphoma might originate in the thymus. e. Pediatric and adult solid tumors are similar.

ANS: A, C, D Pediatric and adult solid tumors are very different. A sarcoma arises from connective or supporting tissues, such as bones or muscle. A carcinoma is cancer arising from glandular and/or epithelial cells. Lymphomas originate in lymphoid organs, such as the lymph nodes, spleen, and thymus.

A child has been admitted with a paraspinal Ewings sarcoma. The nursing instructor questions the student about assessing for signs of spinal cord compression. Which manifestations does this include? (Select all that apply.) a. Burning pain down the legs b. Difficulty with swallowing c. Foot drop, causing a limp d. Respiratory depression e. Weakness in the hands

ANS: A, C, E Common manifestations of spinal cord compression include burning pain, often down the legs; foot drop causing difficulty with ambulation; and weakness in the hands. Other manifestations include numbness, cramping, and loss of sensation in the feet, and sexual dysfunction in the older patient. Swallowing problems and respiratory depression are not related.

A student nurse is preparing to administer odansetron (Zofran) to a child receiving chemotherapy. The child weighs 44 lb (20 kg). Which actions by the student nurse require intervention by the faculty? (Select all that apply.) a. Assesses the childs pain with a pediatric scale b. Discusses side effects with the parents/child c. Draws up 300 mg for IV administration d. Prepares to administer 3 mg IV push e. Withdraws a 200-mg suppository for use

ANS: A, C, E Odansetron is an anti-emetic (not a pain medication) and can be given IV at 0.15 mg/kg, making the correct dose 3 mg. The faculty member should intervene if the student assesses pain, not nausea; draws up 300 mg; or tries to obtain a suppository for the child. Odansetron can also be given PO. Discussing side effects is a responsibility when giving medications.

The nurse working with pediatric oncology patients educates the patients and families regarding best long- term follow-up practices. Which recommendations does this include? (Select all that apply.) a. Continued care by an interdisciplinary team b. Height measurements until puberty is reached c. Genetic testing prior to having children d. Risk-based follow-up appointments e. Thyroid screening for 5 years after remission

ANS: A, D Best-practice recommendations for follow-up include risk-based referrals and continued involvement of an interdisciplinary team of specialists. Height measurements are important for children until their adult height is achieved. Genetic testing is only recommended for certain types of cancer. Thyroid screening is important throughout the lifetime of survivors who were treated with radiotherapy to the neck, spine, or brain.

A child is being discharged after surgical resection of a retinoblastoma with enucleation. Which discharge instruction is most important based on the diagnosis? a. Encouraging healthy eating b. Irrigation of the surgical site c. Monitoring the childs temperature d. Pain assessment and control

ANS: B After enucleation (removal of the eye), the eye socket must be irrigated and a thin layer of antibiotic ointment applied. The other options are valid for all postoperative pediatric patients.

A nurse is caring for a child who is scheduled to have intrathecal chemotherapy today. Which action by the nurse is most important when providing care to this patient and family? a. Educating family on side effects of chemotherapy b. Ensuring a signed consent is on the chart c. Providing distraction techniques during the process d. Reassuring the child the parents will be present

ANS: B Intrathecal chemotherapy (introducing chemotherapy into the subarachnoid space of the spinal cord) is an invasive procedure and requires a signed consent. Although all actions are important for this child, the priority is ensuring the consent is executed appropriately and on the chart.

A child has been cured of a retinoblastoma. When the parents ask how long monitoring for bone-related complications of radiation therapy should continue, which is the most appropriate response by the nurse? a. After 5 years, you can stop worrying about this. b. Cancers of the bone can occur up to 15 years later. c. Probably all complications will occur within 3 years. d. Radiation complications do not occur in bones.

ANS: B Osteosarcoma can occur as a consequence of radiation therapy up to 15 years later.

A nurse works on a pediatric oncology unit. After receiving report, which child should the nurse assess first? a. Having infusion of D5 NS and sodium bicarbonate b. On high-dose methotrexate (Rheumatrex), urine pH of 7.8 c. Receiving cyclophosphamide (Cytoxan), urine specific gravity of 1.008 d. 2 days posttumor resection, complaining of pain

ANS: B Patients on high-dose methotrexate need their urine pH to be higher than 7.0. This child needs the nurses attention first. An IV with NaHCO3 is common prior to receiving methotrexate. A urine specific gravity of 1.010 is required for children on chemotherapy. Pain would be an expected finding 2 days postoperatively, and should be treated, but not before the nurse assesses the other child.

A neutropenic child is admitted to the hospital and placed in protective isolation. Which instruction does the nurse give the family to help maintain a safe environment for the child? a. Do not let the child have chewing gum b. Flowers, plants, and produce are not allowed c. The child can only have one visitor at a time d. Toys and items from home cannot be brought in

ANS: B The neutropenic child should not have fresh flowers, plants, fruits, or vegetables because they can harbor infectious microorganisms. The other instructions are not needed.

A nurse assesses a toddler using the FLACC score. The child is kicking and crying steadily. The mother is upset, as she is unable to console the child. Which action by the nurse is most appropriate? a. Administer acetaminophen (Tylenol). b. Give a dose of morphine (Duramorph). c. Play soothing, quiet music. d. Prepare a dose of propofol (Diprovan).

ANS: B This child exhibits several behaviors seen in the severe pain category according to the FLACC score. The best medication for this level of pain is an opioid analgesic, such as morphine. Tylenol is used for mild to moderate pain. Nonpharmacological measures can be used as an adjunct, but it will not relieve this degree of pain alone. Propofol is usually used for procedures.

A parent brings a child to the clinic and reports that the child is reluctant to walk and has a new limp. The parent also reports that the child seems lethargic and tired all the time. The nurse notes that the child appears pale. Which other finding would warrant immediate notification of the health-care provider? a. Difficulty staying asleep at night b. Left-sided abdominal enlargement c. Polyphagia and polydipsia d. Swelling of the legs and feet

ANS: B This child has some manifestations of acute lymphocytic leukemia (ALL). Left-sided abdominal enlargement could be indicative of splenomegaly, which is another manifestation of this disease. The nurse should report these findings immediately. Difficulty staying asleep at night is vague and could be related to a number of causes, both physical and behavioral. Polydipsia and polyphagia are two of the three classic signs of diabetes. Swelling of the legs and feet is not a manifestation of ALL.

A nurse is caring for several patients with acute lymphocytic leukemia (ALL). Which children does the nurse understand have the best prognosis? a. Infant b. < 10 years of age c. > 25% abnormal cells in bone marrow aspirate d. White count 4,200/mm3 e. White count 25,000/mm3

ANS: B, D The best prognosis for ALL occurs in children 2 to 9 years of age and in children whose initial white blood cell count is < 5,000/mm3. Children 10 and older and whose initial white blood cell counts are ?= 50,000/mm3 have worse prognoses. Infants have a very poor prognosis.

A child is 2 hours postoperative after a resection of a brain tumor. Which assessment by the nurse takes priority? a. Blood pressure b. Intake and output c. Neurological exam d. Temperature

ANS: C All actions are appropriate for a child postoperatively. However, the answer that is most specific to this childs procedure is the neurological exam.

A nursing faculty member explains to the class that which item is the most important for tumor cell growth? a. Age of transforming cells b. Programmed cell death c. Proximity to a capillary d. Rapidity of cell growth

ANS: C All cells, including tumor cells, need a consistent supply of oxygen and nutrients, delivered via the capillaries. Neoplastic cells must be in close enough proximity to a capillary to provide these required elements. The other factors do not have such an important role, if any, in neoplastic growth.

A nurse is caring for four patients who have Hodgkins lymphoma. Which child should the nurse see first? a. Anorexia for a week b. Enlarged cervical lymph nodes c. Fever of 102.1F (38.9C) d. Mediastinal mass

ANS: C All options are possible manifestations of Hodgkins lymphoma. However, the child with a fever may have another cause for the temperature, including infection, that needs to be ruled out. This is especially true of a child receiving chemotherapy, a standard treatment for this disorder.

An 8-year-old child has been diagnosed with a brain tumor. Based on knowledge of childhood cancers, which intervention does the nurse plan to implement when the child is admitted to the hospital? a. Aspiration precautions b. Protective isolation c. Safety precautions d. Seizure precautions

ANS: C Brain tumors in children 1 to 10 years of age are usually infratentorial and involve the brainstem and cerebellum. Manifestations of brainstem tumors result from involvement of the cranial nerves and include hemiparesis, spastic gait, and frequent stumbling and falling. The nurse implements safety precautions for this child. The other precautions may or may not be needed depending on the childs specific condition, treatment, and side effects of treatment.

A child is in the hospital receiving chemotherapy for Hodgkins lymphoma. What action by a new nurse causes the precepting nurse to intervene? a. Assesses the need for anti-emetics prior to starting chemotherapy b. Checks the IV for blood return before giving the chemotherapy c. Double wraps the chemotherapy bags and places in the trash can d. Performs hand hygiene prior to and after caring for the patient

ANS: C Chemotherapeutic agents are considered hazardous waste and must be disposed of in specific containers, not the trash can. The other actions are appropriate.

A nurse is caring for a child who has acute lymphocytic leukemia and has been treated with doxorubicin (Adriamycin). Which assessment finding would the nurse report immediately? a. Loss of appetite b. Low WBC count c. Peripheral edema d. Temperature of 100.6F (38.1C), once

ANS: C Doxorubicin and other anthracycline drugs are known to cause heart damage. Peripheral edema may signal heart failure and should be reported right away. Loss of appetite and low WBC count are common findings for a child on chemotherapy. A single temperature of 100.6F does not need to be reported.

A 7-year-old child presents to the emergency department, where the parent reports a 3-week history of pale skin, extreme fatigue, and dizziness. Which laboratory value would the nurse correlate with the patients current condition? a. Hematocrit: 33% b. Hemoglobin: 13.2 g/dL c. Red blood cell count: 2.8/mm3 d. White blood cell count: 12.3/mm3

ANS: C For a child of this age, a normal RBC count is 45.2/mm3. Low RBCs can lead to pallor, fatigue, headaches, and dizziness, as tissues are not being oxygenated. The other laboratory values are normal.

A nurse is looking at photographs of a friends infant. The nurse notes a whitish glow in the childs eyes, and the friend asks why the babys eyes look so odd. Which response by the nurse is the most appropriate? a. If his eyes look like this by 6 months, he needs to see a doctor. b. Take him to the doctor to see whats wrong with his eyes. c. This is called leukocoria and may signify retinoblastoma. d. Your baby may have a brain tumor; take him to the hospital.

ANS: C Leukocoria (also known as the cats-eye reflex) is a whitish glow in the pupil, often noticed on photographs, and is seen in children with retinoblastoma. The child needs to be seen by his health-care provider. The mother should not wait 6 months. Advising the mother to find out whats wrong with his eyes is not as accurate as explaining the manifestation. This sign is not seen in brain tumors.

A child is receiving chemotherapy. The nurse assesses the childs oral cavity and notes the following: raspy voice, thick saliva, and debris on the teeth. Which action by the nurse is the most appropriate? a. Have the child use commercial mouthwash. b. Hold the next dose of chemotherapy. c. Increase the frequency of oral care. d. Place the child on NPO status.

ANS: C Mucositis is a diffuse inflammation of the mouth and oral mucous membranes, and is common during chemotherapy. The nurse should increase the frequency of oral care in the child who is manifesting signs of this problem. Commercial mouthwash contains alcohol, which would burn the tissues. The chemotherapy would not be interrupted. The child should be encouraged to eat and drink as tolerated.

A parent brings a 10-year-old child to the clinic, reporting that the child fell while playing and now has a limp several days later. In completing a history, which other finding would the nurse correlate more with bone cancer than a minor trauma? a. Decreased appetite for the last month b. Fatigues easily when playing outdoors c. Limping several weeks prior to the fall d. Often has unexplained extremity bruises

ANS: C Pain and swelling are the most common manifestations of osteosarcoma. Often the child has a limp. The child also may have a dull pain at the tumor site, and if it is on a leg (weight-bearing), it could easily cause a limp that has lasted for several weeks before really being noticed. The other manifestations are vague and could be related to other problems.

A nurse sees the term proptosis in a childs medical record. Which physical assessment does the nurse plan to incorporate into the childs exam based on this finding? a. Balance testing b. Hearing screen c. Visual acuity d. Strength testing

ANS: C Proptosis is a downward displacement of the eyeball that can affect visual acuity and is frequently seen in children with rhabdomyosarcoma. The other assessments are not related.

A clinic nurse notes that a child brought in for a physical has swelling and bruising around the eyes. The patient denies any trauma and the parent reports no environmental allergies. Which assessment is most important? a. Auscultate lungs bilaterally. b. Inspect skin on the back. c. Palpate abdomen and neck. d. Percuss abdomen and flank.

ANS: C Swelling and bruising around the face and eyes is often seen in children with neuroblastoma. Most commonly the tumor can be found by palpation of the abdomen or neck, where the tumor will present as a hard, painless mass that crosses the midline.

A nurse hears that a new admission to the hospital was recently diagnosed with the most common kind of childhood cancer. Which collaborative care does the nurse prepare to provide to this patient? a. Antibiotic administration b. Bone marrow transplant c. Chemotherapy d. Liver transplant

ANS: C The most common type of childhood cancer is acute lymphocytic leukemia (ALL). First-line treatment for ALL is inducing remission with chemotherapy. Antibiotics are not used unless the child has an infection. Bone marrow transplant may be considered later in the childs course of care. A liver transplant would not be a treatment for ALL.

A child has cancer, is unresponsive, and is doing poorly. Which action by the nursing student causes the faculty to intervene? a. Allows the parents to hold the child b. Places the child on NPO status c. Takes the childs rectal temperature d. Turns the child even if she moans

ANS: C The nurse avoids the rectal route for anything: temperatures, suppositories, and enemas are not allowed, as the rectal mucosa is fragile and prone to injury, which can lead to infection. The other actions are appropriate.

A nurse notes in a patients medical record high levels of vanillymandelic acid (VMA). Based on this information, which condition does the nurse prepare to educate the patient and family about? a. Ewings sarcoma b. Hodgkins lymphoma c. Neuroblastoma d. Wilms tumor

ANS: C VMA and homovanillic acid (HVA) are tests used to measure the level of catecholamine metabolites in the urine. Neuroblastomas typically secrete catecholamines, so high levels of either substance are indicative of neuroblastoma.

A nurse is reviewing a patients chart and notes that the patient has a cancerous tumor that has invaded other organs. Based on this information, at which stage is this patients cancer classified? a. Stage O b. Stage I c. Stage III d. Stage IV

ANS: D A stage IV cancer is one that has invaded other organs. Stage 0 is early cancer, present only in the cells in which it began. Stages I-III are more extensive, with larger tumors and spread to nearby lymph nodes or adjacent organs.

A child has nausea after chemotherapy despite anti-emetics. However, the child complains that my tummy is growling. Which other action should the nurse take to promote comfort for this child? a. Avoid hard, difficult-to-chew foods. b. Encourage a high fluid intake with meals. c. Offer the child hard candy to suck on. d. Provide bland items, such as plain mashed potatoes.

ANS: D Several actions can help the child with nausea: offering plain, bland foods; avoiding spicy, heavy, or fatty foods; decreasing the odor associated with foods if that bothers the child; and having the child take food separately from liquids. Liquid together with food can make the child feel full, inducing nausea. The other options are good choices for other nutritional problems.

A child has been diagnosed with chronic myelogenous leukemia (CML). Which statement by the nurse to the parents is most appropriate? a. Radiation therapy is the standard treatment. b. The prognosis for this disease is extremely poor. c. There are lots of good medications for nausea. d. We need to test siblings for a bone marrow match.

ANS: D The preferred treatment for CML is a bone marrow or stem cell transplant from a matching sibling, which can be curative in up to 80% of patients. Radiation therapy is not used. Although there are many good medications for nausea, this statement is not the best choice, because it is not specific to this childs condition.

A nurse works on the pediatric oncology floor. After receiving the handoff report, which child does the nurse assess first? a. Child on protective isolation b. 4 hours postbone marrow biopsy c. Not eating an hour after chemotherapy d. Temperature of 101.5F (38.5C)

ANS: D This fever indicates a probable infection. The nurse will see this child first and provide report to the physician, if this has not already been done. This child is the sickest and should be seen first; one might be tempted to see the child in protective isolation first to avoid cross-contamination, but by following isolation precautions, this risk is minimized. Not eating after chemotherapy is not cause for concern, and the child 4 hours postbone marrow biopsy should be stable.