Chapter 46: Hematologic Disease

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

"If the trait is inherited from both parents the child will have the disease." Rational: When the trait is inherited from both parents (homozygous state), the child has sickle cell disease, and anemia develops. The trait does not skip generations. The trait occurs most commonly in black clients. Either sex can have the trait and disease.

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

"The MRI uses radio waves and magnets to produce a computerized image of the body."

Nursing students are reviewing information about childhood cancers. They demonstrate understanding of the information when they identify what as the most frequent type? a.Non-hodgkin lymphoma b.Leukemia c.Brain stem tumor d.Wilms tumor

.Leukemia Rational:Although Wilms tumor, brain stem tumors, and non-Hodgkin lymphoma can occur in children, the most frequent type of cancer in children is leukemia.

The nurse is caring for a child in sickle cell crisis. To best promote hemodilution, the nurse would expect to administer how much fluid per day intravenously or orally? a.150 ml/kg of fluids b.130 ml/kg of fluids per day c.120 ml/kg of fluids per day d.110 ml/kg of fluids

150 ml/kg of fluids Rational: To promote hemodilution in sickle cell crisis, the nurse would provide 150 ml/kg of fluids per day or as much as double maintenance, either orally or intravenously.

The nurse is caring for a pediatric client who is scheduled for the surgical removal of a Wilms tumor. Which action is contraindicated in the client's care? a.Foley catheter placement b.IV Fluids c.Abdominal palpation d.Supine positioning

Abdominal palpation Rational:Abdominal palpation is contraindicated preoperatively in a client with a Wilms tumor. Cells may break loose and spread the tumor. Intravenous fluids and supine positioning are appropriate in the client's care. A Foley catheter is typically not placed.

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

Assessing the child's level of consciousness. Rational:The priority intervention is to monitor for increases in intracranial pressure because brain tumors may block cerebral fluid flow or cause edema in the brain. A change in the level of consciousness is just one of several subtle changes that can occur indicating a change in intracranial pressure. Lower priority interventions include providing a tour of the ICU to prepare the child and parents for after the surgery, and educating the child and parents about shunts.

A 4-year-old child diagnosed with Wilms tumor is admitted for surgery. What information would be most important for the nurse to include in the child's preoperative plan of care? a.Administering analgesics for pain b.Avoiding further abdominal palpation c.Performing dressing changes to the affected area d.Preparing the child for amputation

Avoiding further abdominal palpation Rational: After the initial assessment is performed on a child with Wilms tumor, further palpation of the abdomen should be avoided because the tumor is highly vascular and soft. Therefore, excessive handling of the tumor may result in tumor seeding and metastasis. Preoperatively, the child with Wilms tumor does not have a wound; therefore, dressing changes are not necessary. Although the child may experience abdominal pain, avoiding further abdominal palpation would be the priority. Surgical removal of the tumor and affected kidney is the treatment of choice for Wilms tumor. Amputation would be more likely for a child with osteosarcoma.

A group of nursing students are studying information about childhood cancers in preparation for a class examination. They are reviewing how childhood cancers differ from adult cancers. The group demonstrates understanding of the information when they identify what location as an unlikely site for childhood cancer? a.Brain b.Bladder c.Kidney d.Blood

Bladder Rational: The most common sites for childhood cancer include the blood, lymph, brain, bone, kidney, and muscle. Bladder is a common site for adult cancer.

The father of an 8-year-old boy who is receiving radiation therapy is upset that his son has to go through 6 weeks of treatments. He doesn't understand why it takes so long. In explaining the need for radiation over such a long time, what should the nurse mention? a.Radiation therapy is very weak, and therefore it takes a long time to achieve therapeutic doses b.It is difficult to locate where the cancer cells are in the body, so the entire body must be irradiated c.Insurance companies typically allow only a short radiation treatment per week, to contain costs d.Cells are only susceptible to treatment by radiation during certain phases of the cell cycle

Cells are only susceptible to treatment by radiation during certain phases of the cell cycle Rational: 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 teenage girl asks why chemotherapy causes hair loss. Which response by the nurse is accurate? a.Hair is not a living tissue, and it is easily damaged by chemotherapy b.Circulation to the head causes large doses of chemotherapy to reach the scalp c.Chemotherapy affects cancer cells and normal cells that multiply rapidly d.Hair is exposed to the sun, which increases sensitivity to chemotherapy

Chemotherapy affects cancer cells and normal cells that multiply rapidly Rational:Chemotherapy is cytotoxic to rapidly proliferating cells—malignant or normal. Normal cells that turn over rapidly include those of bone marrow, hair, and mucous membranes.

The nurse assesses that the client is at risk for an infection related to chemotherapy-induced immunosuppression. What will the nurse include in the teaching plan for the child and parents to help reduce this risk? Select all that apply. a.Have the child sleep in a single bed and room. b.Cheer up the environment with fresh flowers and plants. c.Provide a low carbohydrate, low protein diet d.Encourage frequent, thorough handwashing e.Encourage frequent contact with multiple visitors

Have the child sleep in a single bed and room. Encourage frequent, thorough handwashing

The nurse is assessing a 3-year-old boy whose mother reports that he is listless and has been having trouble swallowing. Which finding suggests the child may have a brain tumor? a.Vital signs show blood pressure measures 120/80 mm Hg. b.Observation reveals nystagmus and head tilt. c.Observation reveals a cough and labored breathing. d.Examination shows temperature of 101.4° F (38.6°C) and headache.

Observation reveals nystagmus and head tilt. Rational: Coupled with the mother's reports, observation of nystagmus and head tilt suggest the child may have a brain tumor. Elevated blood pressure of 120/80 mm Hg may be indicative of Wilms tumor. Fever and headaches are common symptoms of acute lymphoblastic leukemia. A cough and labored breathing points to rhabdomyosarcoma near the child's airway.

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? a.Pain due to neoplastic process in bone b.Compromised family coping related to long-term chemotherapy regimen c.Disturbed body image related to loss of hair after chemotherapy d.Risk for imbalanced nutrition, less than body requirements, related to inflammation

Risk for imbalanced nutrition, less than body requirements, related to inflammation Rational: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 school-aged child with sickle-cell anemia. Which assessment finding is consistent with this child's diagnosis? a.Slightly yellow sclera b.Increased growth of long bones c.Depigmented areas on the abdomen d.Enlarged mandibular growth

Slightly yellow sclera Rational: In sickle-cell anemia, eye scleras become icteric or yellowed from the release of bilirubin from the destruction of the sickled cells. Mandibular and long bone growth and depigmentation are not manifestations of this health problem.

A nurse is providing teaching to a child receiving chemotherapy and the parents. The nurse determines that the teaching was successful when the parents state that they will contact the primary health care provider if which occurs? a.The child has no appetite because of nausea. b.The child has redness or swelling at the central venous access site. c.The child has increased urinary output or vomiting. d.The child has a bruise on the arm.

The child has redness or swelling at the central venous access site. Rational:The family should contact the health care provider if the child exhibits redness, swelling, or leakage at the central venous access site; or if the device has cracks, is pulled out, or does not flush. Loss of apetite, increased urinary output and vomitting, and bruising are expected adverse effects. The parent only need contact the health care provider if these effects become excessive.

The nurse will select which meal as the best choice for a child with iron-deficiency anemia? a.chicken breast, French fries, and sweetened tea b.peanut butter sandwich, cheese stick, and applesauce c.cheeseburger, broccoli, and fresh strawberries d.two slices of pepperoni pizza and a glass of skim milk

cheeseburger, broccoli, and fresh strawberries Rational:Children with iron-deficiency anemia require diets rich in iron and vitamin C (vitamin C enhances iron absorption). Meats are excellent sources of iron. Broccoli is a good source of iron, and strawberries are a good source of vitamin C. To help the body absorb the most iron from the meal, tea and foods rich in calcium (such as milk and cheese) should be avoided.

A 5-year-old child is at the pediatric clinic for a well-child visit. Which symptom alerts the health care provider that this child might have acute lymphoblastic leukemia (ALL)? a.abdominal pain, nausea, and vomiting b.anorexia and weight loss c.joint pain and swelling d.lethargy, bruises, and lymphadenopathy

lethargy, bruises, and lymphadenopathy

A nurse is conducting a class to a group of parents on sickle cell anemia. Which statement by a parent indicates teaching has been effective? a."Fluid restriction is necessary to control sickle cell anemia." b."The sickle shape of red blood cells decreases oxygen to tissues." c."Sickle cell anemia is common in people of Asian descent." d."This is a hereditary disease that is transmitted by one affected gene."

"The sickle shape of red blood cells decreases oxygen to tissues." Rational:The sickle shape of the red blood cells impedes the flow of blood through the vessels, thus causing hypoxia to the tissues. Sickle cell anemia is a hereditary disease but it is autosomal recessive, meaning it requires two genes in order for the disease to be transmitted. Sickle cell anemia is common in people of African, Mediterranean, and Indian descent. Hydration is important to controlling sickle cell anemia. Dehydration is a trigger for sickle cell crisis.

A 3-year-old child is hospitalized with a diagnosis of sickle cell anemia and is experiencing a pain crisis. Using the FACES scale, the nurse assesses the child's pain to be a 10 on a scale of 1 to 10. The child is receiving intravenous fluids and oxygen at 2 L/min via nasal cannula. The parent is at the bedside holding the child's hand and has a concerned look. What is the nurse's priority in caring for the child? a. Contact the health care provider to meet with the parent. b.Ask the parent if he or she has questions about the plan of care. c.Implement strategies to address the child's pain. d.Provide diversional activities for the child.

Implement strategies to address the child's pain. Rational: In this case, the nurse's priority is to address the child's pain. The child is already receiving IV fluids and oxygen. That, in combination with analgesia, will assist in resolving the crisis. Asking the parent if he or she has questions, asking the health care provider to meet with the parent, and providing distraction for the child are all appropriate interventions, but the priority is to address the child's pain.

A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in the child's care plan should be given priority? a.Seeing that the child ingests a protein-rich diet b. Encouraging the child to take deep breaths hourly c.Maintaining fluids through an intravenous line d.Beginning active range-of-motion exercises

Maintaining fluids through an intravenous line Rational: Sickle cells clump together and prevent normal blood flow. This leads to tissue hypoxia. With a vaso-occlusive crisis, the cells are clumped together and prevent blood flow to the joint or organ. The blood with the clumped sickled cells is very viscous. Adequate hydration is crucial in relieving the problems of a vaso-occlusive crisis. The hydration dilutes the blood and decreases the viscosity. During a crisis the recommended fluid intake (IV and PO) is 150 ml/kg/day. During a vaso-occlusive crisis, the child has severe pain. The goal is to get the pain under control and increase blood flow. Range-of-motion exercises will add to the increased pain during this period of time, so should not be started until crisis in under control. The diet and hourly deep breaths are important, but they are not crucial to correcting the crisis.

A nurse is providing care to a child with hemophilia who is experiencing muscle and joint involvement related to the bleeding. Which would the nurse include as an adjunctive measure to control bleeding? a.exercise b.heat c.lowering extremities d.compression

compression

The nurse is assessing a child who is experiencing an acute splenic sequestration secondary to sickle cell disease. What treatment would be a priority? a.oxygen administration b.antibiotic administration c.emergent transfusion d.pain relief

emergent transfusion Rational:Acute splenic sequestration can rapidly progress to cardiovascular collapse and death. Prepare the child for emergent transfusion with packed red blood cells. Pain relief would be a priority for a vaso-occlusive crisis. Antibiotic administration would be a priority for a febrile child with sickle cell disease. Oxygen administration would be a priority for a child with acute chest syndrome (a vaso-occlusive crisis).

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

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

The nurse is teaching the parents of a 15-year-old boy who is being treated for acute myeloid leukemia about the side effects of chemotherapy. For which symptoms should the parents seek medical care immediately? a.blisters, ulcers, or a rash appear b.difficulty or pain when swallowing c.temperature of 101°F (38.3°C) or greater d.earache, stiff neck, or sore throat

temperature of 101°F (38.3°C) or greater Rational:The parents should seek medical care immediately if the child has a temperature of 101°F (38.3° C) or greater. This is because many chemotherapeutic drugs cause bone marrow suppression; the parents must be directed to take action at the first sign of infection in order to prevent overwhelming sepsis. The appearance of earache, stiff neck, sore throat, blisters, ulcers, or rashes (or difficulty/pain when swallowing) are reasons to seek medical care, but are not as grave as the risk of infection.

A child with sickle cell anemia is scheduled for a splenectomy. After the parents receive teaching about the rationale for this surgery, the nurse determines that the teaching was successful when the parents make which statement? a.It will help to reduce the number of infections the child will get." b."The surgery should help prevent any further crisis episodes." c."It will help to decrease the amount of anemia." d."The surgery is being done to cure the condition."

"It will help to decrease the amount of anemia."

A child with sickle cell disease is brought to the emergency department by his parents. He is in excruciating pain. A vaso-occlusive crisis is suspected and analgesia is prescribed. What would the nurse expect as least likely to be ordered? a.Meperidine b.Morphine c.Hydromorphone d.Nalbuphine

Meperidine Rational: Meperidine is contraindicated for ongoing pain management in a child with vaso-occlusive crisis because it increases the risk for seizures. Analgesics such as morphine, nalbuphine, or hydromorphone are commonly used.

A 14-year-old girl who is a vegetarian has recently developed anemia. Blood smear results show large, fragile, immature erythrocytes. She claims to take an iron supplement regularly and is surprised to learn that she is anemic, as she is otherwise healthy. As the nurse considers all of the data in the case, which anemia will the nurse discuss when collaborating with the primary healthcare provider? a.Sickle cell disorder b.Acute blood loss c.Vitamin b12 deficiency d.Iron deficiency

Vitamin b12 deficiency Rational: Vitamin B12 is necessary for the maturation of RBCs. Pernicious anemia results from deficiency or inability to use the vitamin, resulting in RBCs that appear abnormally large and are immature megaloblasts (nucleated immature red cells). Thus, pernicious anemia is one of the megaloblastic anemias. In children, the cause is more often lack of ingestion of vitamin B12 rather than poor absorption. Adolescents may be deficient in vitamin B12 if they have a long-term, poorly formulated vegetarian diet, as the vitamin is found primarily in foods of animal origin. Since the client is taking iron, iron deficiency anemia is ruled out. The blood cells in a client with sickle cell anemia are crescent-shaped and do not display the characteristics noted. There are no symptoms of blood loss or acute bleeding, as the client is otherwise healthy.

A 3-year-old boy has been brought to the doctor's office with symptoms of anorexia and abdominal pain. A blood test reveals a lead level of 20 μg/100 mL. The child is prescribed an oral chelating agent. On discharge, the nurse should counsel the parents regarding: a.putting child safety locks on kitchen cabinets. b.placing house plants out of reach of children. c.putting medicine away where children cannot reach it. d.removal or covering of flaking paint on the walls of the home.

removal or covering of flaking paint on the walls of the home. Rational:The usual sources of ingested lead are paint chips or paint dust, home-glazed pottery, or fumes from burning or swallowed batteries. A child with a blood lead level over 5 μg/dl needs to be rescreened to confirm the level and then active interventions begun to prevent further lead exposure, such as removal of the child from the environment containing the lead source or removal of the source of lead from the child's environment. Removal of the lead source is not an easy task in homes because simple repainting or wallpapering does not necessarily remove the source of peeling paint adequately. After some months, the new paint will begin to peel because of the defective paint underneath. The walls must therefore be covered by paneling or drywall or other solid protective material.

A child with cancer is to start chemotherapy. The nurse wishes to assess the psychosocial status of the child and the family. Which therapeutic communication technique would be best for the nurse to use? a.using broad opening b.reassuring c.giving recognition d.encouraging expression

using broad opening Rational: During therapy for cancer, it is important to assess and evaluate the child's and family's psychosocial status. Many factors impact this status: fear of dying, economic impact, child's isolation from friends and school, etc. When completing an assessment, it is important for the nurse to use therapeutic communication techniques. The best option is to use broad openings by using open-ended questions. This opens up the discussion and prevents yes-or-no answers. These types of questions allow the child or parents to take the lead in the interaction. Giving reassurance is a nontherapeutic technique. Reassuring will indicate that there is not any reason for the child or family to be anxious. Giving recognition is a therapeutic technique. Giving recognition indicates to the child and family that the nurse is aware they have stress but it does not assess their feelings. Encouraging expression is a therapeutic technique, but it is useful only in asking the child and family to look at their current situation, not explore their feelings about them.

A parent is angry about the adolescent's diagnosis of osteosarcoma. The parent is telling the adolescent that if he hadn't played football last year and broken his leg, this would not have happened. What is the nurse's best response to the parent's statement? a"Playing sports does not cause osteosarcoma. It may draw attention to the weakened bone from the tumor, though." b."Does bone cancer run in your family? Maybe your adolescent inherited it through genes." c."Cancer in the bone can result from old injuries so it probably was not caused from getting hurt last year, but an earlier injury." d."When your adolescent broke the leg last year, it may have weakened the bone, allowing cancer to start there."

"Playing sports does not cause osteosarcoma. It may draw attention to the weakened bone from the tumor, though." Rational: Osteosarcoma does not result from bone injuries but may be diagnosed when there is a fracture secondary to bone weakening from the tumor. Playing sports has no effect on development of osteosarcoma.

A mother asks the nurse why her infant who was born at 34 weeks' gestation is being prescribed ferrous sulfate. Which response by the nurse is most appropriate? a."Preterm infants are at risk for iron-deficiency anemia." b."Your infant may have been having excessive diarrhea." c."Infants with pyloric stenosis require ferrous sulfate." d."Ferrous sulfate helps improve red blood cell formation."

"Preterm infants are at risk for iron-deficiency anemia." Rational:Infants born prematurely are at risk for iron-deficiency anemia because iron stores are built during the last few weeks of gestation. Although some infants with pyloric stenosis may require an iron supplement, such as ferrous sulfate, not all infants will. Infants with excessive diarrhea may develop iron-deficiency anemia, and ferrous sulfate helps improve red blood cell formation, but this does not explain why a preterm infant is being prescribed an iron supplement.

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

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

A couple is expecting a child. The fetus undergoes genetic testing and the couple discover the fetus has sickle cell disease. The couple ask the nurse how most commonly happens. Which statement is accurate for the nurse to provide? a."Sickle cell disease occurs from a random genetic mutation." b."Sickle cell disease is passed to a fetus when one of the parents has the gene." c."Sickle cell disease is passed to a fetus when both parents have the gene." d. "Sickle cell disease can be passed to the fetus in many ways. We will know more at birth."

"Sickle cell disease can be passed to the fetus in many ways. We will know more at birth." Rational:Sickle cell disease is an inherited disease. The recessive gene is passed from both parents who either have the disease or the trait. There is no need for further testing to determine the cause. There are no other ways to pass the disease other than through genetics. Informing the parents that the gene was passed from both parents is most informative. Sickle cell anemia is not a dominant disease, which is passed when only one parent has the gene, nor is caused by a random mutation.

The nurse is explaining the procedure of bone marrow aspiration to a 6-year-old child with leukemia. What explanation would be best to give to the child? a."The numbing medicine on your skin will keep you from having pain." b."You will have to lie on your back and hold your breath." c."You will need to lie still afterward to prevent a headache." d."You may feel pressure on your hip during the procedure."

"You may feel pressure on your hip during the procedure." Rational: The bone marrow aspiration is performed on the iliac crest if the child is older and on the femur if the child is an infant. Bone marrow aspiration requires hard pressure to allow the needle to puncture the bone. A lidocaine/prilocaine cream is applied to the skin anywhere from 1 to 3 hours prior to the procedure to help numb the site where the needle will be inserted. Bone marrow aspirations and biopsies are usually performed with conscious sedation. If the child is an infant or there are special circumstances the procedure may be performed under anesthesia. The child is placed on the side for the procedure so the health care provider has better access to the iliac crest. The child will need to rest after the procedure to prevent bleeding, but is not required to lay flat on the back. Children who have had a lumbar puncture may need to lie on the back and are at risk for a headache.