Quiz 1

The nurse is teaching the parent of a child with cystic fibrosis about nutrition requirements for the child. What should be included in this teaching? Select all that apply. A. "Give your child high-calorie foods and snacks." B. "Feed your child foods that are high in protein." C. "Administer water soluble vitamins." D. "Give pancreatic enzymes with meals." E. "Give your child foods high in fat."

A. "Give your child high-calorie foods and snacks." B. "Feed your child foods that are high in protein." D. "Give pancreatic enzymes with meals." Rationale: Children with cystic fibrosis (CF) have trouble digesting and absorbing nutrients. They tend to be underweight. For optimal health, their diets should be high in calories and high in protein, with the supplementation of fat soluble vitamins and pancreatic enzymes. This diet helps with growth and the optimal nutrients. The fat soluble vitamins (vitamins A, D, E and K) are needed, because children with CF have trouble absorbing fat and need the vitamin supplementation to aid in fat absorption. Water soluble vitamins (the B vitamins and vitamin C) do not aid in fat absorption. The child should not have a high-fat diet, because the extra fat is difficult to digest and be absorbed. Pancreatic enzymes are necessary because they are missing due to the disease process. They are necessary to aid in digestion. They should be ingested with meals.

The nurse is obtaining a health history of a child suspected of tuberculosis. What question would the nurse ask first about the child's cough? A. "How long has your child had a cough?" B. "Does your child cough only at night?" C. "Does your child cough up anything when coughing?" D. "Has your child been around anyone who is coughing?"

A. "How long has your child had a cough?" Rationale: Tuberculosis is a highly contagious disease. Most children contract it from an infected immediate household member. When taking the health history, the nurse should ask about symptoms such as malaise, weight loss, anorexia, chest tightness and a cough. The child's cough from tuberculosis is described as progressing slowly over several weeks and months rather than having an acute onset. Asking about the production from the cough is a way to determine if hemoptysis has occurred. Asking about being around anyone coughing is a way to determine if the child has been exposed to anyone with tuberculosis. Coughing only at night could be related to other respiratory disorders such as asthma.

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 uses radio waves and magnets to produce a computerized image of the body." B. "The MRI is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement." C. "The MRI uses sound waves to create images that visualize body structures and locate masses." D. "The MRI uses radiation to examine soft tissue and bony structures of the body."

A. "The MRI uses radio waves and magnets to produce a computerized image of the body." Rationale: The MRI uses radio waves and magnets to produce a computerized image of the body. The bone scan is a nuclear scanning test to rule out cancer involving the bones or determine extent of bone involvement. The ultrasound uses sound waves to create images that visualize body structures and locate masses. Radiography uses radiation to examine soft tissue and bony structures of the body.

A nurse is providing care to a child with hemophilia who is experiencing muscle and joint involvement related to the bleeding. Which intervention will the nurse include as an adjunctive measure to control bleeding? A. compression B. heat C. exercise D. lowering extremities

A. compression Rationale: Complications associated with bleeding most often involve joints and muscles. Adjunct measures include rest, ice, compression, and elevation (RICE). In addition, corticosteroids such as prednisone may be used to reduce inflammation in the joint.

A parent with a child who has cystic fibrosis asks the nurse how to determine if the child is receiving an adequate amount of pancreatic enzymes. How should the nurse respond? Select all that apply. A. "The dose is adequate when your child is only having 1 to 2 stools per day." B. "The dose is adequate when your child's weight is improving." C. "The dose prescribed is based on your child's pancreatic laboratory values so it should be correct." D. "When your child starts to eat more quantity of food you will need to adjust the amount of enzyme pills." E. "You will need to give your child less enzyme pills when high-fat foods are eaten."

A. "The dose is adequate when your child is only having 1 to 2 stools per day." B. "The dose is adequate when your child's weight is improving." D. "When your child starts to eat more quantity of food you will need to adjust the amount of enzyme pills." Rationale: Pancreatic enzymes are required for the child with cystic fibrosis (CF) to help absorb nutrients from the diet and to aid in digestion. They are given with each meal and snack the child eats. The number of capsules required at each dose depends upon the diagnosis of how the pancreas is functioning and the amount of food needing to be digested. The pancreatic laboratory values may determine a baseline for the number of pills to start with, but the dosage is adjusted regularly. The dosage of pancreatic enzymes is adjusted until an adequate growth pattern is established and the child is having no more than 1 to 2 stools per day. The child should be given an increased number of enzyme pills when a meal with high-fat content is consumed, not fewer.

A young child has been diagnosed with Wilms tumor. The parents ask how this could have happened to their child. What is the nurse's best response? A. "This is usually related to a gene mutation." B. "It is usually associated with viral exposure." C. "No one knows what causes Wilms tumor." D. "This often occurs due to environmental factors."

A. "This is usually related to a gene mutation." Rationale: A number of gene mutations have been identified as associated with Wilms tumor. It does not seem to be related to viral exposure or environmental factors.

A nurse is reviewing the laboratory test results of a 3-year-old child. Which absolute neutrophil count would the nurse identify as indicating neutropenia? A. 1.0 B. 1.5 C. 2.0 D. 2.5

A. 1.0 Rationale: The normal absolute neutrophil count (ANC) ranges from 1.5 to 8.0 (1500 to 8000/mm3). An ANC less than 1.5 (1500/mm3) in children over age 1 indicates neutropenia.

The nurse is reviewing the results of a clotting study for a healthy 6-year-old. What would the nurse document as a normal prothrombin finding? A. 11.0 to 13.0 seconds B. 6.0 to 9.0 seconds C. 21.0 to 35.0 seconds D. 16.0 to 18.0 seconds

A. 11.0 to 13.0 seconds Rationale: The nurse would identify a prothrombin time of 11.0 to 13.0 seconds as normal for a healthy child. A result of 21.0 to 35.0 seconds would be the expected range for partial thromboplastin time and activated partial thromboplastin time. Findings of 6.0 to 9.0 seconds and 16.0 to 18.0 seconds are outside the normal range.

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. 110 ml/kg of fluids C. 130 ml/kg of fluids per day D. 120 ml/kg of fluids per day

A. 150 ml/kg of fluids Rationale: 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 preparing a room for a child being transferred out of the intensive care unit. The child has a tracheostomy. What item(s) are essential for the nurse to have available at the bedside in case of emergency? Select all that apply. A. A new tracheostomy tube of the same size B. A new tracheostomy tube of a smaller size C. A bag valve mask D. A sterile tracheostomy kit E. Cleaning supplies for the tracheostomy

A. A new tracheostomy tube of the same size B. A new tracheostomy tube of a smaller size C. A bag valve mask Rationale: A child with a tracheostomy can have an emergent situation for any number of reasons. It is important to always have emergency equipment at the bedside to provide immediate care when these situations arrive. Two spare tracheostomy tubes should always be at the bedside, one the same size as in place and once a size smaller. These would be needed if the tube became dislodged. A bag valve mask needs to remain at the bedside at all times. Ideally it should be connected to oxygen, but that is an individual protocol for the health care organization. The bag can be used to hyperoxygenate the child prior to or following suctioning or it can be used in an emergent situation such as a respiratory arrest. Sterile tracheostomy kits and cleaning supplies can be available at the bedside, but they are used for routine cleaning and not for emergencies.

A child is in the emergency department with an asthma exacerbation. Upon auscultation the nurse is unable to hear air movement in the lungs. What action should the nurse take first? A. Administer a beta-2 adrenergic agonist B. Administer oxygen C. Start a peripheral IV D. Administer corticosteroids

A. Administer a beta-2 adrenergic agonist Rationale: When lungs sounds are unable to be heard in a child with asthma, the child is very ill. This means there is severe airway obstruction. The air movement is so severe wheezes cannot be heard. The priority treatment is to administer an inhaled short term bronchodilator (beta-2 adrenergic agonist). The child may require numerous inhalations until bronchodilation occurs and air can pass through the bronchi. Oxygen can be started but until the bronchi are dilated no oxygen can get through to the lung fields. In IV would need to be started and IV steroids administered to reduce the inflammation, but the priority is bronchodilation.

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

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

A nurse is preparing a teaching plan for a child with hemophilia and his parents. Which information would the nurse be least likely to include to manage a bleeding episode? A. Apply heat to the site of bleeding. B. Apply direct pressure to the area. C. Elevate the injured area such as a leg or arm. D. Administer factor VIII replacement.

A. Apply heat to the site of bleeding. Rationale: Ice or cold compresses, not heat, would be applied to the site of bleeding. Direct pressure is applied until the bleeding stops. The injured part is elevated unless elevating would contribute to further injury. Factor VIII replacement is given to replace the missing clotting factor.

A child has been prescribed a nasal cannula for oxygen delivery. What should the nurse do before applying the cannula? A. Assess patency of the nares B. Test the oxygen saturation C. Add humidification to the delivery device D. Assess the lung sounds

A. Assess patency of the nares Rationale: A nasal cannula is a good delivery device for children, because it allows them to eat and talk unobstructed. Because the device is designed for flow through the nares, the patency of the nares should be assessed prior to using the cannula. If the nares are blocked from secretions, suctioning may be required. If there is a defect in the upper airway causing blockage, the nasal cannula may not be an appropriate oxygen delivery device. The oxygen saturation should have been measured and used as a guide for the prescription of oxygen therapy. Adding humidification is a way to keep the upper airways from becoming too dry, but oxygen can be started before humidity is added. Anytime a child is sick enough to require oxygen all respiratory assessments, including lung sounds, should be done. It does not matter, however, what the lung sounds are if the child is in enough distress to require oxygen. The lung sounds can be assessed after oxygen is started.

A child being treated for leukemia is diagnosed with neutropenia. What nursing instructions directly prevent client infections? Select all that apply. A. Avoid large crowds. B. Inspect the skin daily for scratches or scrapes. C. Increase the intake of fresh fruits and vegetables. D. Remove house plants, flowers, and goldfish from the home environment. E. Stay away from people who have obvious colds, rashes, or other infections.

A. Avoid large crowds. B. Inspect the skin daily for scratches or scrapes. D. Remove house plants, flowers, and goldfish from the home environment. E. Stay away from people who have obvious colds, rashes, or other infections. Rationale: Strategies to prevent infections in a child with neutropenia include avoiding large crowds; inspecting the skin daily for scratches or scrapes; removing house plants, flowers, and goldfish from the home environment; and staying away from people who have obvious colds, rashes, or other infections. The child's intake of fresh fruits and vegetables should be limited because this could be a source for bacteria.

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. Cells are only susceptible to treatment by radiation during certain phases of the cell cycle B. It is difficult to locate where the cancer cells are in the body, so the entire body must be irradiated C. Radiation therapy is very weak, and therefore it takes a long time to achieve therapeutic doses D. Insurance companies typically allow only a short radiation treatment per week, to contain costs

A. Cells are only susceptible to treatment by radiation during certain phases of the cell cycle Rationale: 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 child is hospitalized with pneumonia. The nurse assesses an increase in the work of breathing and in the respiratory rate. What intervention should the nurse do first to help this child? A. Elevate the head of the bed B. Administer oxygen C. Notify the health care provider D. Obtain oxygen saturation levels

A. Elevate the head of the bed Rationale: The child who is experiencing increased work of breathing should be placed in a position to better open the airway and provide more room for lung expansion. Generally this is accomplished by elevating the head of the bed. If this does not improve the work of breathing, then administering oxygen should be done. The oxygen saturation should be measured because it will provide information as to the severity of the respiratory problem, but this measurement will not directly help the child. The health care provider should be notified if the child continues to deteriorate.

The nurse is providing care to an adolescent who has been diagnosed with cancer. Which actions would be appropriate for the nurse to take to foster the adolescent's ability to cope? Select all that apply. A. Encourage the adolescent to engage in usual activities. B. Encourage the adolescent to make plans for the future. C. Control the amount of information given to others about the adolescent's condition. D. Discourage relationships with other adolescents who have cancer E. Act as an advisor, not a friend, to promote cooperation in the care plan. F. Encouraging postponing the return to school for as long as possible.

A. Encourage the adolescent to engage in usual activities. B. Encourage the adolescent to make plans for the future. C. Control the amount of information given to others about the adolescent's condition. Rationale: The nurse should encourage usual activities and plans for the future and control the amount of information outsiders know about the child's condition. Relationships with other clients with cancer should be encouraged as well as an early return to school. The nurse should be a friend as well as an advisor to the adolescent.

The pediatric nurse examines the radiographs of a client that indicate lesions on the bone. This finding is indicative of: A. Ewing sarcoma. B. Hodgkin disease. C. non-Hodgkin lymphoma. D. neuroblastoma.

A. Ewing sarcoma. Rationale: Radiographs that show lesions on the bone may indicate tumors (e.g., Ewing sarcoma, osteosarcoma) or metastasis of tumors. Osteosarcoma is the most common type of bone malignancy in children. It occurs primarily in the long bones. Ewing sarcoma is a highly malignant bone cancer. It occurs in the pelvis, chest wall, vertebrae, and midshaft of the long bones. Neuroblastomas are seen in children younger than 5 years old and arise from immature nerve cells and the adrenal glands. Hodgkin disease develops from the immune system. Non-Hodgkin lymphoma is a blood cancer.

A child is scheduled for chemotherapy as treatment for leukemia. As the nurse is collaborating with another colleague, the discussion turns to the client's first phase of chemotherapy. This phase is known as: A. induction. B. sanctuary. C. delayed intensive therapy. D. maintenance.

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

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. Encourage frequent, thorough handwashing. C. Provide a low-carbohydrate, low-protein diet. D. Encourage frequent contact with multiple visitors. E. Cheer up the environment with fresh flowers and plants.

A. Have the child sleep in a single bed and room. B. Encourage frequent, thorough handwashing. Rationale: To reduce the risk for infection, the nurse should teach the child and parents about minimizing the child's exposure to potentially infectious situations. The nurse should encourage the parents to arrange for the child to sleep in a single bed and room and, if possible, avoid close contact with other family members who may be developing upper respiratory tract infections. Thorough and frequent handwashing, especially after using the bathroom and before eating, is essential. A high-calorie, high-protein diet helps to rebuild white blood cells and should be encouraged. If possible, the child's exposure to large crowds and visitors should be limited because of the increased risk of infection from these individuals. Fresh flowers and plants should be avoided because they could harbor mold spores.

During a physical examination of a 13-year-old boy, the nurse observes a single, enlarged, rubbery-feeling cervical lymph node in the armpit. The boy also reports unexplained loss of weight and malaise. Which condition should the nurse most suspect in this client? A. Hodgkin lymphoma B. Non-Hodgkin lymphoma C. Acute lymphoblastic leukemia (ALL) D. Acute myeloid leukemia (AML)

A. Hodgkin lymphoma Rationale: Symptoms of Hodgkin disease usually begin with the enlargement of only one painless, enlarged, rubbery-feeling cervical lymph node. Other nodes then become involved, along with the liver, spleen, bone marrow, and, eventually, the central nervous system. The child usually reports accompanying symptoms of anorexia, malaise, night sweats, and loss of weight. Fever may be present. Non-Hodgkin lymphomas tend to involve the lymph glands of the neck and chest most commonly, although axillary, abdominal, or inguinal nodes may be the first involved. If mediastinal lymph glands are swollen, the child may notice a cough or chest "tightness." Because mediastinal nodes press on the veins returning blood from the head, edema of the face may result. The first symptoms of ALL in children usually are those associated with decreased RBC production (anemia) such as pallor, low-grade fever, and lethargy. Children with AML have the same symptoms as those with ALL.

The nurse is educating the parents of a 7-year-old boy with asthma about the medications that have been prescribed. Which drug would the nurse identify as an adjunct to a β2-adrenergic agonist for treatment of bronchospasm? A. Ipratropium B. Montelukast C. Cromolyn D. Theophylline

A. Ipratropium Rationale: Ipratropium is an anticholinergic administered via inhalation to produce bronchodilation without systemic effects. It is generally used as an adjunct to a β2-adrenergic agonist. Montelukast decreases the inflammatory response by antagonizing the effects of leukotrienes. Cromolyn prevents release of histamine from sensitized mast cells. Theophylline provides for continuous airway relaxation.

An infant with a high respiratory rate is NPO and is receiving IV fluids. What assessment(s) will the nurse make to assure this infant is hydrated? Select all that apply. A. Measure skin turgor B. Palpate anterior fontanel C. Determine urine output D. Review electrolyte laboratory results E. Assess the lung sounds

A. Measure skin turgor B. Palpate anterior fontanel C. Determine urine output Rationale: IV fluids are necessary many times for infants and children who are experiencing high respiratory rates. The high respiratory rates make the child very tired from the increased work of breathing. In an infant there are very little reserves so the infant tires very quickly, especially when the work of sucking is added to the compromised respiratory state. To determine if the infant is hydrated the nurse should assess the skin turgor, palpate for a flat anterior fontanel, observe for moist mucus membranes and measure the urine output. The urine output should be 1 to 2ml/kg/hr. The electrolyte laboratory results will tell the nurse if the infant has an electrolyte imbalance, not a fluid imbalance. Assessing the lung sounds will not tell if the child is hydrated, only if the lungs are "wet" and fluid overloaded. The infant would also exhibit additional signs of respiratory distress if the lungs are fluid overloaded.

When providing care for a child immediately after a bone marrow aspiration, which nursing action is priority? A. Monitor the site dressing and vital signs. B. Evaluate pain and administer medication. C. Educate the family on proper handwashing. D. Allow the child to play with a doll and syringe.

A. Monitor the site dressing and vital signs. Rationale: Monitoring vital signs and the dressing for signs of bleeding is a priority after bone marrow aspiration. Although providing pain medication, educating on handwashing, and allowing for therapeutic play are all important, these should only be performed after first stabilizing the child.

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. Observation reveals nystagmus and head tilt. B. Vital signs show blood pressure measures 120/80 mm Hg. C. Examination shows temperature of 101.4° F (38.6°C) and headache. D. Observation reveals a cough and labored breathing.

A. Observation reveals nystagmus and head tilt. Rationale: 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.

The nurse is preparing to provide tracheostomy care to an infant. After gathering the necessary equipment, what would the nurse do next? A. Position the infant supine with a towel roll under the neck. B. Cut the new tracheostomy ties to the appropriate length. C. Cut the tracheostomy ties from around the tracheostomy tube. D. Cleanse around the site of the tracheostomy with the prescribed solution.

A. Position the infant supine with a towel roll under the neck. Rationale: After gathering the necessary equipment, the nurse would position the infant supine with a blanket or towel roll to extend the neck. Then the nurse would open all the packaging and cut the new tracheostomy ties to the appropriate length. This would be followed by cleaning the site with the appropriate solution and then rinsing it. After placing the precut sterile gauze under the tracheostomy tube, the nurse would cut the ties and remove them from the tube while an assistant holds the tube in place.

A hospitalized child suddenly begins reporting "my chest hurts," is tachypneic, and has tachycardia. The nurse auscultates the lung sounds and finds absent breath sounds on one side. After notifying the health care provide what action would the nurse take first? A. Prepare for chest tube insertion B. Administer oxygen C. Obtain oxygen saturation measurement D. Prepare for mechanical ventilation

A. Prepare for chest tube insertion Rationale: A pneumothorax is a collection of air in the pleural space. Trapped air consumes space in the pleural cavity causing a partial or complete collapse. The priority symptom a nurse would assess is the decreased or absent lung sounds on the affected side. A pneumothorax can occur spontaneously in a healthy child or it can occur in a child with chronic lung disease, has been on a ventilator or has had thoracic surgery. Additional symptoms the child would experience would be chest pain, tachypnea, retractions, grunting, cyanosis and tachycardia. Many of these symptoms could be present with any child with an acute or chronic lung disease or respiratory distress, but the defining symptom is the absent breath sounds. The treatment for a pneumothorax is with a chest tube so the priority action would be to gather supplies and prepare for the health care provider to insert a chest tube. Obtaining an oxygen saturation level measurement will only provide data, it will not help the child in distress. Oxygen may need to be administered, but with a pneumothorax it will be very ineffective. Mechanical ventilation would be a last resort and could actually make the situation worse if the lung was not reinflated.

What is the priority action the nurse should take when caring for a child newly diagnosed with Wilms tumor (nephroblastoma)? A. Protect the abdomen from manipulation. B. Assess for constipation. C. Control acute pain. D. Obtain a catheterized urine specimen.

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

A child requires supplemental oxygen therapy at 8 liters per minute. Which delivery device would the nurse most likely expect to be used? A. Simple mask B. Venturi mask C. Nasal cannula D. Oxygen hood

A. Simple mask Rationale: A simple mask would be used to deliver a flow rate of 8 liters per minute. A Venturi mask would be used to deliver a specific percentage of oxygen, from 24% to 50%. A nasal cannula would be used to deliver no more than 4 liters per minute. An oxygen hood requires a liter flow of 10 to 15 liters per minute.

The nurse is caring for a 3-year-old girl with a respiratory disorder. The nurse anticipates the need for providing supplemental oxygen to the child when performing which action? A. Suctioning a tracheostomy tube B. Administering drugs with a nebulizer C. Providing tracheostomy care D. Suctioning with a bulb syringe

A. Suctioning a tracheostomy tube Rationale: Supplemental oxygenation may be necessary before, and is always performed after, suctioning a child with a tracheostomy tube. Providing tracheostomy care, administering drugs with a nebulizer, and suctioning with a bulb syringe do not require supplemental oxygen.

The nurse is caring for a 17-year-old girl in the terminal phase of osteosarcoma. Which action demonstrates integration of the recommendations of the American Academy of Pediatrics (AAP) Committee on Bioethics? A. Telling the child exactly what to expect of further treatments. B. Encouraging the child to support the wishes of her parents. C. Explaining the prognosis using accepted clinical terminology. D. Allowing the child to listen during discussions of the care plan.

A. Telling the child exactly what to expect of further treatments. Rationale: The committee recommends telling the child exactly what to expect of further treatments and procedures, explaining the prognosis in a developmentally appropriate way to ensure the child's understanding, and endeavoring to gain the child's candid opinion of the proposed care plan. It also recommends that decision-making for older children and adolescents should include the assent of the child or adolescent.

The child has been diagnosed with cancer and is being treated with chemotherapy. Which findings are common side effects of this type of treatment? Select all that apply. A. The child's mother states, "It seems like he catches every bug that comes along." B. The child's teeth are enlarged. C. The child has no hair on his head. D. The child's mother states that she often has to repeat herself because he can't hear very well. E. The child reports feeling nauseated.

A. The child's mother states, "It seems like he catches every bug that comes along." C. The child has no hair on his head. D. The child's mother states that she often has to repeat herself because he can't hear very well. E. The child reports feeling nauseated. Rationale: Common adverse effects of chemotherapeutic drugs are: immunosuppression, alopecia, hearing changes, and nausea. Another common adverse effect is microdontia, not enlarged teeth.

A 5-year-old girl is cyanotic, dusky, and anxious when she arrives in the emergency department. Which action would be most appropriate? A. Ventilating the child with a bag-valve-mask B. Estimating the child's weight using a Broselow tape C. Providing therapy using automated external defibrillation D. Using rescue breathing and chest compressions

A. Ventilating the child with a bag-valve-mask Rationale: The child is exhibiting signs of ineffective oxygenation and ventilation. Therefore, ventilating the child with a bag-valve-mask and 100% oxygen would be effective and efficient. Estimating the child's weight with a Broselow tape is typically done by ambulatory care providers. According to the American Heart Association, automated external defibrillators are recommended for use in children who are older than age 1 year who have no pulse and have suffered a sudden, witnessed collapse outside the hospital setting. Rescue breathing and chest compressions are implemented for children who are not breathing and do not have a pulse or when the pulse rate is less than 60 beats per minute.

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

A. cheeseburger, broccoli, and fresh strawberries Rationale: 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 child with cancer has developed neutropenia and is in isolation with neutropenic precautions. What nursing assessment takes priority for this child? A. infection symptoms B. vital signs C. mucositis D. bleeding

A. infection symptoms The neutrophils are the primary means of fighting bacterial infection. When the neutrophil count is very low, the child has the potential to have an overwhelming bacterial infection. The child is at the greatest risk when the neutrophil count is less than 500/mcl (0.50 ×109/l). The nurse's priority would be to assess for signs and symptoms of infection. A bacterial infection can be life-threatening for this child. This child would be placed in neutropenic precautions. This is a form of isolation where the child is protected from health care workers and outside visitors. Among other precautions, no plants would be allowed in the room, raw fruits or vegetables would not be consumed unless washed under running water and lightly scrubbed, and the child should have no rectal examinations or medications and not experience a urinary catheterization. To prevent an infection, the nurse would administer broad spectrum antibiotics. The vital signs should be assessed every 4 hours, and alterations could indicate more problems than just infection. Mucositis occurs when there is an ulcerated oral mucosa. It should be assessed but is not the priority. Bleeding would be more related to low platelet count and not neutrophils.

A child with cancer is dying and in hospice care. When developing the plan of care, which intervention should the nurse include as the primary focus? A. keeping the child pain-free B. managing the symptoms of dyspnea C. providing emotional support D. delivering appropriate developmental care

A. keeping the child pain-free Rationale: Children die from cancer. They may die at home or in the hospital, and hospice care can be provided in either setting. Children with terminal cancer often experience a great deal of pain, particularly when death is imminent. The primary goal of caring for a dying child is the prevention and alleviation of pain. The nurse would work with the parents to determine the pharmacologic and nonpharmacologic methods which work best. Many times, dyspnea and agitation can occur as a result of pain. These symptoms are reduced with pain management. Any care to the child, even in hospice care, should be developmentally appropriate. Emotional support is a necessity, both for the child and the parents, but pain relief is the priority.

The nurse is evaluating the complete blood count of a 7-year-old child with a suspected hematological disorder. Which finding is associated with an elevated mean corpuscular volume (MCV)? A. macrocytic red blood cells (RBCs) B. decreased white blood cells (WBCs) C. platelet count of 250,000 D. hemoglobin (Hgb) of 11.2 g/dl (112 g/L)

A. macrocytic red blood cells (RBCs) Rationale: When the MCV is elevated, the RBCs are larger and referred to as macrocytic. The WBC count does not affect the MCV. The platelet count and Hgb are within normal ranges for a 7-year-old child.

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

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

The nurse is reviewing the medical record of a child diagnosed with Hodgkin lymphoma at the asymptomatic stage. Which would the nurse identify as typically the first sign reported by the child? A. painless, enlarged lymph node B. anorexia C. weight loss D. night sweats

A. painless, enlarged lymph node Rationale: Children with Hodgkin lymphoma typically present with swollen, painless, and rubbery-feeling lymph nodes in the cervical or supraclavicular region. Depending on the extent of the disease at diagnosis, other symptoms may be present. However, this child was diagnosed in stage I (asymptomatic). If the lymph nodes of the chest are involved, the child has moved to the symptomatic stages and may experience dyspnea and cough. Chest pain may result from the pressure exerted by the enlarged nodes. General symptoms can also include fever, drenching night sweats, and weight loss.

The nurse is assessing a child and notices pinpoint hemorrhages appearing on several different areas of the body. The hemorrhages do not blanch on pressure. The nurse documents this finding as: A. petechiae. B. purpura. C. ecchymosis. D. poikilocytosis.

A. petechiae. Rationale: Petechiae are pinpoint hemorrhages that occur anywhere on the body and do not blanch with pressure. Purpura are larger areas of hemorrhage in which blood collects under the tissues and appear purple in color. Ecchymosis refers to areas of bruising. Poikilocytosis refers to the variation in the size and shape of the red blood cells commonly found in children with thalassemia.

The nurse develops a meal plan for a child with iron-deficiency anemia. Which meal would the nurse teach the parent has the highest amount of iron? A. red meat, eggs, oatmeal, and dried fruit B. chicken, corn, brown rice, and oranges C. pork, broccoli, white rice, and strawberries D. tuna salad with eggs, whole wheat crackers, and blueberries

A. red meat, eggs, oatmeal, and dried fruit Rationale: Iron-deficiency anemia occurs when the blood does not have enough iron to produce hemoglobin. The anemia can be corrected via iron supplementation, nutrition, and even blood transfusion if the anemia is severe. Foods that have the highest sources of iron include red meat, tuna, eggs, tofu, enriched grains, dried beans and peas, dried fruits, green leafy vegetables and iron-fortified breakfast cereals. The nurse should teach the meal containing red meat, eggs, oatmeal, and dried fruit has the highest amount of iron. Chicken has less iron than red meat, and corn has only a small amount. All the fruits listed have iron, but when dried, the iron levels increase. Pork has a limited amount of iron, and white rice contains almost no iron. Brown rice and whole grains contain higher iron amounts.

The oncology nurse is alert for clients displaying signs and symptoms of disseminated intravascular coagulation (DIC). Which symptom would alert the nurse to this emergency condition? A. uncontrolled bleeding B. platelet count 10,000/mm3 (10 ×109/L) C. decreased D-dimer assay D. increased antithrombin III levels

A. uncontrolled bleeding Rationale: DIC is a complex condition that is secondary to other problems such as sepsis. It is life-threatening. Symptoms of DIC include uncontrolled bleeding, petechiae, ecchymosis, purpuric rash, prolonged prothrombin time and partial thromboplastin time, an increased D-dimer assay, decreased antithrombin III levels, below-normal fibrinogen levels, and increased fibrin-degradation products. The platelet count is decreased in DIC. In moderate to severe cases it is less than 50,000/mm3 (50 ×109/L). The symptom the nurse would see first is uncontrolled bleeding. The remainder are laboratory results that would be used to make the diagnosis.

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. vitamin B12 deficiency B. iron deficiency C. sickle-cell disorder D. acute blood loss

A. vitamin B12 deficiency Rationale: 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.

In discussing the causes of iron-deficiency anemia in children with a group of nurses, the following statements are made. Which of these statements is a misconception related to iron-deficiency anemia? A. "A family's economic problems are often a cause of malnutrition." B. "Milk is a perfect food, and babies should be able to have all the milk they want." C. "Caregivers sometimes don't understand the importance of iron and proper nutrition." D. "Children have a hard time getting enough iron from food during their first few years."

B. "Milk is a perfect food, and babies should be able to have all the milk they want." Rationale: Babies with an inordinate fondness for milk can take in an astonishing amount and, with their appetites satisfied, may show little interest in solid foods. These babies are prime candidates for iron-deficiency anemia. Many children with iron-deficiency anemia, however, are undernourished because of the family's economic problems. A caregiver's knowledge deficit about nutrition is often present. Because only 10 percent of dietary iron is absorbed, a diet containing 8 to 10 mg of iron is needed for good health. During the first years of life, obtaining this quantity of iron from food is often difficult for a child. If the diet is inadequate, anemia quickly results.

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

B. "Preterm infants are at risk for iron-deficiency anemia." Rationale: 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.

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 both parents have the gene." C. "Sickle cell disease is passed to a fetus when one of the parents has the gene." D. "Sickle cell disease can be passed to the fetus in many ways. We will know more at birth."

B. "Sickle cell disease is passed to a fetus when both parents have the gene." Rationale: 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 caring for a child with aplastic anemia. The nurse is reviewing the child's blood work and notes the granulocyte count is about 500, platelet count is over 20,000, and the reticulocyte count is over 1%. The parents ask if these values have any significance. Which response by the nurse is appropriate? A. "The doctor will discuss these findings with you when he comes to the hospital." B. "These values will help us monitor the disease." C. "These labs are just common labs for children with this disease." D. "I'm really not allowed to discuss these findings with you."

B. "These values will help us monitor the disease." Rationale: This response answers the parent's questions. In the nonsevere form, the granulocyte count remains about 500, the platelets are over 20,000, and the reticulocyte count is over 1%. The other responses do not address what the parents are asking and would block therapeutic communication.

The nurse in the emergency department is caring for a 10-year-old female child with sickle cell crisis. Child rates pain 10 on a scale of 0 to 10. Vital signs: 99.8°F (37.6°C); heart rate, 122 beats/min; blood pressure, 92/50 mm Hg; respiratory rate, 26 breaths/min; oxygen saturation, 92% on room air. The nurse receives orders for the child. Click to highlight the order(s) that needs to be implemented immediately. A. Administer acetaminophen for headache or temperature greater than 101°F (38.3°C). B. Administer oxygen to maintain oxygen saturation greater than 95%. C. Start normal saline continuous intravenous (IV) infusion at 200 ml/hr. D. Administer 100 mcg/kg morphine IV for pain prn q4 hours. E. Initiate a regular diet as tolerated.

B. Administer oxygen to maintain oxygen saturation greater than 95%. C. Start normal saline continuous intravenous (IV) infusion at 200 ml/hr. D. Administer 100 mcg/kg morphine IV for pain prn q4 hours. Rationale: Nursing interventions should always be prioritized according to the ABCs (airway, breathing, circulation). Because the child's oxygen saturation is only 92% on room air, the nurse should apply oxygen to achieve an oxygen saturation of 95% or greater. After implementing measures to ensure a patent airway, the nurse should address circulation. In sickle cell crisis, the red blood cells (RBCs) clump together blocking microcirculation, which causes pain due to ischemia. The nurse should start intravenous (IV) fluids to prevent clumping of the RBCs to improve circulation. The child is reporting pain that is a 10 out of 10. The child will require an intravenous (IV) opioid analgesic such as morphine. The child's temperature is slightly elevated at 99.8°F (37.6°C). This is most likely due to dehydration (water is cooling, and less water in the body will increase the temperature slightly). Therefore, acetaminophen does not need to be administered. Initiating a regular diet at this time is not a priority. The child's respiratory rate of 18 breaths/min are within normal limits.

A group of nursing students are reviewing the medications used to treat asthma. The students demonstrate understanding of the information when they identify which agent as appropriate for an acute episode of bronchospasm? A. Salmeterol B. Albuterol C. Ipratropium D. Cromolyn

B. Albuterol Rationale: Albuterol is a short-acting β2-adrenergic agonist that is used for treatment of acute bronchospasm. Salmeterol is a long-acting β2-adrenergic agonist used for long-term control or exercise-induced asthma. Ipratropium is an anticholinergic agent used as an adjunct to β2- adrenergic agonists for treatment of bronchospasm. Cromolyn is a mast cell stabilizer used prophylactically but not to relieve bronchospasm during an acute wheezing episode.

The nurse is preparing to send a child with cancer for a radiation treatment. Which medication should the nurse provide to premedicate the child for this procedure? A. Analgesic B. Antiemetic C. Antipyretic D. Antineoplastic

B. Antiemetic Rationale: Radiation has systemic effects. Radiation sickness that includes nausea and vomiting is the most frequently encountered systemic effect. It also occurs to some extent as a result of the release of toxic substances from destroyed tumor cells. To counteract this, a child is prescribed an antiemetic before each procedure. The child does not need an analgesic, antipyretic, or antineoplastic agent prior to receiving a radiation treatment.

The nurse is caring for a 7-year-old boy experiencing respiratory distress who is scheduled to have a chest radiograph. What would be most important for the nurse to include in the child's plan of care? A. Administering a sedative to help calm the child B. Assisting the child to lie still during the chest radiograph C. Accompanying the child to continue observation D. Informing the child that he might hear a loud banging noise

B. Assisting the child to lie still during the chest radiograph Rationale: Chest radiographs that disclose alterations in normal anatomy or lung expansion, or evidence of pneumonia, tumor, or foreign body, are commonly performed for respiratory emergencies. Therefore, the nurse would need to assist the child in remaining still during the procedure. A sedative may be ordered for magnetic resonance imaging (MRI). Accompanying the child to continue observation would be necessary if the child was to undergo a computed tomography scan. Telling the child about a loud banging noise would be appropriate if the child was having an MRI.

The child is prescribed liquid ferrous sulfate. The nurse should encourage the child to take which action immediately after each dose to best eliminate possible side effects? A. Drink a glass of milk B. Brush his or her teeth C. Remain in an upright position for at least 15 minutes D. Not eat or drink for one hour

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

A group of nursing students are reviewing information about the variations in respiratory anatomy and physiology in children in comparison to adults. The students demonstrate understanding of the information when they identify which finding? A. Children's demand for oxygen is lower than that of adults. B. Children develop hypoxemia more rapidly than adults do. C. An increase in oxygen saturation leads to a much larger decrease in pO2. D. Children's bronchi are wider in diameter than those of an adult.

B. Children develop hypoxemia more rapidly than adults do. Rationale: Children develop hypoxemia more rapidly than adults do because they have a significantly higher metabolic rate and faster resting respiratory rates than adults do, which leads to a higher demand for oxygen. A smaller decrease in oxygen saturation reflects a disproportionately much larger decrease in pO2. The bronchi in children are narrower than in adults, placing them at higher risk for lower airway obstruction.

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

B. Children's cancers, unlike those of adults, often are detected accidentally, not through screening. Rationale: Children's cancers are often found during a routine checkup, following an injury, or when symptoms appear—not through screening procedures or other specific detection practices. A very small percentage of children may be followed closely because they are known to be at high risk genetically. Most children's cancers are highly responsive to therapy. Few prevention strategies are available for children, although many are known to be effective for adults. Several lifestyle and environmental influences regarding children's cancers are suspect, but few have been scientifically documented. The reverse is true in the adult population.

A nurse is reviewing the medical record of a child receiving chemotherapy and notes that the child is receiving an alkylating agent. Which medication falls into the medication classification as a potential agent? Select all that apply. A. Methotrexate B. Cyclophosphamide C. Vincristine D. Dactinomycin E. Chlorambucil

B. Cyclophosphamide E. Chlorambucil Rationale: Cyclophosphamide and chlorambucil are alkylating agents. Methotrexate is an antimetabolite. Vincristine is a plant alkaloid. Dactinomycin is an antibiotic.

A nursing instructor is describing childhood hematologic disorders to students. Which would the instructor include as being commonly affected by hematologic disorders? Select all that apply. A. Plasma B. Erythrocytes C. Leukocytes D. Thrombocytes E. Whole blood

B. Erythrocytes C. Leukocytes D. Thrombocytes Rationale: The formed elements, the erythrocytes, leukocytes, and thrombocytes are the portions of the blood most commonly affected by hematologic disorders in children. Plasma and whole blood are not major sites of hematologic disease.

A nurse is preparing a teaching plan for the family of a child with allergic rhinitis. When describing the immune reaction that occurs, the nurse would identify the role of which immunoglobulin? A. IgA B. IgE C. IgG D. IgM

B. IgE Rationale: The immunoglobulin involved in the immune response associated with allergic rhinitis is IgE. IgA, IgG, and IgM are not involved in this response.

A nurse is teaching the parents of a child with sickle cell disease about factors that predispose the child to a sickle cell crisis. The nurse determines that the teaching was successful when the parents identify what as a factor? A. Fluid overload B. Infection C. Respiratory distress D. Pallor

B. Infection Rationale: Factors that may precipitate a sickle cell crisis include: fever, infection, dehydration, hot or humid environment, cold air or water temperature, high altitude, or excessive physical activity. Respiratory distress and pallor are general signs and symptoms of a sickle cell crisis.

A child with hypoplastic anemia develops hemosiderosis. What nursing instruction promotes the treatment goals? A. Avoid all products containing aspirin B. Infuse deferoxamine at home C. Administer daily doses of ferrous sulfate D. Adhere to a strict schedule of prednisone

B. Infuse deferoxamine at home Rationale: Treatment of anemia is through transfusion of packed red blood cells to increase erythrocyte levels. As a result of the necessary number of transfusions, hemosiderosis or the deposition of iron in body tissue can occur. Treatment for hemosiderosis is iron chelation through the use of subcutaneous infusions of deferoxamine. These infusions are to be given at home overnight for 5 to 6 nights per week. There is not enough information to determine if aspirin should be avoided. Ferrous sulfate will add more iron to the child's body and should be avoided. Children with congenital hypoplastic anemia may receive corticosteroid therapy along with transfusions of packed RBCs to raise erythrocyte levels.

A nursing instructor is preparing a class on chronic lung disease. What information would the instructor include when describing this disorder? A. It is a result of cystic fibrosis. B. It is seen most commonly in premature infants. C. It typically affects females more often than males. D. It is characterized by bradypnea.

B. It is seen most commonly in premature infants. Rationale: Chronic lung disease, formerly known as bronchopulmonary dysplasia, is often diagnosed in infants who have experienced respiratory distress syndrome, most commonly seen in premature infants. Male gender is a risk factor for development. Tachypnea and increased work of breathing are characteristic of chronic lung disease.

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

B. Not to pick or irritate the nose Rationale: Idiopathic thrombocytopenic purpura (ITP) occurs as an immune response following a viral infection. It produces antiplatelet antibodies that destroy platelets. This leads to the classic symptoms of petechiae, purpura, and excessive bruising. Without adequate platelets, children bleed easily from lesions. If the child "picks" the nose, an area could be opened and bleeding could occur. Folic acid will have no effect on the disease process. The lesions are not itchy and are open or draining, so cold water washing and soothing lotions are not required.

The nurse is preparing to perform a physical examination of a child with asthma. Which technique would the nurse be least likely to perform? A. Inspection B. Palpation C. Percussion D. Auscultation

B. Palpation Rationale: When examining the child with asthma, the nurse would inspect, auscultate, and percuss. Palpation would not be used.

Which intervention is best to use with the 6-year-old who has developed stomatitis as a side effect of chemotherapy? A. Limit foods to cool, clear liquids B. Practice frequent, gentle oral hygiene C. Use lidocaine rinses D. Have the child freely choose desired foods and beverages

B. Practice frequent, gentle oral hygiene Rationale: Frequent, gentle oral hygiene will keep the vulnerable oral mucosa clean and will prevent secondary infection. Offering only cool, clear liquids will limit nutrition. Freely choosing foods and beverages gives some control to the 6-year-old but is likely to result in ingestion of foods that are irritating to the mouth, lips, and throat. Lidocaine used as a rinse can create risks for children younger than 8 years because often some is swallowed, and this inhibits the gag reflex.

A child is receiving chemotherapy and develops stomatitis. The nurse identifies a nursing diagnosis of Impaired oral mucous membranes related to the effects of chemotherapy. What instructions would the nurse include in the child's plan of care? Select all that apply. A. Vigorously rub the child's gums with gauze to clean them. B. Provide various soft and bland foods to minimize further irritation. C. Have the child rinse the mouth with lukewarm water three times a day. D. Give the child acidic foods (e.g., orange juice) to cleanse the mouth. E. Apply a lip balm or petroleum jelly to prevent cracking.

B. Provide various soft and bland foods to minimize further irritation. C. Have the child rinse the mouth with lukewarm water three times a day. E. Apply a lip balm or petroleum jelly to prevent cracking. Rationale: For the child with stomatitis, the nurse should provide soft foods to prevent further abrasions, have the child rinse the mouth three times a day with lukewarm water to promote comfort and healing, avoid giving the child acidic foods that would further irritate the tissue, and apply a lip balm or petroleum jelly to prevent cracking of the lips. The nurse should offer a soft toothbrush to minimize discomfort.

The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurse anticipates which test as most helpful in determining the extent of the child's hypoxia? A. Pulmonary function test B. Pulse oximetry C. Peak expiratory flow D. Chest radiograph

B. Pulse oximetry Rationale: Pulse oximetry is a useful tool for determining the extent of hypoxia. It can be used by the nurse for continuous or intermittent monitoring. Pulmonary function testing measures respiratory flow and lung volumes and is indicated for asthma, cystic fibrosis, and chronic lung disease. Peak expiratory flow testing is used to monitor the adequacy of asthma control. Chest radiographs can show hyperinflation, atelectasis, pneumonia, foreign bodies, pleural effusion, and abnormal heart or lung size.

Which nursing diagnosis should the nurse identify as being the most appropriate for a child with idiopathic thrombocytopenic purpura? A. Risk for infection related to abnormal immune system B. Risk for bleeding related to insufficient platelet formation C. Risk for altered urinary elimination related to kidney impairment D. Ineffective breathing pattern related to decreased white blood count

B. Risk for bleeding related to insufficient platelet formation Rationale: Idiopathic thrombocytopenic purpura is the result of a decrease in the number of circulating platelets in the presence of adequate megakaryocytes, which are precursors to platelets. Because bleeding can occur with this disease process, the diagnosis most appropriate for the client at this time is risk for bleeding related to insufficient platelet formation. Reduced numbers of platelets would not increase the client's risk for infection. Reduced numbers of platelets does not increase the client's risk for renal impairment. Reduced risk of platelets will not lead to an ineffective breathing pattern.

The nurse is assessing a 5-year-old girl who is anxious, has a high fever, speaks in a whisper, and sits up with her neck thrust forward. Based on these findings, what would be least appropriate for the nurse to perform? A. Providing 100% oxygen B. Visualizing the throat C. Having the child sit forward D. Auscultating for lung sounds

B. Visualizing the throat Rationale: The child is exhibiting signs and symptoms of epiglottitis, which can be life- threatening. Under no circumstances should the nurse attempt to visualize the throat. Reflex laryngospasm may occur, precipitating immediate airway occlusion. Providing 100% oxygen in the least invasive manner that is most acceptable to the child is a sound intervention, as is allowing the child to assume a position of sitting forward with the neck extended. Auscultation would reveal breath sounds consistent with an obstructed airway.

The nurse is caring for a child admitted with suspected leukemia. The nurse has taken the child's history and performed an assessment. The nurse will plan to prepare the child for which additional diagnostic test first? A. urinalysis B. complete blood cell count (CBC) C. bone marrow aspiration D. magnetic resonance imaging (MRI)

B. complete blood cell count (CBC) Rationale: After obtaining the child's history and symptoms, the nurse would prepare the child for laboratory blood studies to assess the child's white blood cell (WBC) count. A complete blood cell (CBC) count will provide data on the child's WBC level. A bone marrow aspiration would be scheduled based on the results of the CBC as it is required to confirm the diagnosis of leukemia. A urinalysis is done for many disorders. In regard to childhood cancers, it is done to assist assessment for neuroblastoma. MRIs can also be done for many disorders. Brain tumors are common childhood cancers where MRIs are used.

A nurse is caring for a child with Hodgkin disease who is in the induction phase of a chemotherapy regimen. The nurse explains to the parents that the goal of this phase is to: A. destroy any remaining cancer cells. B. kill enough cancerous cells to induce remission. C. destroy any residual cancer cells. D. follow up for recurrent disease or late effects.

B. kill enough cancerous cells to induce remission. Rationale: During induction, the initial phase, intensive therapy is given to kill enough cancerous cells to induce a remission. In the consolidation phase, intensive therapy is given to destroy remaining cancer cells. The maintenance phase is a designated period during which treatment is continued to destroy any residual cancer cells. During the observation phase, therapy has ended and the child is followed up for recurrent disease or late effects of treatment.

The nurse is caring for a toddler taking ferrous sulfate for severe iron-deficiency anemia. Which report by the parent is most concerning? A. "I brush my child's teeth once every day." B. "My child's stools are darker than usual." C. "I mix ferrous sulfate with milk in a bottle." D. "My child takes ferrous sulfate after meals."

C. "I mix ferrous sulfate with milk in a bottle." Rationale: Ferrous sulfate may not be absorbed if taken with milk or tea, and if the parent mixes the medicine with milk in a bottle, there is also concern that if the child does not drink the entire amount of medication. Ferrous sulfate may be taken after meals to prevent gastrointestinal irritation. Dark stools are a common side effect of ferrous sulfate. Parents should be encouraged to brush the child's teeth thoroughly to prevent teeth staining.

A parent asks the nurse about immunizing her 7-month-old daughter against the flu. Which response by the nurse would be most appropriate? A. "She really doesn't need the vaccine until she reaches 1 year of age." B. "She will probably receive it the next time she is to get her routine shots." C. "Since your daughter is older than 6 months, she should get the vaccine every year." D. "The vaccine has many side effects, so she wouldn't get it until she's ready to go to school."

C. "Since your daughter is older than 6 months, she should get the vaccine every year." Rationale: The current recommendations are for all children older than 6 months of age to be immunized yearly against influenza.

A parent calls the pediatric oncology clinic about the child having headaches after chemotherapy. What is the nurse's best advice? A. Administer ibuprofen every 6 hours. B. Use an ice pack on the child's head. C. Administer acetaminophen as needed. D. Administer oral hydrocodone as needed.

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

A teenage girl asks why chemotherapy causes hair loss. Which response by the nurse is accurate? A. Circulation to the head causes large doses of chemotherapy to reach the scalp. B. Hair is not a living tissue, and it is easily damaged by chemotherapy. C. Chemotherapy affects cancer cells and normal cells that multiply rapidly. D. Hair is exposed to the sun, which increases sensitivity to chemotherapy.

C. Chemotherapy affects cancer cells and normal cells that multiply rapidly. Rationale: 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.

A child with a pneumothorax has a chest tube attached to a water seal system. When assessing the child, the nurse notices that the chest tube has become disconnected from the drainage system. What would the nurse do first? A. Notify the physician. B. Apply an occlusive dressing. C. Clamp the chest tube. D. Perform a respiratory assessment.

C. Clamp the chest tube. Rationale: If a chest tube becomes disconnected from the water seal drainage system, the nurse would first clamp the chest tube to prevent air from entering the child's chest cavity. Then the nurse would perform a respiratory assessment and notify the physician. An occlusive dressing would be applied first if the chest tube became dislodged from the child's chest.

When performing the physical examination of a child with cystic fibrosis, what would the nurse expect to assess? A. Dullness over the lung fields B. Increased diaphragmatic excursion C. Decreased tactile fremitus D. Hyperresonance over the liver

C. Decreased tactile fremitus Rationale: Examination of a child with cystic fibrosis typically reveals decreased tactile fremitus over areas of atelectasis, hyperresonance over the lung fields from air trapping, decreased diaphragmatic excursion, and dullness over the liver when enlarged.

A high school football player has been diagnosed as having osteosarcoma of the femur. The parents are angry because they told their adolescent not to play football. Which health teaching points will the nurse include in the teaching plan for the adolescent and parents? A. There will be some discoloration of the leg following chemotherapy. B. Osteosarcoma often follows trauma, such as a football injury. C. Football injuries do not contribute to the development of a tumor. D. Tumor growth is related to the adolescent's dislike of milk.

C. Football injuries do not contribute to the development of a tumor. Rationale: Osteosarcoma is the most malignant form of bone cancer. It is caused by the embryonic mesenchymal tissue that forms in the bones. A football injury may predispose more scrutiny of a lesion, but it will not be the cause of the cancer, nor will the dislike of milk. Osteosarcoma may be treated with chemotherapy and radiation. It may also involve an amputation. The parents who state they are angry at their adolescent for playing football are more likely projecting their fears of the diagnosis and it what it means for their child's future.

A nurse is administering 100% oxygen to a child with a pneumothorax based on the understanding that this treatment is used primarily for which reason? A. Improve gas exchange B. Bypass the obstruction C. Hasten air reabsorption D. Prevent hypoxemia

C. Hasten air reabsorption Rationale: Administration of 100% oxygen is used to treat pneumothorax primarily because it hastens the reabsorption of air. Generally this is used only for a few hours. Although the oxygen also improves gas exchange and prevents hypoxemia, these are not the reasons for its use in this situation. There is no obstruction with a pneumothorax.

The parent contacts the health care provider because their preschool-age child has a temperature of 101.5°F (38.6°C). The child received outpatient chemotherapy 1 week ago. Which is the most appropriate response by the nurse? A. Instruct the parent to administer acetaminophen every 4 hours until the fever dissipates. B. Ask whether any family members or other close associates are ill. C. Have the parent bring the child to the pediatric oncology clinic as soon as possible. D. Instruct the parent to immediately obtain and give the antibiotic that the oncologist calls in to the pharmacy.

C. Have the parent bring the child to the pediatric oncology clinic as soon as possible. Rationale: The preschool-age child is considered immunosuppressed following recent chemotherapy. A fever can mean sepsis, which would require immediate investigation of blood and other body fluids to identify the organism, plus prompt treatment with an IV antibiotic. This can be accomplished only by seeing the pediatric oncologist and is likely to result in hospitalization. The other responses may be implemented after the child arrives at the clinic.

The nurse is discussing discharge instructions with the parents of a 6-year-old who had a tonsillectomy. What is the most important thing to stress? A. Administer analgesics. B. Encourage the child to drink liquids. C. Inspect the throat for bleeding. D. Apply an ice collar.

C. Inspect the throat for bleeding. Rationale: Inspecting the throat for bleeding is the most important discharge information to give the parents. Hemorrhage is unusual postoperatively but may occur any time from the immediate postoperative period to as late as 10 days after surgery. The nurse should inspect the throat for bleeding. Mucus tinged with blood may be expected, but fresh blood in the secretions indicates bleeding. Administering analgesics, encouraging fluids and applying an ice color are important but not as important as assessing for bleeding.

A school-aged child with cancer is receiving chemotherapy. Which nursing action would best promote the oral comfort of a child receiving chemotherapy? A. Having the child solely eat or drink cold foods to reduce mucosal pain B. Encouraging the use of acidic fruit juices to decrease mouth organisms C. Keeping the child's lips moist with petroleum jelly to prohibit cracking D. Vigorously brushing the teeth and gums to remove secretions

C. Keeping the child's lips moist with petroleum jelly to prohibit cracking Rationale: The mouth of a child receiving chemotherapy can become very inflamed and painful. It is important for the nurse to assess the oral cavity for redness, lesions, and plaques frequently. If the child is NPO, ice chips can be used to provide hydration to the mucosa. It is important to use a soft-bristle toothbrush when brushing the teeth. Excessive pressure on the gums will cause bleeding. If the gums are very inflamed, the child may use a saltwater solution or commercial mouthwash to keep the mouth clean. Instruct the child that this may cause burning. If burning or stinging occurs then discontinue the practice and provide solutions with pain medication. Using a petroleum product on the lips will provide hydration to the lips and keep them from being irritated or cracking. Drinking cold or hot foods will cause more pain in the mouth and may cause further irritation. Acidic fruit juices will cause increased pain and irritation in the mouth and may cause more inflammation.

When caring for an 8-year-old boy injured in an automobile accident, the nurse demonstrates understanding of the principles of Pediatric Advanced Life Support (PALS) by which action? A. Assisting ventilation with a bag-valve-mask (BVM) device B. Treating ventricular fibrillation using a defibrillator C. Managing compensated shock to prevent decompensated shock D. Treating supraventricular tachycardia using cardioversion

C. Managing compensated shock to prevent decompensated shock Rationale: The principles of PALS stress evaluating and managing compensated shock with the goal of preventing decompensated shock and thereby preventing cardiopulmonary arrest. Assisting ventilation with a BVM device, treating ventricular fibrillation using a defibrillator, and treating supraventricular tachycardia using cardioversion are interventions that may be used to treat both children and adults.

Bacterial pneumonia is suspected in a 4-year-old boy with fever, headache, and chest pain. Which assessment finding would most likely indicate the need for this child to be hospitalized? A. Fever B. Oxygen saturation level of 96% C. Tachypnea with retractions D. Pale skin color

C. Tachypnea with retractions Rationale: Pneumonia is usually a self-limiting disease. Children with bacterial pneumonia can be successfully managed at home if the work of breathing is not severe and oxygen saturation is within normal limits. Hospitalization would most likely be required for the child with tachypnea, significant retractions, poor oral intake, or lethargy for the administration of supplemental oxygen, intravenous hydration, and antibiotics. Fever, although common in children with pneumonia, would not necessitate hospitalization. An oxygen saturation level of 96% would be within normal limits. Pallor (pale skin color) occurs as a result of peripheral vasoconstriction in an effort to conserve oxygen for vital functions; this finding also would not necessitate hospitalization.

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 increased urinary output or vomiting. C. The child has redness or swelling at the central venous access site. D. The child has a bruise on the arm.

C. The child has redness or swelling at the central venous access site. Rationale: 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 is caring for a child admitted to the hospital for an open fracture of the femur following a motor vehicle accident. The nurse notes the following lab values: white blood cells 10,000/mm3, hemoglobin 7.9 g/dl (79 g/L), hematocrit 28%, platelets 151,000/mm3. Which nursing action is priority? A. Ask the child to rate pain on a scale 0 to 10. B. Administer antibiotics intravenously stat. C. Transfuse 1 unit of packed red blood cells. D. Provide the family with preoperative instructions.

C. Transfuse 1 unit of packed red blood cells. Rationale: In a situation where the child exhibits signs of anemia related to acute hemorrhage, the nurse should anticipate administering a transfusion of packed red blood cells to improve oxygenation and circulation. Administration of antibiotics, pain assessment, and family education can be performed after the beginning the blood transfusion.

The 2-year-old child receiving treatment for a cancer diagnosis is seen for a well-child checkup. Which health maintenance activity will the nurse exclude? A. plotting height and weight on a growth chart B. assessing dietary intake by addressing "picky eating" and "food jags" C. administering the measles, mumps, rubella (MMR) vaccine D. teaching the importance of taking water safety measures

C. administering the measles, mumps, rubella (MMR) vaccine Rationale: Live vaccines (viral or bacterial) should not be administered to an immunosuppressed child because of the risk of causing disease. The other health maintenance activities are important for the health maintenance of the child and should be included during the well-child visit.

The nurse is caring for an 18-month-old client with suspected iron-deficiency anemia. The nurse will expect to prepare the client for which laboratory tests first? A. hemoglobin and white blood cell levels B. iron and thrombocyte levels C. complete blood count and iron level D. ferritin and glycosylated hemoglobin levels

C. complete blood count and iron level Rationale: The nurse would expect the client to undergo a complete blood count, hemoglobin, hematocrit, reticulocyte, iron, ferritin, and free erythrocyte protoporphyrin levels to confirm the diagnosis. Laboratory evaluation will reveal decreased hemoglobin and hematocrit, decreased reticulocyte count, microcytosis, and hypochromia, decreased serum iron and ferritin levels, and increased FEP level. The other findings do not point to iron-deficiency anemia. A white blood cell is used to diagnosis infection. A thrombocyte level is used to assess platelet counts. Glycosylated hemoglobin levels are used to assess glucose levels over the past 2 to 3 months.

A child is sent to pediatric intensive care following surgery for a brain tumor. Which prescription would the nurse question? A. phenytoin B. docusate sodium C. elevate head of bed 90 degrees D. position on nonsurgical side

C. elevate head of bed 90 degrees Rationale: An anticonvulsant such as phenytoin will be prescribed if the child is experiencing seizures or if surgery is apt to induce seizures. A child will usually receive a stool softener such as docusate sodium to prevent straining with bowel movements. In general, a child is positioned on the side opposite the surgical incision. Keep the bed flat or only slightly elevated, again, as prescribed, because this helps to reduce intracranial pressure from accumulation of fluid in the surgical area. Therefore, the nurse would need to question the prescription to elevate the head of bed 90 degrees.

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

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

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. earache, stiff neck, or sore throat B. blisters, ulcers, or a rash appear C. temperature of 101°F (38.3°C) or greater D. difficulty or pain when swallowing

C. temperature of 101°F (38.3°C) or greater Rationale: 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.

The nurse is caring for a 6-year-old girl who was injured in a bicycle accident. Which question would be most important for the nurse to ask during the health history? A. "Has she been diagnosed with any chronic disorders?" B. "Is your daughter currently taking any medications?" C. "Is she allergic to any medications or drugs?" D. "Tell me how the bicycle accident happened."

D. "Tell me how the bicycle accident happened." Rationale: The priority inquiry is to determine the nature of the emergency so that appropriate interventions may be initiated. This will also provide direction for obtaining more in- depth information as time permits. Information about allergic reactions to drugs, medications being taken, and chronic disorders that may affect treatment will be gathered next.

The nurse is providing care to several children who have been brought to the clinic by the parents reporting cold-like symptoms. The nurse would most likely suspect sinusitis in which child? A. A 2-year-old with thin watery nasal discharge B. A 3-year-old with sneezing and coughing C. A 5-year-old with nasal congestion and sore throat D. A 7-year-old with halitosis and thick, yellow nasal discharge

D. A 7-year-old with halitosis and thick, yellow nasal discharge Rationale: The frontal sinuses, those most commonly associated with sinus infection, develop by age 6 to 8 years. Therefore, the 7-year-old would most likely experience sinusitis. In addition, this child also exhibits halitosis and a thick, yellow nasal discharge, other findings associated with sinusitis. Thin watery discharge in a 2-year-old is more likely to indicate allergic rhinitis. A 3-year-old with coughing and sneezing or a 5-year-old with nasal congestion and sore throat suggests the common cold.

Which diagnosis would be most appropriate for an infant with a large retinoblastoma after surgery? A. Anticipatory grieving related to change in body image B. Fear related to loss of normal vision C. Pain related to retinal removal D. Disturbed sensory perception related to enucleation

D. Disturbed sensory perception related to enucleation Rationale: Retinoblastoma is a congenital highly malignant tumor. When there is early detection the goal is to treat the tumor and preserve as much vision as possible. If there is advanced disease, enucleation is necessary. It may be difficult for an infant or young child to learn to see the world with only one eye and adapt to this sensation. Pain may be present but it is not related to retinal removal. The entire eye structure is removed. If the eye needs to be removed the child has not experienced normal vision for some time previous to surgery so there would not be fear relating to the loss of normal vision. Anticipatory grieving would occur more from the parents than the infant.

A child is brought to the emergency department by his parents because he suddenly developed a barking cough. Further assessment leads the nurse to suspect that the child is experiencing croup. What would the nurse have most likely assessed? A. High fever B. Dysphagia C. Toxic appearance D. Inspiratory stridor

D. Inspiratory stridor Rationale: A child with croup typically develops a bark-like cough often at night. This may be accompanied by inspiratory stridor and suprasternal retractions. Temperature may be normal or slightly elevated. A high fever, dysphagia, and toxic appearance are associated with epiglottitis.

A nurse is teaching the parents of a child diagnosed with cystic fibrosis about medication therapy. Which would the nurse instruct the parents to administer orally? A. Recombinant human DNase B. Bronchodilators C. Anti-inflammatory agents D. Pancreatic enzymes

D. Pancreatic enzymes Rationale: Pancreatic enzymes are administered orally to promote adequate digestion and absorption of nutrients. Recombinant human DNase, bronchodilators, and anti-inflammatory agents are typically administered by inhalation.

A child diagnosed with hemophilia presents with warm, swollen, painful joints. Which action will the nurse take first? A. Document the presence of hemarthrosis in the client's chart B. Notify the client's primary health care provider C. Assess the client's urine and stool for blood D. Prepare to administer factor replacement medication

D. Prepare to administer factor replacement medication Rationale: Many clients with hemophilia have repeated episodes of hemarthrosis or bleeding into the joints, and develop functional impairment of the joints, despite careful treatment. To assist in limiting impairment, the nurse would prepare to administer factor replacement medications, such as plasma, recombinant clotting factor VIII, or a clotting promotor medication. The nurse would document the finding, notify the health care provider, and assess the client for additional symptoms after limiting the amount of blood loss.

The nurse is examining a 5-year-old. Which sign or symptom is a reliable first indication of respiratory illness in children? A. Slow, irregular breathing B. A bluish tinge to the lips C. Increasing lethargy D. Rapid, shallow breathing

D. Rapid, shallow breathing Rationale: Tachypnea, or increased respiratory rate, is often the first sign of respiratory illness in infants and children. Slow, irregular breathing and increasing listlessness are signs that the child's condition is worsening. Cyanosis (a bluish tinge to the lips) or the degree of cyanosis present is not always an accurate indication of the severity of respiratory involvement.

The nurse is planning care for a school-aged child recovering from being hit by a motor vehicle while riding a bicycle. For what will the nurse assess to determine the onset of disseminated intravascular coagulation (DIC) in this child? A. blurred vision B. nausea and vomiting C. sudden onset of knee pain D. bleeding from intravenous sites

D. bleeding from intravenous sites Rationale: Disseminated intravascular coagulation (DIC) is an acquired disorder of blood clotting that results from excessive trauma. The child begins to develop petechiae or have uncontrolled bleeding from puncture sites from injections or intravenous therapy. Blurred vision, nausea, vomiting, and a sudden onset of knee pain are not manifestations associated with DIC.

After teaching a group of students about hemophilia, the instructor determines that the students have understood the information when they identify hemophilia A as involving a problem with: A. platelets B. factor IX. C. plasmin. D. factor VIII.

D. factor VIII. Rationale: In hemophilia A, the problem is with factor VIII, and in hemophilia B the problem lies with factor IX. Platelets are problematic in idiopathic thrombocytopenic purpura (ITP). Plasmin is involved in the pathophysiologic events of disseminated intravascular coagulation.

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

D. lethargy, bruises, and lymphadenopathy Rationale: Although all of these symptoms could be related to leukemia, the most likely are lethargy, bruises, and lymphadenopathy. Joint pain and swelling could also be juvenile arthritis or another disorder. Anorexia and weight loss are fairly nonspecific, as is abdominal pain, nausea, and vomiting. With ALL, because the bone marrow overproduces lymphocytes and therefore is unable to continue normal production of other blood components, the first symptoms of ALL in children usually are those associated with decreased RBC production (anemia) such as pallor, low-grade fever, and lethargy. A low thrombocyte (platelet) count will lead to petechiae and bleeding from oral mucous membranes and cause easy bruising on arms and legs. As the spleen and liver begin to enlarge from infiltration of abnormal cells, abdominal pain, vomiting, and anorexia occur. As abnormal lymphocytes invade the bone periosteum, the child experiences bone and joint pain. Central nervous system (CNS) invasion leads to symptoms such as headache or unsteady gait. On physical assessment, painless, generalized swelling of lymph nodes is revealed.