Nursing Care of the Child With an Alteration in Cellular Regulation/Hematologic or Neoplastic Disorder

The nurse is reinforcing teaching with a group of caregivers of children diagnosed with iron deficiency anemia. One of the caregivers tells the group, "I give my child ferrous sulfate." Which statement made by the caregivers is correct regarding giving ferrous sulfate?

"My husband gives our daughter orange juice when she takes her ferrous sulfate, so she gets Vitamin C." When ferrous sulfate is administered, it should be given between meals with juice (preferably orange juice, because vitamin C aids in iron absorption). For best results, iron should not be given with meals. Ferrous sulfate can cause constipation or turn the child's stools black

A nurse is providing dietary interventions for a 5-year-old with an iron deficiency. Which response indicates a need for further teaching?

"Red meat is a good option; he loves the hamburgers from the drive-thru." While iron from red meat is the easiest for the body to absorb, the nurse must limit fast food consumption from the drive-thru as it is also high in fat, fillers, and sodium

The nurse caring for a 14-year-old scheduled for magnetic resonance imaging (MRI) explains how the test works to the family. Which response accurately describes this test?

"The MRI uses radio waves and magnets to produce a computerized image of the body." 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 10-year-old who is receiving chemotherapy has received ondansetron before this therapy session. About an hour later, the child tells the nurse that his mouth feels really dry. The child has urinated several times and his skin turgor is normal. Which response by the nurse would be most appropriate?

"The drug you got to help with the nausea can cause dry mouth." Ondansetron is associated with dry mouth. Increasing IV fluids may or may not be appropriate. The child is urinating and his skin turgor is normal so it doesn't appear that he is dehydrated and in need of extra fluid. A severe allergic reaction would more likely be manifested by itching, hives, and increasing respiratory distress. Dry mouth is not an indicator of infection

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?

"These values will help us monitor the disease." 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.

A 9-year-old child with leukemia is scheduled to undergo an allogenic hematopoietic stem cell transplant. When teaching the child and parents, what information would the nurse include?

"We'll need to have a match to a donor." An allogenic hematopoietic stem cell transplantation (HSCT) refers to transplantation using stem cells from another individual that are harvested from the bone marrow, peripheral blood, or umbilical cord blood. With this type of transplant, human leukocyte antibody (HLA) matching must occur. Therefore, the lesser the degree of HLA matching in the donor, the higher the risk for graft rejection and graft-versus-host disease (GVHD). Regardless of the type of transplant, a period of purging of abnormal cells in the child is necessary and accomplished through high-dose chemotherapy or irradiation. The procedure is accomplished by intravenously infusing hematopoietic stem cells into the child

When explaining the procedure of bone marrow aspiration to a child with leukemia, what would be the best explanation?

"You will feel pressure on your hip from the needle." Bone marrow aspiration requires hard pressure to allow the needle to puncture the bone. It is usually done under local anesthesia or conscious sedation.

The mother of a child with hemophilia asks the nurse how long her child will need to be treated for hemophilia. What is the best response to this question? a. "Hemophilia is a lifelong blood disorder." b. "There is a 25% chance that your child will have spontaneous remission and treatment will no longer be necessary." c. "Treatment is indicated until after your child has progressed through the toddler years." d. "It is unlikely that your child will need to be treated for his hemophilia because your first child does not have the disease."

ANS: A Feedback A Hemophilia is a lifelong hereditary blood disorder with no cure. Prevention by avoiding activities that induce bleeding and by treatment is lifelong. The management of hemophilia is highly individual and depends on the severity of the illness. B This is an untrue statement. Hemophilia is a lifelong hereditary blood disorder with no cure. Treatment is lifelong. C This is an untrue statement. Hemophilia is a lifelong hereditary blood disorder with no cure. Treatment is lifelong. D Because hemophilia has an X chromosome-linked recessive inheritance, there is a risk with each pregnancy that a child will either have the disease or be a carrier. Hemophilia is a life-long hereditary blood disorder with no cure. Treatment is lifelong.

What is the priority nursing intervention for a child hospitalized with hemarthrosis resulting from hemophilia? a. Immobilization and elevation of the affected joint b. Administration of acetaminophen for pain relief c. Assessment of the child's response to hospitalization d. Assessment of the impact of hospitalization on the family system

ANS: A Feedback A Immobilization and elevation of the joint will prevent further injury until bleeding is resolved. B Although acetaminophen may help with pain associated with the treatment of hemarthrosis, it is not the priority nursing intervention. C Assessment of a child's response to hospitalization is relevant to all hospitalized children; however, in this situation, psychosocial concerns are secondary to physiologic concerns. A priority nursing concern for this child is the management of hemarthrosis. D Assessing the impact of hospitalization on the family system is relevant to all hospitalized children, but it is not the priority in this situation.

What is true about the genetic transmission of sickle cell disease? a. Both parents must carry the sickle cell trait. b. Both parents must have sickle cell disease. c. One parent must have the sickle cell trait. d. Sickle cell disease has no known pattern of inheritance.

ANS: A Feedback A In this scenario, there is a 50% risk of having a child with sickle cell disease. B The sickle cell trait, not the disease itself, must be present in the parents for the child to have the disease. C An autosomal recessive pattern of inheritance means that both parents must be carriers of the sickle cell trait. D Sickle cell disease is known to have an autosomal recessive pattern of inheritance.

An assessment of a 7-month-old infant with a hemoglobin level of 6.5 mg/dL is likely to reveal an infant who is a. Lethargic, pale, and irritable b. Thin, energetic, and sleeps little c. Anorexic, vomiting, and has watery stools d. Flushed, fussy, and tired

ANS: A Feedback A Pallor, lethargy, irritability, and tachycardia are clinical manifestations of iron deficiency anemia. A child with a hemoglobin level of 6.5 mg/dL has anemia. B A child with a hemoglobin level of 6.5 mg/dL has anemia. Infants with iron deficiency anemia are not typically thin and energetic but do tend to sleep a lot. C A child with a hemoglobin level of 6.5 mg/dL has anemia. Gastrointestinal symptoms are not clinical manifestations associated with iron deficiency anemia. D A child with a hemoglobin level of 6.5 mg/dL has anemia. Although the infant with iron deficiency anemia may be tired and fussy, pallor, rather than a flushed appearance, is characteristic of a low hemoglobin level.

The nurse is caring for a child with iron-deficiency anemia. What should the nurse expect to find when reviewing the results of the complete blood count (CBC)? Select all that apply. a. Low hemoglobin levels b. Elevated red blood cell (RBC) levels c. Elevated mean cell volume (MCV) levels d. Low reticulocyte count e. Decreased MCV levels

ANS: A, E Feedback Correct The results of the complete blood count in a child with iron-deficiency anemia will show low hemoglobin levels (6 to 11 g/dL) and microcytic, hypochromic RBCs; this manifests as decreased MCV and decreased mean cell hemoglobin. The reticulocyte count is usually slightly elevated or normal. Incorrect The reticulocyte count is usually slightly elevated or normal, and mean cell volume levels are decreased, not increased.

What are the nursing priorities for a child with sickle cell disease in vaso-occlusive crisis? a. Administration of antibiotics and nebulizer treatments b. Hydration and pain management c. Blood transfusions and an increased calorie diet d. School work and diversion

ANS: B Feedback A Antibiotics may be given prophylactically. Oxygen therapy rather than nebulizer treatments is used to prevent further sickling. B Hydration and pain management decrease the cells' oxygen demands and prevent sickling. C Although blood transfusions and increased calories may be indicated, they are not primary considerations for vaso-occlusive crisis. D School work and diversion are not major considerations when the child is in a vaso-occlusive crisis

A condition in which the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin is known as a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron-deficiency anemia

ANS: B Feedback A Aplastic anemia is a lack of cellular elements being produced. B Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by an abnormal hemoglobin. C Hemophilia refers to a group of bleeding disorders in which there is deficiency of one of the factors necessary for coagulation. D Iron-deficiency anemia affects size and depth of color and does not involve an abnormal hemoglobin.

What is the nurse's best response to a parent with questions about how her child's blood disorder will be treated? a. "Your child may be able to receive home care." b. "What did the physician tell you?" c. "Blood diseases are transient, so there is no need to worry." d. "Your child will be tired for awhile and then be back to her old self."

ANS: B Feedback A Treatment depends on the child's condition and the type of blood disorder. Although it is possible that the child could be treated in the home, the child may need to be treated as an outpatient or in the hospital. It is best to first assess what the parent has been told by the physician. B Providing the parent an opportunity to express what she was told by the physician allows the nurse to assess the parent's understanding and provide further information. C Minimizing the parent's concern is inappropriate. D The nurse needs to assess the parent's knowledge before teaching about the disease.

The nurse is caring for a child with aplastic anemia. What nursing diagnoses are appropriate? Select all that apply. a. Acute Pain related to vaso-occlusion b. Risk for Infection related to inadequate secondary defenses or immunosuppression c. Ineffective Protection related to thrombocytopenia d. Ineffective Tissue Perfusion related to anemia e. Ineffective Protection related to abnormal clotting

ANS: B, C, D Feedback Correct These are appropriate nursing diagnosis for the nurse planning care for a child with aplastic anemia. Aplastic anemia is a condition in which the bone marrow ceases production of the cells it normally manufactures, resulting in pancytopenia. The child will have varying degrees of the disease depending on how low the values are for absolute neutrophil count (affecting the body's response to infection), platelet count (putting the child at risk for bleeding), and absolute reticulocyte count (causing the child to have anemia). Incorrect Acute pain related to vaso-occlusion is an appropriate nursing diagnosis for sickle cell anemia for the child in vaso-occlusive crisis, but it is not applicable to a child with aplastic anemia. Ineffective protection related to abnormal clotting is an appropriate diagnosis for von Willebrand disease.

What is the best response to a parent who asks the nurse whether her 5-month-old infant can have cow's milk? a. "You need to wait until she is 8 months old and eating solids well." b. "Yes, if you think that she will eat enough meat to get the iron she needs." c. "Infants younger than 12 months need iron-rich formula to get the iron they need." d. "Try it and see how she tolerates it."

ANS: C Feedback A A 5-month-old infant cannot get adequate iron without drinking an iron-fortified formula or taking an iron supplement. B The American Academy of Pediatrics recommends beginning solid foods at 4 to 6 months of age. Meats are typically introduced in later infancy. Iron-fortified formula is still recommended. C Infants younger than 12 months need iron-fortified formula or breast milk. Infants who drink cow's milk do not get adequate iron and are at risk for iron deficiency anemia. D Counseling a parent to give a 5-month-old infant cow's milk is inappropriate.

Which statement best describes beta-thalassemia major (Cooley anemia)? a. All formed elements of the blood are depressed. b. Inadequate numbers of red blood cells are present. c. Increased incidence occurs in families of Mediterranean extraction. d. Increased incidence occurs in persons of West African descent.

ANS: C Feedback A An overproduction of red cells occurs. Although numerous, the red cells are relatively unstable. B An overproduction of red cells occurs. Although numerous, the red cells are relatively unstable. C Individuals who live near the Mediterranean Sea and their descendants have the highest incidence of thalassemia. D Sickle cell disease is common in blacks of West African descent.

How should the nurse respond when asked by the mother of a child with beta-thalassemia why the child is receiving deferoxamine? a. "To improve the anemia." b. "To decrease liver and spleen swelling." c. "To eliminate excessive iron being stored in the organs." d. "To prepare your child for a bone marrow transplant."

ANS: C Feedback A Chronic transfusion therapy is the treatment for anemia. Deferoxamine is administered to prevent complications from repeated transfusions. B Deferoxamine is used to prevent organ damage, not as a treatment for existing conditions such as hepatosplenomegaly. C Multiple transfusions result in hemosiderosis. Deferoxamine is given to chelate iron and prevent organ damage. D Preparation for a bone marrow transplant does not include administration of deferoxamine.

What is a priority intervention in planning care for the child with disseminated intravascular coagulation (DIC)? a. Hospitalization at the first sign of bleeding b. Teaching the child relaxation techniques for pain control c. Management in the intensive care unit d. Provision of adequate hydration to prevent complications

ANS: C Feedback A DIC typically develops in a child who is already hospitalized. B Relaxation techniques and pain control are not high priorities for the child with DIC. C The child with DIC is seriously ill and needs to be monitored in an intensive care unit. D Hydration is not the major concern for the child with DIC.

What describes the pathologic changes of sickle cell anemia? a. Sickle-shaped cells carry excess oxygen. b. Sickle-shaped cells decrease blood viscosity. c. Increased red blood cell destruction occurs. d. Decreased red blood cell destruction occurs

ANS: C Feedback A Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension. B When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. C The clinical features of sickle cell anemia are primarily the result of increased red blood cell destruction and obstruction caused by the sickle-shaped red blood cells. D Increased red blood cell destruction occurs.

What is descriptive of most cases of hemophilia? a. Autosomal dominant disorder causing deficiency is a factor involved in the blood-clotting reaction b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged bleeding c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient d. Y-linked recessive inherited disorder in which the red blood cells become moon shaped

ANS: C Feedback A The inheritance pattern is X-linked recessive. B The disorder involves coagulation factors, not platelets. C The inheritance pattern in 80% of all of the cases of hemophilia is X-linked recessive. The two most common forms of the disorder are factor VIII deficiency, hemophilia A or classic hemophilia; and factor IX deficiency, hemophilia B or Christmas disease. D The disorder does not involve red cells or the Y chromosome.

A nurse is teaching home care instructions to parents of a child with sickle cell disease. Which instructions should the nurse include? Select all that apply. a. Limit fluid intake. b. Administer aspirin for fever. c. Administer penicillin as ordered. d. Avoid cold and extreme heat. e. Provide for adequate rest periods.

ANS: C, D, E Feedback Correct Parents should be taught to avoid cold, which can increase sickling, and extreme heat, which can cause dehydration. Adequate rest periods should be provided. Penicillin should be administered daily as ordered. Incorrect The use of aspirin should be avoided; acetaminophen or ibuprofen should be used as an alternative. Fluids should be encouraged and an increase in fluid intake is encouraged in hot weather or when there are other risks for dehydration.

What action is not appropriate for a 14-month-old child with iron deficiency anemia? a. Decreasing the infant's daily milk intake to 24 oz or less b. Giving oral iron supplements between meals with orange juice c. Including apricots, dark-green leafy vegetables, and egg yolk in the infant's diet d. Allowing the infant to drink the iron supplement from a small medicine cup

ANS: D Feedback A A daily milk intake in toddlers of less than 24 oz will encourage the consumption of iron-rich solid foods. B Because food interferes with the absorption of iron, iron supplements are taken between meals. Administering this medication with foods rich in vitamin C facilitates absorption of iron. C Apricots, dark-green leafy vegetables, and egg yolks are rich sources of iron. Other iron-rich foods include liver, dried beans, Cream of Wheat, iron-fortified cereal, and prunes. D Iron supplements should be administered through a straw or by a medicine dropper placed at the back of the mouth because iron temporarily stains the teeth.

Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an acute vaso-occlusive crisis? a. Circulatory collapse b. Cardiomegaly, systolic murmurs c. Hepatomegaly, intrahepatic cholestasis d. Painful swelling of hands and feet; painful joints

ANS: D Feedback A Circulatory collapse results from sequestration crises. B Cardiomegaly, systolic murmurs, hepatomegaly, and intrahepatic cholestasis result from chronic vaso-occlusive phenomena. C Cardiomegaly, systolic murmurs, hepatomegaly, and intrahepatic cholestasis result from chronic vaso-occlusive phenomena. D A vaso-occlusive crisis is characterized by severe pain in the area of involvement. If in the extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances occur.

An accurate description of anemia is a. Increased blood viscosity b. Depressed hematopoietic system c. Presence of abnormal hemoglobin d. Decreased oxygen-carrying capacity of blood

ANS: D Feedback A Increased blood viscosity is usually a function of too many cells or of dehydration, not of anemia. B A depressed hematopoietic system or abnormal hemoglobin can contribute to anemia, but the definition is dependent on the deceased oxygen-carrying capacity of the blood. C A depressed hematopoietic system or abnormal hemoglobin can contribute to anemia, but the definition is dependent on the decreased oxygen-carrying capacity of the blood. D Anemia is a condition in which the number of red blood cells or hemoglobin concentration is reduced below the normal values for age. This results in a decreased oxygen-carrying capacity of blood.

What should the discharge plan for a school-age child with sickle cell disease include? a. Restricting the child's participation in outside activities b. Administering aspirin for pain or fever c. Limiting the child's interaction with peers d. Administering penicillin daily as ordered

ANS: D Feedback A Sickle cell disease does not prohibit the child from outdoor play. Active and passive exercises help promote circulation. B Aspirin use should be avoided. Acetaminophen or ibuprofen should be administered for fever or pain. C The child needs to interact with peers to meet his developmental needs. D Children with sickle cell disease are at a high risk for pneumococcal infections and should receive long-term penicillin therapy and preventive immunizations.

A child who has been in good health has a platelet count of 45,000/mm3, petechiae, and excessive bruising that covers the body. The nurse is aware that these signs are clinical manifestations of a. Erythroblastopenia b. von Willebrand disease c. Hemophilia d. Immune thrombocytopenic purpura (ITP)

ANS: D Feedback A The clinical manifestations of erythroblastopenia are pallor, lethargy, headache, fainting, and a history of upper respiratory infection. B The clinical manifestations of von Willebrand disease are bleeding from the gums or nose, prolonged bleeding from cuts, and excessive bleeding after surgery or trauma. C Bleeding is the clinical manifestation of hemophilia and results from a deficiency of normal factor activity necessary to produce blood clotting. D Excessive bruising and petechiae, especially involving the mucous membranes and gums in a child who is otherwise healthy, are the clinical manifestations of ITP, resulting from decreased platelets. The etiology of ITP is unknown, but it is considered to be an autoimmune process.

The nurse is evaluating lab results to determine if her patient is experiencing a diagnosis of DIC. The nurse should anticipate the following results: increased red blood cell count, low platelet counts, and an increased fibrinogen level. Is this statement true or false?

ANS: F The results indicate a decreased red blood cell count, low platelets, red blood cell fragments, prolonged prothrombin time, and a decreased fibrinogen level with an increased D-dimer.

When reviewing information about the incidence of the various types of childhood cancer, nursing students demonstrate understanding of the information when they identify which type as having the highest incidence?

Acute lymphocytic (lymphoblastic) leukemia Acute lymphocytic leukemia accounts for approximately 32% of all childhood cancers. Neuroblastomas account for 8%; non-Hodgkin's lymphoma accounts for 6%; osteogenic sarcoma accounts for 3%.

Antiemetics are ordered to control nausea and vomiting in the child undergoing chemotherapy. How can the nurse most effectively use these medications?

Administer the antiemetic before starting chemotherapy Antiemetics are most effective when given before chemotherapy begins and then on a regular schedule to prevent nausea and vomiting throughout administration of chemotherapy. Nonpharmacologic measures can be used in conjunction with antiemetics but not in place of them

The nurse is caring for a 6-year-old boy with an abdominal neuroblastoma prior to having a magnetic resonance imaging (MRI) scan without contrast done. Which intervention would the nurse expect to perform?

Administering a sedative as ordered to keep the child still The nurse would expect to administer a sedative as ordered to keep the child still because the machine makes a loud thumping noise that could frighten the child. The child must lie without moving while the MRI is being done. Encouraging fluid intake to increase radionuclide uptake is necessary for a bone scan. Advising the physician that the child is allergic to shellfish is an intervention for a computed tomograph (CT) scan with contrast. If the child did not have an IV prior to the MRI and contrast was going to be used, then an IV would need to be inserted for the contrast after the noncontrast MRI was finished. Applying EMLA to an injection site prior to inserting an IV would be appropriate for both the CT and bone scans

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?

Avoiding further abdominal palpation 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

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

Calling the doctor if the child gets a sore throat Calling the doctor if the child gets a sore throat is the priority. Because of the child's impaired immune system, any sign of potential infection, such as sore throat, must be evaluated by a physician. Using acetaminophen if the child needs an analgesic, writing down phone numbers and appointments, and keeping a written copy of the treatment plan are important teaching points but secondary to guarding against infection.

The father of an 8-year-old boy who is receiving radiation therapy is upset that his son has to go through 6 weeks of treatments. He doesn't understand why it takes so long. In explaining the need for radiation over such a long time, what should the nurse mention?

Cells are only susceptible to treatment by radiation during certain phases of the cell cycle Radiation is not effective on cells that have a low oxygen content (a proportion of cells in every tumor), nor is it effective at the time of cell division (mitosis). Therefore, radiation schedules are designed so that therapy occurs over a period of 1 to 6 weeks and includes time intervals when cells will be in a susceptible stage

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

Children's cancers, unlike those of adults, often are detected accidentally, not through screening. 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

In hemophilia A, the classic form, only females manifest a bleeding disorder.

False The classic form of hemophilia is caused by deficiency of the coagulation component factor VIII, the antihemophilic factor, and transmitted as a sex-linked recessive trait. In the United States, the incidence is approximately 1 in 10,000 white males. A female carrier may have slightly lowered but sufficient levels of the factor VIII component so that she does not manifest a bleeding disorder. Males with the disease also have varying levels of factor VIII; their bleeding tendency varies accordingly, from mild to severe

The primary intervention for beta-thalassemia is a chronic transfusion program of packed white blood cells with iron chelation.

False The primary intervention for beta-thalassemia is a chronic transfusion program of packed red blood cells with iron chelation. Such a program facilitates adequate oxygenation of body tissues and practically eliminates all symptoms of thalassemia.

The nurse is caring for a child with leukemia. Which nursing intervention would be the highest priority for this child?

Following guidelines for protective isolation 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 protective 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 caring for a 4-year-old boy following surgical removal of a stage I neuroblastoma. Which intervention is most appropriate for this child?

Giving medications as ordered via least invasive route Giving medications as ordered using the least invasive route is a postsurgery intervention focused on providing atraumatic care and is appropriate for this child. Since the child has a stage I tumor, it can be treated by surgical removal, and does not require chemotherapy or radiation therapy. Applying aloe vera lotion is good skin care following radiation therapy. Administering antiemetics and maintaining isolation are interventions used to treat side effects of chemotherapy.

A nurse is preparing a 7-year-old girl for bone marrow aspiration. Which site should she prepare?

Iliac crest Bone marrow aspiration provides samples of bone marrow so the type and quantity of cells being produced can be determined. In children, the aspiration sites used are the iliac crests or spines (rather than the sternum, which is commonly used in adults) because performing the test at these sites is usually less frightening for children; these sites also have the largest marrow compartments during childhood. In neonates, the anterior tibia can be used as an additional site.

The child with thalassemia may be given which classification of medication to prevent one of the complications frequently seen with the treatment of this disorder?

Iron-chelating drugs Frequent transfusions can lead to complications and additional concerns for the child, including the possibility of iron overload. For these children, iron-chelating drugs such as deferoxamine mesylate (Desferal) may be given. Vitamin and potassium supplements would not be given to treat the iron overload. Factor VIII preparations are given to the child with hemophilia

Nursing students are reviewing information about childhood cancers. They demonstrate understanding of the information when they identify what as the most frequent type?

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

A 15-year-old boy has been diagnosed with an osteogenic sarcoma of the distal femur. He also demonstrates a chronic cough, dyspnea, and chest pain, along with chronic leg pain. Based on these findings, the nurse should suspect metastasis to which body area?

Lungs Metastasis occurs early with bone tumors because of the extensive vascular system in bones. Metastasis to the lungs is very common; as many as 25% of adolescents will have lung metastasis already by the time of initial diagnosis. When this is present, the adolescent usually has noticed a chronic cough, dyspnea, and chest pain in addition to chronic leg pain. Other common sites of metastasis are brain and other bone tissue

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)?

Macrocytic red blood cells (RBCs) 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

To prevent further sickle cell crisis, you would advise the parents of a child with sickle cell anemia to:

Notify a health care provider if the child develops an upper respiratory infection. Reduction of oxygen and dehydration lead to increased sickling of cells. Early prevention of these with respiratory illness is important.

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?

Observation reveals nystagmus and head tilt 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 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:

Petechiae. 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

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

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

The 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?

Telling the child exactly what to expect of further treatments 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 nurse is teaching the parents of a 15-year-old boy who is being treated for acute myelogenous leukemia about the side effects of chemotherapy. For which symptoms should the parents seek medical care immediately?

Temperature of 101° F (38.3° C) or greater 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 or pain when swallowing are reasons to seek medical care, but are not as grave as the risk of infection

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. The nurse recognizes that this is the likely cause of this type of anemia:

Vitamin B12 deficiency 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 are ingesting a long-term, poorly formulated vegetarian diet as the vitamin is found primarily in foods of animal origin

Parents ask why their child just diagnosed with leukemia needs a "spinal tap." Which is the best response by the nurse?

"Checking the cerebrospinal fluid will reveal whether leukemic cells have entered the central nervous system." The cerebrospinal fluid is checked so the clinician can determine whether leukemic cells have invaded the central nervous system. It is common for a chemotherapy medication, usually methotrexate, to be administered immediately following lumbar puncture as treatment for potential infiltration. The other responses are incorrect

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

"I will report this to the pediatrician." The "white glow" may indicate retinoblastoma; immediate investigation is needed. The red reflex is indicative of eye health. Eye rubbing and a plugged tear duct are unrelated to the symptom described.

The nurse is teaching an inservice program to a group of nurses on the topic of children diagnosed with sickle cell anemia. The nurses in the group make the following statements. Which statement is most accurate regarding sickle cell anemia?

"If the trait is inherited from both parents the child will have the disease." 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 African Americans. Either sex can have the trait and disease

A group of newly hired nurses who will be working on the pediatric unit are attending an in-service program about sickle cell disease. During the program, the nurse manager describes the steps for managing sickle cell pain. Place these steps in the sequence in which the nurse manager would describe them.

-Assess the pain. -Believe the child's report of pain. -Look for complications or cause of pain. -Give medications and use distraction. -Provide rest in a quiet area. -Administer fluids. The ABCs of managing sickle cell pain are assess the pain (use a pain assessment tool); believe the child's report of pain; complications or cause of pain (look for complications); drugs and distraction: pain medication (opiates and nonsteroidal anti-inflammatory drugs (NSAIDs), if no contraindications); use fixed dosing; give on a timed schedule; no PRN dosing for pain medications; distraction with music, TV, and relaxation techniques; environment (rest in quiet area with privacy); and fluids.

A nurse is reviewing the medical records of several children who have undergone lead screening. The nurse would identify the child with which lead level as requiring no further action?

8 mcg/dL A blood lead level less than 10 mcg/dL requires no action. A level of 14 mcg/dL would need to be confirmed with a repeat test in 1 month along with parental education for decreased lead exposure and then a repeat test in 3 months. Levels of 20 mcg/dL and 26 mcg/dL need to be confirmed with a repeat test in 1 week along with parental education and a referral to the local health department for investigation of the home for lead reduction.

In teaching family members about their child's von Willebrand disease, what is the priority outcome for the child that the nurse should discuss? a. Prevention of injury b. Maintaining adequate hydration c. Compliance with chronic transfusion therapy d. Prevention of respiratory infections

ANS: A Feedback A Hemorrhage as a result of injury is the child's greatest threat to life. B Fluid volume status becomes a concern when hemorrhage has occurred. C The treatment of von Willebrand disease is desmopressin acetate (DDAVP), which is administered intranasally or intravenously. D Respiratory infections do not constitute a major threat to the child with von Willebrand disease.

What is the priority in the discharge plan for a child with immune thrombocytopenic purpura (ITP)? a. Teaching the parents to report excessive fatigue to the physician b. Monitoring the child's hemoglobin level every 2 weeks c. Providing a diet that contains iron-rich foods d. Establishing a safe, age-appropriate home environment

ANS: D Feedback A Excessive fatigue is not a significant problem for the child with ITP. B ITP is associated with low platelet levels. C Increasing the child's intake of iron in the diet will not correct ITP. D Prevention of injury is a priority concern for a child with ITP.

A child is to receive radiation therapy this morning. The nurse would expect to see which type of drug prescribed to this child?

Antiemetic Radiation therapy causes nausea because it destroys rapid-growing cells. Among these are the cells of the stomach lining, the reason that nausea occurs.

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?

Apply heat to the site of bleeding. 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

The nurse is providing preoperative care for a 7-year-old boy with a brain tumor and his parents. Which intervention is priority?

Assessing the child's level of consciousness 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 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?

Bladder 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 nurse is admitting to an examination room a child with the diagnosis of "probable acute lymphoblastic leukemia." What will confirm this diagnosis?

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

How can the nurse most simply describe for distressed parents a rhabdomyosarcoma that has been found in their 5-year-old?

Call it a tumor of muscle tissue A rhabdomyosarcoma is a tumor of striated muscle that most commonly develops in the head, neck, arms, and legs, as well as in the genitourinary tract, of children.

A child receiving chemotherapy is experiencing significant reduction in red blood cells secondary to myelosuppression. Which agent would the nurse most likely expect to be ordered?

Epoetin alfa Epoetin alfa is a colony-stimulating factor used to stimulate production of red blood cells. Filgrastim is a colony-stimulating factor used to stimulate production of granulocytes. Sargramostim is a colony-stimulating factor used to stimulate production of granulocytes. Gamma interferon is used to stimulate macrophage production to fight bacteria and fungus

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

Ewing sarcoma. Radiographs that show lesions on the bone may indicate tumors (e.g., Ewing sarcoma, osteosarcoma) or metastasis of tumors and warrant further investigation by bone scan, CT, or MRI. Positron emission tomography is the most effective test to diagnose Hodgkin disease, non-Hodgkin lymphoma, a neuroblastoma, bone tumors, lung and colon cancers, and brain tumors

A toddler who is beginning to walk has fallen and hit his head on the corner of a low table. The caregiver has been unable to stop the bleeding and brings the child to the pediatric clinic. The nurse is gathering data during the admission process and notes several bruises and swollen joints. A diagnosis of hemophilia is confirmed. This child most likely has a deficiency of which blood factor?

Factor VIII The most common types of hemophilia are factor VIII deficiency and factor IX deficiency, which are inherited as sex-linked recessive traits, with transmission to male offspring by carrier females.

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:

Factor VIII In hemophilia A, the problem is with factor VIII, and in hemophilia B it is factor IX. Platelets are problematic in idiopathic thrombocytopenia purpura. Plasmin is involved in the pathophysiologic events of disseminated intravascular coagulation.

Which nursing diagnosis would be most appropriate for a child with idiopathic thrombocytopenic purpura?

Ineffective tissue perfusion related to poor platelet formation Idiopathic thrombocytopenic purpura results in decreased platelets, so bleeding into tissue can occur.

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?

Infection 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 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?

Meperidine 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 group of nursing students are reviewing the process of blood cell formation. The students demonstrate understanding of this process when they place the formation events in their proper sequence. What is the proper sequence?

Multipotent stem cell Myeloid progenitor Megakaryocyte/erythroid progenitor Megakaryocyte Platelets The process begins with the multipotent stem cell that then becomes a myeloid progenitor, then a megakaryocyte/erythroid progenitor, a megakaryocyte, and finally platelets.

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:

Removal or covering of flaking paint on the walls of the home 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 dry wall or other solid protective material

When developing the postoperative plan of care for a child with sickle cell anemia who has undergone a splenectomy, which would the nurse identify as the priority?

Risk for infection Removal of the spleen places the child at significant risk for infection. Although the child's skin integrity is disrupted due to the surgery, this is not the priority nursing diagnosis. Loss of fluids occurs during surgery and adequate hydration is important to prevent a sickle cell crisis, but this diagnosis is not the priority in the postoperative period. Although the child is at risk for delayed growth and development, the priority postoperatively is to prevent infection

The nurse is administering meperidine as ordered for pain management for a 10-year-old boy in sickle cell crisis. The nurse would be alert for:

Seizures. Repeated use of meperidine for pain management during sickle cell crisis increases the risk of seizures when used in children with sickle cell anemia. Behavioral addiction is rarely a concern in the child with sickle cell anemia if the narcotic is used for the alleviation of severe pain. Priapism is a complication of sickle cell anemia unrelated to meperidine administration. Leg ulcers are a complication of sickle cell anemia unrelated to meperidine administration.

The nurse is caring for a 4-year-old with sickle cell anemia. A physical finding you might expect to see in him is:

Slightly yellow sclerae. Many children with sickle cell anemia develop mild scleral yellowing from excess bilirubin from breakdown of damaged cells.

The nurse is examining the hands of a child with suspected iron deficiency anemia. Which finding should the nurse expect?

Spooning of nails A convex shape of the fingernails termed 'spooning' can occur with iron deficiency anemia. Capillary refill in less than 2 seconds, pink palms and nail beds, and absence of bruising are normal findings

A 3-year-old female is brought to the ER by her parents and presents with bruising and mucous membrane bleeding from the nose and mouth. The nurse knows that these symptoms are indicative of:

Von Willebrand disease The primary clinical manifestations of von Willebrand disease are bruising and mucous membrane bleeding from the nose, mouth, and gastrointestinal tract; bleeding may be severe and lead to anemia and shock. Deep bleeding into joints and muscles, like that seen in hemophilia, is rare, except with type III von Willebrand disease

A nurse is providing care for a child with disseminated intravascular coagulation (DIC). What would alert the nurse to possible neurologic compromise?

Widely fluctuating blood pressure A key aspect of the nurse's role is to assess the child for signs and symptoms of impaired tissue perfusion in the various body systems that may be affected by DIC. Unstable or abnormal blood pressure such as wide fluctuations in blood pressure or unequal pupil size may suggest neurologic compromise. Hematuria would suggest renal compromise. Petechiae would be indicative of bleeding into the skin.

A syndrome that leads to the deposition of platelets and fibrinogen plugs in the vasculature and the simultaneous depletion of platelets and clotting factor proteins is commonly known as DIC or _____________________.

disseminated intravascular coagulation The pathophysiology of DIC is complicated and not easily understood because both extreme bleeding and clotting occur at the same time.

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?

• Have the child rinse the mouth with lukewarm water three times a day. • Apply a lip balm or petroleum jelly to prevent cracking. • Provide various soft and bland foods to minimize further irritation. 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 identifies the nursing diagnosis of risk for infection related to chemotherapy-induced immunosuppression. What would the nurse include in the teaching plan for the child and parents about reducing the child's risk?

• Having the child sleep in a single bed and room • Encouraging frequent, thorough handwashing To reduce the risk of 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