Pediatric - Oncologic disorders prepU
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." Explanation: 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.
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." Explanation: 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.
A 3-year-old who has been attending preschool has been diagnosed with leukemia. The caregivers of this child ask the nurse what they can do to help their child feel secure. Which recommendation could the nurse make to these caregivers that would be helpful in making the child feel secure?
"Let your child continue to attend preschool as much as possible." Explanation: Maintaining routine as much as possible helps to give the ill or dying toddler a greater sense of security.
A 3-year-old boy has been on chemotherapy for cancer. He complains about a sore throat, is experiencing malaise, and has a temperature of 99.8° F (37.7° C) orally. His mother calls the child's physician. What is the appropriate information for the nurse to tell his mother at this time?
"Plan to bring the child into the physician's office today." Explanation: Some chemotherapy agents mask the signs of infection, so the child could be very ill. The child needs to be assessed. Aspirin is not used in children of this age because of the chance of Reye syndrome. Continuing to watch the child and giving cool fluids would be appropriate if the child was not receiving chemotherapy. The child should be dressed lightly and warm binding clothing should be avoided. In addition, for this situation, these actions are incorrect because they do not address the need for the child to be assessed.
The nurse is explaining the procedure of bone marrow aspiration to a 6-year-old child with leukemia. What explanation would be best to give to the child?
"You may feel pressure on your hip during the procedure." Explanation: The bone marrow aspiration is performed on the iliac crest if the child is older and on the femur if the child is an infant. Bone marrow aspiration requires hard pressure to allow the needle to puncture the bone. A lidocaine/prilocaine cream is applied to the skin anywhere from 1 to 3 hours prior to the procedure to help numb the site where the needle will be inserted. Bone marrow aspirations and biopsies are usually performed with conscious sedation. If the child is an infant or there are special circumstances the procedure may be performed under anesthesia. The child is placed on the side for the procedure so the health care provider has better access to the iliac crest. The child will need to rest after the procedure to prevent bleeding, but is not required to lay flat on the back. Children who have had a lumbar puncture may need to lie on the back and are at risk for a headache.
A nurse is preparing a presentation for a parent group on childhood cancers. As part of the presentation, the nurse plans to discuss rhabdomyosarcoma. What are some common sites where rhabdomyosarcoma occurs? Select all that apply.
- Head - Neck - Extremities Explanation: The most common locations for rhabdomyosarcoma are the head and neck, genitourinary tract, and extremities.
A school nurse is teaching a group of parents about signs and symptoms of cancer in children. Which symptom is an early sign of a brain tumor?
- Headache - Vision changes - Vomiting Explanation: Children with any form of brain tumor develop symptoms of increased intracranial pressure: headache, vision changes, vomiting, an enlarging head circumference, or papilledema. Lethargy, projectile vomiting, and coma are late signs. Epistaxis is not usually related to a brain tumor. A growing tumor produces specific localized signs, such as nystagmus (constant horizontal movement of the eye) or visual field defects. As tumor growth continues, symptoms of ataxia, personality change (e.g., emotional lability, irritability), and seizures may occur. These would be later symptoms.
The nurse is caring for a 6-year-old girl with leukemia who is having an oncologic emergency. Which signs and symptoms would indicate hyperleukocytosis?
- Tachycardia - Respiratory distress Explanation: Increased heart rate, murmur, and respiratory distress are symptoms of hyperleukocytosis (high white blood cell count) which is associated with leukemia. Increased heart rate and blood pressure are indicative of tumor lysis syndrome, which may occur with acute lymphoblastic leukemia, lymphoma, and neuroblastoma. Wheezing and diminished breath sounds are signs of superior vena cava syndrome related to non-Hodgkin's lymphoma or neuroblastoma. Respiratory distress and poor perfusion are symptoms of massive hepatomegaly which is caused by a neuroblastoma filling a large portion of the abdominal cavity.
Wilms tumor is suspected in a 5-year-old child. Which action would be avoided?
Abdominal palpation Explanation: If Wilms tumor is suspected, the abdomen should not be palpated. Palpating the abdomen may cause the tumor capsule to rupture, resulting in tumor spillage. Tumor spillage can change the tumor from stage I to stage II or III, depending on the amount of spillage that occurs.
The toddler with a cancer diagnosis is seen for a well-child checkup. Which health maintenance activity will the nurse exclude?
Administering the measles, mumps, rubella (MMR) vaccine Explanation: Live vaccines (viral or bacterial) should not be administered to an immune suppressed child because of the risk of causing disease. The other health maintenance activities are important for the health maintenance of the toddler and should be included during the well-child visit.
A nurse is caring for a teen who is in the end stage of cancer. Which of the following nursing interventions provides self-esteem and self-worth to the teen?
Allowing the teen to completely participate in decisions Explanation: The adolescent stage of development thrives on feelings of self-worth and self-control. Allowing the teen to be involved in the care and decisions will increase self-esteem.
A child is to receive radiation therapy this morning. The nurse would expect to see which type of drug prescribed to this child?
Antiemetic (anti-nausea medication) Explanation: Radiation therapy causes nausea because it destroys rapid-growing cells. Among these are the cells of the stomach lining, the reason that nausea occurs.
The nurse is examining a child who was diagnosed with acute lymphoblastic leukemia (ALL) 6 months ago. The child exhibits pallor, ecchymoses, and petechiae. The nurse interprets these findings as indicating that the cancer has invaded which part of the body?
Bone marrow Explanation: A child with cancer often appears pale and thin, with symptoms of lethargy and generalized malaise. The presence of pallor, ecchymoses, and petechiae may indicate that the cancer has invaded the bone marrow and is interrupting the normal production of red blood cells and platelets, as in leukemia.
The nurse is providing care to a child who is nearing death. Which of the following would be most important for the nurse to keep in mind when communicating with the child?
Communication can be key in helping to meet the psychological needs of the dying child Explanation: Communication can work out unresolved issues, discover fears, and help a child make plans. Dying children are usually aware of their illness and the fact that they are dying. Not talking about these issues actually adds to the child's burdens because he or she must then expend energy to leave this very important topic out of conversations. If their impending death is not discussed, children do not always initiate the discussion because they sense that doing so will make their parents sad.
The pediatric nurse examines the radiographs of a client that indicate lesions on the bone. This finding is indicative of:
Ewing sarcoma Explanation: 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 patient and family have just been told that the child has a malignant brain tumor that appears inoperable. Which of the following nursing interventions would be most beneficial to this family and patient?
Explain that death is possible and offer curative and palliative care together. Explanation: It is difficult to ask families to abruptly switch from curative-intent therapy to comfort care. It is helpful if healthcare professionals explain early within the illness that death is possible and thus offer curative and palliative care simultaneously. The nurse should not start by saying the future looks difficult, because this is not therapeutic. The family does not need to be informed at this time that many others have died. This is not compassionate or therapeutic.
The nurse is explaining the chemotherapeutic effect of busulfan to the parents of a child receiving the drug as treatment for a bone tumor. Which information would the nurse integrate into the explanation?
It is a cell cycle non-specific alkylating antineoplastic agent Explanation: Alkylating agents, like busulfan, are cell cycle-nonspecific agents destroying both resting and dividing cells. During alkylation, the hydrogen atoms of some molecules within the cell are replaced by an alkyl group. This group interferes with DNA replication and RNA transcription. Antimetabolites alter the function of the molecule.
The nurse is planning a discussion group for parents with children who have cancer. How would the nurse describe a difference between cancer in children and adults?
Most childhood cancers affect the tissues rather than organs Explanation: Childhood cancers usually affect the tissues, not the organs, as in adults. Metastasis often is present when the childhood cancer is diagnosed. Childhood cancers, unlike adult cancers, are very responsive to treatment. Unfortunately, little is known about cancer prevention in children.
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?
Painless, enlarged lymph nodes Explanation: 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.
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 Explanation: 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 5-year-old client has been diagnosed with leukemia and is currently on chemotherapy and radiation. The child is having difficulty due to mucositis. Which is the most appropriate nursing diagnosis for this child?
Risk for imbalanced nutrition, less than body requirements, related to inflammation Explanation: Mucositis is inflammation of the oral mucosa, which puts this child at risk for risk for imbalanced nutrition. The client may have pain due to neoplastic process in the bone, but that is not mentioned in the scenario. The client may have lost hair, but that is not mentioned. The client's family coping is also not mentioned.
The nurse is working with a family whose daughter is dying of a brain tumor. When addressing the situation with the child's siblings, the nurse should prioritize what consideration?
The children's stages of growth and development Explanation: Interventions must always be chosen in light of children's growth and development. Interventions that are culturally appropriate but inappropriate to growth and developmental stage are of no benefit. Age differences between the patient and siblings are not a priority variable, and socioeconomic status does not appreciably affect the nurse's choice of interventions.
A mother contacts the oncology nurse concerned about the redness and tenderness of her child's skin following radiation treatments. What is the nurse's best response?
Use mild soap and unscented moisturizer. Explanation: Skin reactions, such as erythema and tenderness, are typical local effects. Maintaining good skin hygiene and use of mild soaps or moisturizers (nonfragrant) may help preserve skin integrity. Keeping skin clean and dry is helpful, but the skin needs a mild moisturizer to preserve skin integrity. Covering with an occlusive dressing is not helpful, as the skin needs hydration. Telling the mother there is nothing that can be done is inaccurate.
The school nurse is providing information to parents of adolescents about prevention of cervical cancer. Which information is included in the teaching?
Vaccine against human papillomavirus (HPV) Explanation: Reminding parents that both boys and girls should receive the vaccine against HPV is an important preventive measure to reduce the incidence of cervical cancer. Papanicolaou tests are not recommended until age 21. Abstinence from intercourse and use of condoms will help, but do not prevent exposure through other sexual contact.
A hospitalized child is postoperative from having a brain tumor resected. Which assessment(s) will the nurse perform to detect if increased intracranial pressure (ICP) is occurring? Select all that apply.
- Assess eyes for pupil size and reactivity - Note increased irritability - Observe for sunset eyes Explanation: As a result of surgical resection of the brain tumor, the surrounding tissues can swell. This swelling can cause a life-threatening situation of increased ICP if it is not monitored carefully and treated early. The nurse's assessments can identify symptoms early. When assessing the eyes, the nurse should pay attention to equal constriction and dilation of the pupils, the size of the pupils and if they are reactive to light. A child with increased ICP will have sunsetting eyes. Generally they are very irritable at first as the pressure increases but become more lethargic as it worsens. The heart rate will be slow, not fast. The child does not have an increased work of breathing. The respiratory rate will become slower as the pressure increases. The child may become apneic.
When providing care to a dying child and his family, which would be most important?
Focusing on the family as the unit of care. Explanation: When caring for a dying child and his family, the most important aspect of care is focusing on the family as the unit of care. Teaching, offering support, and assisting in decision-making are important, but these actions must be implemented while focusing on the family as the unit of care.
The family of a terminally ill client is asking about the benefits of hospice care. Which statement by the nurse provides accurate information?
Hospice is designed to meet the individual client's needs Explanation: The focus of hospice care is to meet the needs and wishes of the dying client. They also work closely with the caregivers to help support them, but caregivers are not the only recipient of care. Hospice care is not designed to find cures. Hospice is not a separate area in a hospital, though some hospitals do contain hospice centers.
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:
Kill enough cancerous cells to induce remission Explanation: 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.
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)?
Lethargy, bruises, and lymphadenopathy Explanation: 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.
Children with acute lymphoblastic leukemia (ALL) may need periodic lumbar punctures. The nurse would teach the parent that this is done to assess for:
Leukemic cells Explanation: Acute lymphoblastic leukemia (ALL) is a rapidly progressive cancer affecting the undifferentiated or immature cells. It is the most common form of cancer in children. Throughout the course of the disease and treatment the child will be tested regularly for complete blood counts, bone marrow aspirations, lumbar punctures, and testing for renal and liver function. Lumbar punctures are performed to determine if leukemic cells have infiltrated the central nervous system. The white blood cells, temperature, and other symptoms would be indicative of meningitis and septicemia. The platelet count would be assessed for the possibility of bleeding.
A 12-year-old child is suspected of having Hodgkin lymphoma. When preparing the child and family for diagnostic testing, which test would the nurse describe as being used to confirm the diagnosis?
Lymph node biopsy Explanation: Hodgkin lymphoma is confirmed by biopsy of the lymph nodes. Further studies such as bone marrow analysis, liver function tests, chest and abdominal computed tomography scans, lymphangiography, and abdominal biopsy are done to classify the clinical stage of the disorder.
A child is receiving carboplatin as part of a chemotherapy protocol. What would be most important for the nurse to include in the child's plan of care?
Maintaining adequate hydration Explanation: When fluorouracil is administered, the nurse must ensure adequate hydration. Monitoring for visual changes is appropriate when giving fludarabine. Eye drops are necessary to prevent conjunctivitis when high doses of cytarabine are administered. Oral mercaptopurine should not be given with meals or food.
A child is undergoing a series of diagnostic tests for a suspected malignancy. Which diagnostic test result is only present in Hodgkin disease?
Reed-Sternberg cells Explanation: With Hodgkin disease, lymphocytes proliferate in the lymph glands, and special Reed-Sternberg cells (large, multinucleated cells that are probably nonfunctioning monocyte-macrophage cells) develop. Although these lymphocytes are capable of DNA synthesis and mitotic division, they are abnormal because they lack both B- and T-lymphocyte surface markers and cannot produce immunoglobulins as do usual B-lymphocytes. There will be elevated lymphocytes, but this is present in leukemias as well. T-lymphocyte surface markers are lacking in Hodgkin disease. Megakaryocyte cells are normal cells in the bone marrow and produce platelets.
A child with acute lymphoblastic leukemia (ALL) is receiving methotrexate for therapy. Which nursing diagnosis would best apply during therapy?
Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy Explanation: Methotrexate is a chemotherapeutic agent; one of its side effects is oral mucositis. Oral ulcerations can interfere with nutrition because of pain and leave a portal for infection. Mucositis can be treated with oral swish and swallow agents or swish and spit agents (diphenhydramine, lidocaine, nystatin). Mucositis is very painful and children will not be able to eat, so alternate ways of delivering nutrition may be necessary. The child receiving methotrexate may need large volumes of hydration to prevent dehydration from the medication effects. The nursing diagnosis of fluid overload from aldosterone production would be incorrect. Methotrexate works on specific cells. It does not affect the central nervous system. The child may have decreased mobility from the cancer effects and any side effects of many drugs the child is receiving as a result of a weakened state, but methotrexate is not a depressant.
The parents of an 11-year-old boy who is dying from cancer are concerned that he is not eating. Which intervention would serve both the parents' and child's needs?
Serving small meals of things the child likes Explanation: The child is more likely to eat small amounts of foods of his choosing. This accommodates the child's reduced appetite, reassures his parents that he is not starving, and gives the child a sense of control. Straightening up the child's area before meals provides a more pleasant eating environment. The use of antiemetics controls nausea but may not increase appetite. Urging the child to eat a substantial meal is unnecessary and creates stress.
The nurse is caring for a child who is receiving peripheral intravenous (IV) chemotherapy. The child tells the nurse that the IV "hurts." The nurse finds that the insertion site is reddened and edematous. Which is the first action the nurse should take?
Stop the infusion Explanation: Stopping the infusion prevents additional sclerosing drug from entering the tissue. Warmth increases tissue absorption/damage. Distraction lessens discomfort but not tissue damage. Retaping is inappropriate.
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?
Temperature of 101° F (38.3° C) or greater Explanation: 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.
