Chapter 24: The Child with Cancer My Nursing Test Banks

Chapter 24: The Child with Cancer

Test Bank

MULTIPLE CHOICE

1. The nurse notes that a childs gums bleed easily and bruising and petechiae are evident on the extremities. Which laboratory value would be consistent with these symptoms?

a.

Platelet count of 19,000/mm3

b.

Prothrombin time of 11 to 15 seconds

c.

Hematocrit of 34

d.

Leukocyte count of 14,000/mm3

ANS: A

The normal platelet count is 150,000 to 400,000/mm3. This finding is very low, indicating an increased bleeding potential. The prothrombin time of 11 to 15 seconds is within normal limits. The normal hematocrit is 35 to 45 and, although this finding is low, it would not create the symptoms presented. A leukocyte count of 14,000/mm3 indicates the probable presence of infection but is not a reflection of bleeding tendency.

DIF: Cognitive Level: Analysis REF: p. 608

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

2. The nurse understands that the type of precautions needed for children receiving chemotherapy is based on which action of chemotherapeutic agents?

a.

Gastrointestinal upset

b.

Bone marrow suppression

c.

Decreased creatinine level

d.

Alopecia

ANS: B

Chemotherapy agents cause bone marrow suppression, which creates the need to institute precautions related to reduced white blood cell, red blood cell, and platelet counts. These precautions focus on preventing infection and bleeding. Although gastrointestinal upset may be an adverse effect of chemotherapy, it is not caused by all chemotherapeutic agents. No special precautions are instituted for gastrointestinal upset. A decreased creatinine level is consistent with renal pathological conditions, not chemotherapy. Not all chemotherapeutic agents cause alopecia. No precautions are taken to prevent alopecia.

DIF: Cognitive Level: Comprehension REF: p. 600

OBJ: Nursing Process Step: Assessment MSC: Safe and Effective Care Environment

3. The nurse should base a response to a parents question about the prognosis of acute lymphoblastic leukemia (ALL) on which information?

a.

Leukemia is a fatal disease although chemotherapy provides increasingly longer periods of remission.

b.

Research to find a cure for childhood cancers is very active.

c.

The majority of children go into remission and remain symptom free when treatment is completed.

d.

It usually takes several months of chemotherapy to achieve a remission.

ANS: C

Children diagnosed with the most common form of leukemia, ALL, can almost always achieve remission, with a 5-year disease-free survival rate approaching 85%. With the majority of children surviving 5 years or longer, it is inappropriate to refer to leukemia as a fatal disease. Although research to find a cure for childhood cancers is very active, it does not address the parents concern. About 95% of children achieve remission within the first month of chemotherapy. If significant numbers of blast cells are still present in the bone marrow after a month of chemotherapy, a new and stronger regimen is begun.

DIF: Cognitive Level: Application REF: p. 605

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

4. Bone marrow transplantation is the standard treatment for which childhood cancer?

a.

Acute lymphoblastic leukemia (ALL)

b.

Non-Hodgkins lymphoma

c.

Wilms tumor

d.

Acute myeloblastic leukemia (AML)

ANS: D

Bone marrow transplantation is currently the standard treatment for children in their first remission with AML. The standard treatment for ALL is combination chemotherapy. The standard treatment for non-Hodgkins lymphoma is chemotherapy. Bone marrow transplantation is used to treat non-Hodgkins lymphoma that is resistant to conventional chemotherapy and radiation. The treatment for Wilms tumor consists of surgery and chemotherapy alone or in combination with radiation therapy.

DIF: Cognitive Level: Knowledge REF: p. 603

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

5. A child with a history of fever of unknown origin, excessive bruising, lymphadenopathy, and fatigue is exhibiting symptoms most suggestive of which condition?

a.

Ewings sarcoma

b.

Wilms tumor

c.

Neuroblastoma

d.

Leukemia

ANS: D

Symptoms of a history of fever of unknown origin, excessive bruising, lymphadenopathy, and fatigue reflect bone marrow failure and organ infiltration, which occur in leukemia. Symptoms of Ewings sarcoma involve pain and soft tissue swelling around the affected bone. Wilms tumor usually manifests as an abdominal mass with abdominal pain and may include renal symptoms, such as hematuria, hypertension, and anemia. Neuroblastoma manifests primarily as an abdominal, chest, bone, or joint mass. Symptoms are dependent on the extent and involvement of the tumor.

DIF: Cognitive Level: Analysis REF: p. 605

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

6. A nurse assesses a whitish reflection instead of the expected red reflex when evaluating an infants eyes. Which action should the nurse take?

a.

Notify the physician.

b.

Chart the finding.

c.

Check the chart to verify that the infant received eye prophylaxis at birth.

d.

Reassess for a red reflex in 1 month.

ANS: A

A whitish reflex in the eye, leukocoria, is a common finding of retinoblastoma. It is an overt sign of cancer and the physician needs to be notified. Checking the chart for routine eye prophylaxis at birth would be done if there was an eye infection. The finding is not normal and by charting the finding or reassessing in 1 month treatment will be delayed.

DIF: Cognitive Level: Application REF: p. 622

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

7. Which nursing diagnosis is a priority for the 4-year-old child newly diagnosed with leukemia?

a.

Ineffective breathing pattern related to mediastinal disease

b.

Risk for infection related to immunosuppressed state

c.

Disturbed body image related to alopecia

d.

Impaired skin integrity related to radiation therapy

ANS: B

Leukemia is characterized by the proliferation of immature white blood cells, which lack the ability to fight infection. An ineffective breathing pattern related to mediastinal disease would apply to a child with non-Hodgkins lymphoma or any cancer involving the chest area. Disturbed body image related to alopecia is a nursing diagnosis related to chemotherapy, but it is not of the highest priority. Not all children have a body image disturbance as a result of alopecia, especially not preschoolers. This would be of more concern to an adolescent. Radiation therapy is not a treatment for leukemia.

DIF: Cognitive Level: Comprehension REF: pp. 605-606

OBJ: Nursing Process Step: Nursing Diagnosis MSC: Physiological Integrity

8. A nurse determines that parents understood the teaching from the pediatric oncologist if the parents indicate that which test confirms the diagnosis of leukemia in children?

a.

Complete blood cell count (CBC)

b.

Lumbar puncture

c.

Bone marrow biopsy

d.

Computed tomography (CT) scan

ANS: C

The confirming test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspiration and biopsy. A CBC may show blast cells that would raise suspicion of leukemia. It is not a confirming diagnostic study. A lumbar puncture is done to check for central nervous system involvement in the child who has been diagnosed with leukemia. A CT scan may be done to check for bone involvement in the child with leukemia. It does not confirm a diagnosis.

DIF: Cognitive Level: Comprehension REF: p. 605

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

9. Which statement made by a nurse to the parents of a child with leukemia should be included in discharge instructions?

a.

Your sons blood pressure must be taken daily while he is on chemotherapy.

b.

Limit your sons fluid intake just in case he has central nervous system (CNS) involvement.

c.

Your son must receive all of his immunizations in a timely manner.

d.

Your sons temperature should be taken daily.

ANS: D

An elevated temperature may be the only sign of an infection in an immunosuppressed child. Parents should be instructed to monitor their childs temperature daily because of the risk for infection, but it is not necessary to take a blood pressure daily. Fluid is never withheld as a precaution against increased intracranial pressure. If a child had confirmed CNS involvement with increased intracranial pressure, limiting fluid intake might be more appropriate. Children who are immunosuppressed should not receive any live virus vaccines.

DIF: Cognitive Level: Application REF: p. 607

OBJ: Nursing Process Step: Evaluation MSC: Psychosocial Integrity

10. What is the most appropriate nursing action when the nurse notes a reddened area on the forearm of a neutropenic child with leukemia?

a.

Massage the area.

b.

Turn the child more frequently.

c.

Document the finding and continue to observe the area.

d.

Notify the physician immediately.

ANS: D

Any signs of infection in a child who is immunosuppressed must be reported immediately because it is considered a medical emergency. When a child is neutropenic, pus may not be produced and the only sign of infection may be redness. In a child with neutropenia, a reddened area may be the only sign of an infection. The area should never be massaged. The forearm is not a typical pressure area; therefore, the likelihood of the redness being related to pressure is very small. The observation should be documented, but because it may be a sign of an infection and immunosuppression, the physician must also be notified.

DIF: Cognitive Level: Application REF: p. 607

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

11. What is the nurses best response to a mother whose child has a diagnosis of acute lymphoblastic leukemia and is expressing guilt about not having responded sooner to her childs symptoms?

a.

You should always call the physician when your child has a change in what is normal for him.

b.

It is better to be safe than sorry.

c.

It is not uncommon for parents not to notice subtle changes in their childrens health.

d.

I hope this delay does not affect the treatment plan.

ANS: C

Suggesting that noticing subtle changes in their childrens health is not uncommon minimizes the role the mother played in not seeking early medical attention. It also displays empathy, which helps to build trust, thereby enabling the mother to talk about her feelings. Identifying concerns and clarifying misconceptions will help families cope with the stress of chronic illness. The goal is to relieve the mothers guilt and build trust so that she can talk about her feelings. Telling the mother that she should have called the pediatrician will only reinforce her guilt. Adages such as It is better to be safe than sorry are flippant and reinforce the belief that the mother was negligent, which will only increase her guilt. Telling the mother that you hope the delay does not affect the treatment plan shows a total lack of empathy and would increase the mothers feelings of guilt.

DIF: Cognitive Level: Application REF: p. 607

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

12. Which is an appropriate nursing action before surgery when caring for a child diagnosed with a Wilms tumor?

a.

Limit fluid intake.

b.

Do not palpate the abdomen.

c.

Force oral fluids.

d.

Palpate the abdomen every 4 hours.

ANS: B

Excessive manipulation of the tumor area can cause seeding of the tumor and spread of the malignant cells. Fluids are not routinely limited in a child with a Wilms tumor. However, intake and output are important because of the kidney involvement. Fluids are not forced on a child with a Wilms tumor. Normal intake for age is usually maintained. The abdomen of a child with a Wilms tumor should never be palpated because of the danger of seeding the tumor and spreading malignant cells.

DIF: Cognitive Level: Comprehension REF: p. 622

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

13. A child with acute lymphocytic leukemia (ALL) is getting chemotherapy for the first time and is at risk for tumor lysis syndrome (TLS). The nurse monitors for which risk associated with TLS?

a.

Liver failure

b.

Central nervous system (CNS) deficit

c.

Kidney failure

d.

Respiratory distress

ANS: C

In TLS, the tumors intracellular contents are dumped into the childs extracellular fluid as the tumor cells are lysed in response to chemotherapy. Because of the large volume of these cells, their intracellular electrolytes overload the kidneys and, if not monitored, can cause kidney failure. TLS is related to intracellular electrolytes overloading the kidney as a response to the rapid lysis of tumor cells. This does not affect the liver, the CNS, or the lungs and cause respiratory distress.

DIF: Cognitive Level: Application REF: p. 615

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

14. Which is a symptom of a brain tumor in an infant?

a.

Blurred vision

b.

Increased head circumference

c.

Vomiting when getting out of bed

d.

Headache

ANS: B

Manifestations of brain tumors vary with tumor location and the childs age and development. Infants with brain tumors may be irritable or lethargic, feed poorly, and have increased head circumference with a bulging fontanel. Visual changes such as nystagmus, diplopia, and strabismus are manifestations of a brain tumor but would not be able to be verbalized by an infant. The change in position on awakening causes an increase in intracranial pressure, which is manifested as vomiting. Vomiting on awakening is considered a hallmark symptom of a brain tumor, but infants do not get themselves out of bed in the morning. Increased intracranial pressure resulting from a brain tumor is manifested as a headache but could not be verbalized by an infant.

DIF: Cognitive Level: Knowledge REF: pp. 611-612

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

15. Which is an expected physical assessment finding for an adolescent with a diagnosis of Hodgkins disease?

a.

Protuberant, firm abdomen

b.

Enlarged painless, firm cervical lymph nodes

c.

Soft tissue swelling

d.

Soft to hard, nontender mass in the pelvic area

ANS: B

Painless, firm, movable adenopathy (enlarged lymph nodes) palpated in the cervical region is an expected assessment finding in Hodgkins disease. Other systemic symptoms include unexplained fevers, weight loss, and night sweats. A protuberant, firm abdomen is present in many cases of neuroblastoma. Soft tissue swelling around the affected bone is a manifestation of Ewings sarcoma. A soft to hard, nontender mass can be palpated when rhabdomyosarcoma is present.

DIF: Cognitive Level: Analysis REF: p. 616

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

16. Which nursing intervention should not be included in the postoperative plan of care for a child undergoing surgery for a brain tumor?

a.

Position with head lower than body.

b.

Perform neurological assessments.

c.

Assess dressings for drainage.

d.

Monitor temperature.

ANS: A

The child is never placed in the Trendelenburg position because it increases intracranial pressure and the risk of bleeding. Increased intracranial pressure is a risk in the postoperative period. The nurse would assess the childs neurological status frequently. Hemorrhage is a risk in the postoperative period. The childs dressing would be inspected frequently for bleeding. Temperature is monitored closely because the child is at risk for infection in the postoperative period.

DIF: Cognitive Level: Comprehension REF: p. 614

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

17. A child with non-Hodgkins lymphoma will be starting chemotherapy. Which intervention is initiated before chemotherapy to prevent tumor lysis syndrome?

a.

Insertion of a central venous catheter

b.

Intravenous (IV) hydration containing sodium bicarbonate

c.

Placement of an externalized ventriculoperitoneal (VP) shunt

d.

Administration of pneumococcal and H. influenzae type B vaccines

ANS: B

Intensive hydration with an IV fluid containing bicarbonate alkalinizes the urine to help prevent the formation of uric acid crystals, which damage the kidney. A central venous catheter is placed to assist in delivering chemotherapy. An externalized VP shunt may be placed to relieve intracranial pressure caused by a brain tumor. If a splenectomy is necessary for a child with Hodgkins disease, the pneumococcal and H. influenzae vaccines are administered before the surgery.

DIF: Cognitive Level: Application REF: p. 607

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

18. The nurse is aware that an abdominal mass found in a 10-month-old infant corresponds with which cancer?

a.

Osteogenic sarcoma

b.

Rhabdomyosarcoma

c.

Neuroblastoma

d.

Non-Hodgkins lymphoma

ANS: C

Neuroblastoma is found exclusively in infants and children. In most cases of neuroblastoma, a primary abdominal mass and protuberant, firm abdomen are present. Osteogenic sarcoma is a bone tumor. Bone tumors typically affect older children. Rhabdomyosarcoma is a malignancy of muscle, or striated tissue. It occurs most often in the periorbital area, in the head and neck in younger children, or in the trunk and extremities in older children. Non-Hodgkins lymphoma is a neoplasm of lymphoid cells. Painless, enlarged lymph nodes are found in the cervical or axillary region. Abdominal signs and symptoms do not include a mass.

DIF: Cognitive Level: Comprehension REF: p. 617

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

19. Which is an appropriate intervention for a hospitalized child with an absolute neutrophil count (ANC) of 900/mm3?

a.

Inspect the childs skin for breaks and redness every shift.

b.

Administer the measles, mumps, rubella (MMR) vaccine if the child is not fully immunized.

c.

Check urine and stools for blood.

d.

Teach the child to blow the nose gently.

ANS: A

An ANC of 900/mm3 reflects a moderate risk of infection. The skin provides a barrier against infection. All areas should be inspected carefully for signs of infection. A live virus vaccine, such as MMR, could produce infection in an immunocompromised child. An appropriate intervention for a child with a low platelet count would be to check urine and stools for blood; an appropriate precaution would be to teach the child to blow the nose gently.

DIF: Cognitive Level: Application REF: p. 607

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

20. A child with acute myeloblastic leukemia is scheduled to have a bone marrow transplant (BMT). The donor is the childs own umbilical cord blood that had been previously harvested and banked. What type of BMT would this be?

a.

Autologous

b.

Allogeneic

c.

Syngeneic

d.

Stem cell

ANS: A

In an autologous transplant, the childs own marrow or previously harvested and banked cord blood is used. In an allogeneic BMT, histocompatibility has been matched with a related or unrelated donor. In a syngeneic transplant, the child receives bone marrow from an identical twin. A stem cell transplantation uses a unique immature cell present in the peripheral circulation.

DIF: Cognitive Level: Comprehension REF: p. 603

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

21. What should the nurse teach parents about oral hygiene for the child receiving chemotherapy?

a.

Brush the teeth briskly to remove bacteria.

b.

Use a mouthwash that contains alcohol.

c.

Inspect the childs mouth daily for ulcers.

d.

Perform oral hygiene twice a day.

ANS: C

The childs mouth is inspected regularly for ulcers. At the first sign of ulceration, an antifungal drug is initiated. The teeth should be brushed with a soft-bristled toothbrush. Excessive force with brushing should be avoided because delicate tissue could be broken, causing infection or bleeding. Mouthwashes containing alcohol may be drying to oral mucosa, thus breaking down the protective barrier of the skin.

DIF: Cognitive Level: Comprehension REF: p. 608

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

22. Which is the best choice when a child with mucositis asks for something to drink?

a.

Hot chocolate

b.

Lemonade

c.

Popsicle

d.

Orange juice

ANS: C

Cool liquids are soothing and ice pops are usually well tolerated. A hot beverage can be irritating to mouth ulcers. Citrus products may be very painful to an ulcerated mouth.

DIF: Cognitive Level: Application REF: p. 609

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

MULTIPLE RESPONSE

1. When an adolescent with a new diagnosis of Ewings sarcoma asks the nurse about treatment, the nurses response should be based on which information? Select all that apply.

a.

This type of tumor invades the bone.

b.

Management includes chemotherapy, surgery, and radiation.

c.

Ewings sarcoma is usually not responsive to either chemotherapy or radiation.

d.

Affected bones such as ribs and proximal fibula may be removed to excise the tumor.

ANS: A, B, D

Ewings sarcoma invades the bone and is found most often in the midshaft of long bones, especially the femur, vertebrae, ribs, and pelvic bones. Treatment for Ewings sarcoma begins with chemotherapy to decrease tumor bulk, followed by surgical resection of the primary tumor. Local control of the tumor can be achieved with surgery or radiation. The affected bone may be removed if it will not affect the childs functioning. Ribs and the proximal fibula are considered expendable and may be removed to excise the tumor without affecting function. Ewings sarcoma is responsive to both chemotherapy and radiation.

DIF: Cognitive Level: Comprehension REF: p. 620

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

2. A child with a brain tumor is undergoing radiation therapy. The nurse should include which information in the discharge instructions to the childs parents? Select all that apply.

a.

Apply over-the-counter creams to the area daily.

b.

Avoid excessive skin exposure to the sun.

c.

Use a washcloth when cleaning the area receiving radiation.

d.

Plan for adequate rest periods for the child.

e.

A darkening of the skin receiving radiation is expected.

ANS: B, D, E

Children receiving cranial radiation are particularly affected by fatigue and an increased need for sleep during and shortly after completion of the course of radiation. Skin damage can include changes in pigmentation (darkening), redness, peeling, and increased sensitivity. Extra care must be taken to avoid excessive skin exposure to heat, sunlight, friction (such as rubbing with a towel or washcloth), and creams or moisturizers. Only topical creams and moisturizers prescribed by the radiation oncologist should be applied to the radiated skin.

DIF: Cognitive Level: Application REF: p. 603

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

SHORT ANSWER

1. What is the absolute neutrophil count (ANC) for a WBC of total count 3000 with 30% neutrophils and 25% bands?

ANS:

1650

The absolute neutrophil count can be easily calculated using the results from the childs CBC. Use the following formula:

Add the percent of neutrophils and the percent of bands.

Convert the summed percentage into decimal form (e.g., 55% = 0.55).

Multiply that figure by the WBC (stated in thousands).

3000 0.55 = 1650.

DIF: Cognitive Level: Application REF: p. 607

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

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