Chapter 31: The Child with Cancer My Nursing Test Banks

Chapter 31: The Child with Cancer

MULTIPLE CHOICE

1. What childhood cancer may demonstrate patterns of inheritance that suggest a familial basis?

a.

Leukemia

b.

Retinoblastoma

c.

Rhabdomyosarcoma

d.

Osteogenic sarcoma

ANS: B

Retinoblastoma is an example of a pediatric cancer that demonstrates inheritance. The absence of the retinoblastoma gene allows for abnormal cell growth and the development of retinoblastoma. Chromosome abnormalities are present in many malignancies. They do not indicate a familial pattern of inheritance. The Philadelphia chromosome is observed in almost all individuals with chronic myelogenous leukemia. There is no evidence of a familial pattern of inheritance for rhabdomyosarcoma or osteogenic sarcoma cancers.

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2. As part of the diagnostic evaluation of a child with cancer, biopsies are important for staging. What statement explains what staging means?

a.

Extent of the disease at the time of diagnosis

b.

Rate normal cells are being replaced by cancer cells

c.

Biologic characteristics of the tumor or lymph nodes

d.

Abnormal, unrestricted growth of cancer cells producing organ damage

ANS: A

Staging is a description of the extent of the disease at the time of diagnosis. Staging criteria exist for most tumors. The stage usually relates directly to the prognosis; the higher the stage, the poorer the prognosis. The rate that normal cells are being replaced by cancer cells is not a definition of staging. Classification of the tumor refers to the biologic characteristics of the tumor or lymph nodes. Abnormal, unrestricted growth of cancer cells producing organ damage describes how cancer cells grow and can cause damage to an organ.

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MSC: Client Needs: Physiological Integrity

3. What statement related to clinical trials developed for pediatric cancers is most accurate?

a.

Are accessible only in major pediatric centers

b.

Do not require consent for standard therapy

c.

Provide the best available therapy compared with an expected improvement

d.

Are standardized to provide the same treatment to all children with the disease

ANS: C

Most clinical trials have a control group in which the patients receive the best available therapy currently known. The experimental group(s) receives treatment that is thought to be even better. The protocol outlines the therapy plan. Protocols are developed for many pediatric cancers. They can be accessed by pediatric oncologists throughout the United States. Consent is always required in treatment of children, especially for research protocols. The protocol is designed to optimize therapy for children based on disease type and stage.

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4. Chemotherapeutic agents are classified according to what feature?

a.

Side effects

b.

Effectiveness

c.

Mechanism of action

d.

Route of administration

ANS: C

Chemotherapeutic agents are classified according to mechanism of action. For example, antimetabolites resemble essential metabolic elements needed for growth but are different enough to block further deoxyribonucleic acid (DNA) synthesis. Although the side effect profiles may be similar for drugs within a classification, they are not the basis for classification. Most chemotherapeutic regimens contain combinations of drugs. The effectiveness of any one drug is relative to the cancer type, combination therapy, and protocol for administration. The route of administration is determined by the pharmacodynamics and pharmacokinetics of each drug.

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5. What type of chemotherapeutic agent alters the function of cells by replacing a hydrogen atom of a molecule?

a.

Plant alkaloids

b.

Antimetabolites

c.

Alkylating agents

d.

Antitumor antibiotics

ANS: C

Alkylating agents replace a hydrogen atom with an alkyl group. The irreversible combination of alkyl groups with nucleotide chains, particularly deoxyribonucleic acid (DNA), causes unbalanced growth of unaffected cell constituents so that the cell eventually dies. Plant alkaloids arrest the cell in metaphase by binding to proteins needed for spindle formation. Antimetabolites resemble essential metabolic elements needed for growth but are different enough to block further DNA synthesis. Antitumor antibiotics are natural substances that interfere with cell division by reacting with DNA in such a way as to prevent further replication of DNA and transcription of ribonucleic acid (RNA).

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6. What side effect commonly occurs with corticosteroid (prednisone) therapy?

a.

Alopecia

b.

Anorexia

c.

Nausea and vomiting

d.

Susceptibility to infection

ANS: D

Corticosteroids have immunosuppressive effects. Children who are taking prednisone are susceptible to infections. Hair loss is not a side effect of corticosteroid therapy. Children taking corticosteroids have increased appetites. Gastric irritation, not nausea and vomiting, is a potential side effect. The medicine should be given with food.

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7. What chemotherapeutic agent is classified as an antitumor antibiotic?

a.

Cisplatin (Platinol AQ)

b.

Vincristine (Oncovin)

c.

Methotrexate (Texall)

d.

Daunorubicin (Cerubidine)

ANS: D

Daunorubicin is an antitumor antibiotic. Cisplatin is classified as an alkylating agent. Vincristine is a plant alkaloid. Methotrexate is an antimetabolite.

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8. The nurse is administering an intravenous chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. What nursing action is most appropriate to initiate?

a.

Recheck the rate of drug infusion.

b.

Stop the drug infusion immediately.

c.

Observe the child closely for next 10 minutes.

d.

Explain to the child that this is an expected side effect.

ANS: B

When an allergic reaction is suspected, the drug is immediately discontinued. Any drug in the line should be withdrawn, and a normal saline infusion begun to keep the line open. The intravenous infusion is stopped to minimize the amount of drug that infuses. The infusion rate can be confirmed at a later time. Observation of the child for 10 minutes is essential, but it is done after the infusion is stopped. These signs are indicative of an allergic reaction, not an expected response.

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9. Total-body irradiation is indicated for what reason?

a.

Palliative care

b.

Lymphoma therapy

c.

Definitive therapy for leukemia

d.

Preparation for bone marrow transplant

ANS: D

Total-body irradiation is used as part of the destruction of the childs immune system necessary for a bone marrow transplant. The child is at great risk for complications because there is no supportive therapy until engraftment of the donor marrow takes place. Irradiation for palliative care is done selectively. The area that is causing pain or potential obstruction is irradiated. Lymphoma and leukemia are treated through a combination of modalities. Total-body irradiation is not indicated.

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10. The parents of a child with cancer tell the nurse that a bone marrow transplant (BMT) may be necessary. What information should the nurse recognize as important when discussing this with the family?

a.

BMT should be done at the time of diagnosis.

b.

Parents and siblings of the child have a 25% chance of being a suitable donor.

c.

If BMT fails, chemotherapy or radiotherapy will need to be continued.

d.

Finding a suitable donor involves matching antigens from the human leukocyte antigen (HLA) system.

ANS: D

The most successful BMTs come from suitable HLA-matched donors. The timing of a BMT depends on the disease process involved. It usually follows intensive high-dose chemotherapy or radiotherapy. Usually, parents only share approximately 50% of the genetic material with their children. A one in four chance exists that two siblings will have two identical haplotypes and will be identically matched at the HLA loci. The decision to continue chemotherapy or radiotherapy if BMT fails is not appropriate to discuss with the parents when planning the BMT. That decision will be made later.

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TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

11. An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that the bone marrow will be administered by which method?

a.

Bone grafting

b.

Intravenous infusion

c.

Bone marrow injection

d.

Intraabdominal infusion

ANS: B

Bone marrow from a donor is infused intravenously, and the transfused stem cells migrate to the recipients marrow and repopulate it.

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MSC: Client Needs: Physiological Integrity

12. After chemotherapy is begun for a child with acute leukemia, prophylaxis to prevent acute tumor lysis syndrome includes which therapeutic intervention?

a.

Hydration

b.

Oxygenation

c.

Corticosteroids

d.

Pain management

ANS: A

Acute tumor lysis syndrome results from the release of intracellular metabolites during the initial treatment of leukemia. Hyperuricemia, hypocalcemia, hyperphosphatemia, and hyperkalemia can result. Hydration is used to reduce the metabolic consequences of the tumor lysis. Oxygenation is not helpful in preventing acute tumor lysis syndrome. Allopurinol, not corticosteroids, is indicated for pharmacologic management. Pain management may be indicated for supportive therapy of the child, but it does not prevent acute tumor lysis syndrome.

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13. Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include which therapeutic intervention?

a.

Restrict oral fluids.

b.

Institute strict isolation.

c.

Use good hand-washing technique.

d.

Give immunizations appropriate for age.

ANS: C

Good hand washing minimizes the exposure to infectious organisms and decreases the chance of infection spread. Oral fluids are encouraged if the child is able to drink. If possible, the intravenous route is not used because of the increased risk of infection from parenteral fluid administration. Strict isolation is not indicated. When the child is immunocompromised, the vaccines are not effective. If necessary, the appropriate immunoglobulin is administered.

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14. In teaching parents how to minimize or prevent bleeding episodes when the child is myelosuppressed, the nurse includes what information?

a.

Meticulous mouth care is essential to avoid mucositis.

b.

Rectal temperatures are necessary to monitor for infection.

c.

Intramuscular injections are preferred to intravenous ones.

d.

Platelet transfusions are given to maintain a count greater than 50,000/mm3.

ANS: A

The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an increase in bleeding. The child and family are taught how to perform good oral hygiene to minimize gingival bleeding and mucositis. Rectal temperatures are avoided to minimize the risk of ulceration. Hygiene is also emphasized. Intramuscular injections are avoided because of the risk of bleeding into the muscle and of infection. Platelet transfusions are usually not given unless there is active bleeding or the platelet count is less than 10,000/mm3. The use of platelets when not necessary can contribute to antibody formation and increased destruction of platelets when transfused.

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15. A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. What is the most appropriate nursing action to prevent or minimize these reactions with subsequent treatments?

a.

Administer the chemotherapy between meals.

b.

Give an antiemetic before chemotherapy begins.

c.

Have the child bring favorite foods for snacks.

d.

Keep the child NPO (nothing by mouth) until nausea and vomiting subside.

ANS: B

The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer a 5-hydroxytryptamine-3 receptor antagonist (e.g., ondansetron) before the chemotherapy is begun. The goal is to prevent anticipatory signs and symptoms. The child will experience nausea with chemotherapy whether or not food is present in the stomach. Because some children develop aversions to foods eaten during chemotherapy, refraining from offering favorite foods is advised. Keeping the child NPO until nausea and vomiting subside will help with this episode, but the child will have discomfort and be at risk for dehydration.

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16. A young child with leukemia has anorexia and severe stomatitis. What approach should the nurse suggest that the parents try?

a.

Relax any eating pressures.

b.

Firmly insist that the child eat normally.

c.

Serve foods that are either hot or cold.

d.

Provide only liquids because chewing is painful.

ANS: A

A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the parents should relax eating pressures. The nurse should suggest that the parents try soft, bland foods; normal saline or bicarbonate mouthwashes; and local anesthetics. Insisting that the child eat normally is not suggested. For some children, not eating may be a way to maintain some control. This can set the child and caregiver in opposition to each other. Hot and cold foods can be painful on ulcerated mucosal membranes. Substitution of high-calorie foods that the child likes and can eat should be used.

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TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

17. The nurse is preparing a child for possible alopecia from chemotherapy. What information should the nurse include?

a.

Wearing hats or scarves is preferable to a wig.

b.

Expose head to sunlight to stimulate hair regrowth.

c.

Hair may have a slightly different color or texture when it regrows.

d.

Regrowth of hair usually begins 12 months after chemotherapy ends.

ANS: C

Alopecia is a side effect of certain chemotherapeutic agents and cranial irradiation. When the hair regrows, it may be of a different color or texture. Children should choose the head covering they prefer. A wig should be selected similar to the childs own hairstyle and color before the hair loss. The head should be protected from sunlight to avoid sunburn. The hair usually grows back within 3 to 6 months after the cessation of treatment.

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TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Psychosocial Integrity

18. What pain management approach is most effective for a child who is having a bone marrow test?

a.

Relaxation techniques

b.

Administration of an opioid

c.

EMLA cream applied over site

d.

Conscious or unconscious sedation

ANS: D

Children need explanations before each procedure that is being done to them. Effective pharmacologic and nonpharmacologic measures should be used to minimize pain associated with procedures. For bone marrow aspiration, conscious or unconscious sedation should be used. Relaxation, opioids, and EMLA can be used to augment the sedation.

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19. The nurse is caring for a child receiving chemotherapy for leukemia. The childs granulocyte count is 600/mm3 and platelet count is 45,000/mm3. What oral care should the nurse recommend for this child?

a.

Rinsing mouth with water

b.

Daily toothbrushing and flossing

c.

Lemon glycerin swabs for cleansing

d.

Wiping teeth with moistened gauze or Toothettes

ANS: B

Oral care is essential for children receiving chemotherapy to prevent infections and other complications. When the childs granulocyte count is above 500/mm3 and platelet count is above 40,000/mm3, daily brushing and flossing are recommended. Rinsing the mouth with water is not effective for oral hygiene. Lemon glycerin swabs are avoided because they have a drying effect on the mucous membranes, and the lemon may irritate eroded tissue and decay the childs teeth. Wiping teeth with moistened gauze or Toothettes is recommended when the childs granulocyte count is below 500/mm3 and platelet count is below 40,000/mm3.

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20. What immunization should not be given to a child receiving chemotherapy for cancer?

a.

Tetanus vaccine

b.

Inactivated poliovirus vaccine

c.

Diphtheria, pertussis, tetanus (DPT)

d.

Measles, mumps, rubella (MMR)

ANS: D

The vaccine used for MMR is a live virus and can cause serious disease in immunocompromised children. The tetanus vaccine, inactivated poliovirus vaccine, and DPT are not live vaccines and can be given to immunosuppressed children. The immune response is likely to be suboptimum, so delaying vaccination is usually recommended.

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21. What description identifies the pathophysiology of leukemia?

a.

Increased blood viscosity

b.

Abnormal stimulation of the first stage of coagulation process

c.

Unrestricted proliferation of immature white blood cells (WBCs)

d.

Thrombocytopenia from an excessive destruction of platelets

ANS: C

Leukemia is a group of malignant disorders of the bone marrow and lymphatic system. It is defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the body. Increased blood viscosity may result secondary to the increased number of WBCs. The coagulation process is unaffected by leukemia. Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow.

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22. A child with leukemia is receiving intrathecal chemotherapy to prevent which condition?

a.

Infection

b.

Brain tumor

c.

Central nervous system (CNS) disease

d.

Drug side effects

ANS: C

Children with leukemia are at risk for invasion of the CNS with leukemic cells. CNS prophylactic therapy is indicated. Intrathecal chemotherapy does not prevent infection or drug side effects. A brain tumor in a child with leukemia would be a second tumor, and additional appropriate therapy would be indicated.

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23. A parent tells the nurse that 80% of children with the same type of leukemia as his sons have a 5-year survival. He believes that because another child on the same protocol as his son has just died, his son now has a better chance of success. What is the best response by the nurse?

a.

It is sad for the other family but good news for your child.

b.

Each child has an 80% likelihood of 5-year survival.

c.

The data suggest that 20% of the children in the clinic will die. There are still many hurdles for your son.

d.

You should avoid the grieving family because you will be benefiting from their loss.

ANS: B

This is a common misconception for parents. The success data are based on numerous factors, including the effectiveness of the protocol and the childs response. These are aggregate data that apply to each child and do not depend on the success or failure in other children. The failure of one child in a protocol does not improve the success rate for other children. Although the son does face more hurdles, these are aggregate data, not specific to the clinic. It may be difficult for this family to be supportive given their concerns about their child. Families usually form support groups in pediatric oncology settings, and support during bereavement is common.

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MSC: Client Needs: Psychosocial Integrity

24. What is a common clinical manifestation of Hodgkin disease?

a.

Petechiae

b.

Bone and joint pain

c.

Painful, enlarged lymph nodes

d.

Nontender enlargement of lymph nodes

ANS: D

Asymptomatic, enlarged cervical or supraclavicular lymphadenopathy is the most common presentation of Hodgkin disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin disease. The enlarged nodes are rarely painful.

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25. What are the most common clinical manifestations of brain tumors in children?

a.

Headaches and vomiting

b.

Blurred vision and ataxia

c.

Hydrocephalus and clumsy gait

d.

Fever and poor fine motor control

ANS: A

Headaches, especially on awakening, and vomiting that is not related to feeding are the most common clinical manifestations of brain tumors in children. Diplopia (double vision), not blurred vision, can be a presenting sign of brainstem glioma. Ataxia is a clinical manifestation of brain tumors, but headaches and vomiting are the most common. Hydrocephalus can be a presenting sign in infants when the sutures have not closed. Children at this age are usually not walking steadily. Poor fine motor coordination may be a presenting sign of astrocytoma, but headaches and vomiting are the most common presenting signs of brain tumors.

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26. A 5-year-old child is being prepared for surgery to remove a brain tumor. Preparation for surgery should be based on which information?

a.

Removal of the tumor will stop the various signs and symptoms.

b.

Usually the postoperative dressing covers the entire scalp.

c.

He is not old enough to be concerned about his head being shaved.

d.

He is not old enough to understand the significance of the brain.

ANS: B

The child should be told what he will look and feel like after surgery. This includes the anticipated size of the dressing. The nurse can demonstrate on a doll the expected size and shape of the dressing. Some of the symptoms may be alleviated by removal of the tumor, but postsurgical headaches and cerebellar symptoms such as ataxia may be aggravated. Children should be prepared for the loss of their hair, and it should be removed in a sensitive, positive manner if the child is awake. Children at this age have poorly defined body boundaries and little knowledge of internal organs. Intrusive experiences are frightening, especially those that disrupt the integrity of the skin.

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27. Essential postoperative nursing management of a child after removal of a brain tumor includes which nursing care?

a.

Turning and positioning every 2 hours

b.

Measuring all fluid intake and output

c.

Changing the dressing when it becomes soiled

d.

Using maximum lighting to ensure accurate observations

ANS: B

After brain surgery, cerebral edema is a risk. Careful monitoring is essential. All fluids, including intravenous antibiotics, are included in the intake. Turning and positioning depend on the surgical procedure. When large tumors are removed, the child is usually not positioned on the operative side. The dressing is not changed. It is reinforced with gauze after the amount of drainage is marked and estimated. A quiet, dimly lit environment is optimum to decrease stimulation and relieve discomfort such as headaches.

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MSC: Client Needs: Physiological Integrity

28. An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. What approach should the nurse implement?

a.

Answer questions with straightforward honesty.

b.

Avoid discussing the seriousness of the condition.

c.

Explain that although the amputation is difficult, it will cure the cancer.

d.

Help the adolescent accept the amputation as better than a long course of chemotherapy.

ANS: A

Honesty is essential to gain the childs cooperation and trust. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared for the surgery so there is time for reflection about the diagnosis and subsequent treatment. This allows questions to be answered. To accept the need for radical surgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will not guarantee a cure. Chemotherapy is an integral part of the therapy with surgery. The child should be informed of the need for chemotherapy and its side effects before surgery.

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29. What is an important priority in dealing with the child suspected of having Wilms tumor?

a.

Intervening to minimize bleeding

b.

Monitoring temperature for infection

c.

Ensuring the abdomen is protected from palpation

d.

Teaching parents how to manage the parenteral nutrition

ANS: C

Wilms tumor, or nephroblastoma, is the most common malignant renal and intraabdominal tumor of childhood. The abdomen is protected, and palpation is avoided. Careful handling and bathing are essential to prevent trauma to the tumor site. Before chemotherapy, the child is not myelosuppressed. Bleeding is not usually a risk. Infection is a concern after surgery and during chemotherapy, not before surgery. Parenteral therapy is not indicated before surgery.

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30. The mother of an infant tells the nurse that sometimes there is a whitish glow in the pupil of his eye. The nurse should suspect which condition?

a.

Brain tumor

b.

Retinoblastoma

c.

Neuroblastoma

d.

Rhabdomyosarcoma

ANS: B

When the nurse examines the eye, the light will reflect off of the tumor, giving the eye a whitish appearance. This is called a cats eye reflex. Brain tumors are not usually visible. Neuroblastoma usually arises from the adrenal medulla and sympathetic nervous system. The most common presentation sites are in the abdomen, head, neck, or pelvis. Supraorbital ecchymosis may be present with distant metastasis. Rhabdomyosarcoma is a soft tissue tumor that derives from skeletal muscle undifferentiated cells.

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31. The nurse is caring for a 6-year-old child with acute lymphoblastic leukemia (ALL). The parent states, My child has a low platelet count, and we are being discharged this afternoon. What do I need to do at home? What statement is most appropriate for the nurse to make?

a.

You should give your child aspirin instead of acetaminophen for fever or pain.

b.

Your child should avoid contact sports or activities that could cause bleeding.

c.

You should feed your child a bland, soft, moist diet for the next week.

d.

Your child should avoid large groups of people for the next week.

ANS: B

A child with a low platelet count needs to avoid activities that could cause bleeding such as playing contact sports, climbing trees, using playground equipment, or bike riding. The child should be given acetaminophen, not aspirin, for fever or pain; the child does not need to be on a soft, bland diet or avoid large groups of people because of the low platelet count.

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MSC: Client Needs: Physiological Integrity

32. One pediatric oncologic emergency is acute tumor lysis syndrome. Symptoms that this may be occurring include what?

a.

Muscle cramps and tetany

b.

Respiratory distress and cyanosis

c.

Thrombocytopenia and sepsis

d.

Upper extremity edema and neck vein distension

ANS: A

Risk factors for development of tumor lysis syndrome include a high white blood cell count at diagnosis, large tumor burden, sensitivity to chemotherapy, and high proliferative rate. In addition to the described metabolic abnormalities, children may develop a spectrum of clinical symptoms, including flank pain, lethargy, nausea and vomiting, muscle cramps, pruritus, tetany, and seizures. Respiratory distress and cyanosis occur with hyperleukocytosis. Thrombocytopenia and sepsis occur with disseminated intravascular coagulation. Upper extremity edema and neck vein distention occur with superior vena cava syndrome.

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33. A child has an absolute neutrophil count (ANC) of 500/mm3. The nurse should expect to be administering which prescribed treatment?

a.

Platelets

b.

Packed red blood cells

c.

Zofran (ondansetron)

d.

G-CSF (Neupogen) daily

ANS: D

G-CSF (filgrastim [Neupogen], pegfilgrastim [Neulasta]) directs granulocyte development and can decrease the duration of neutropenia following immunosuppressive therapy. G-CSF is discontinued when the ANC surpasses 10,000/mm3.

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34. What specific gravity of the urine is desired so that hemorrhagic cystitis is prevented?

a.

1.035

b.

1.030

c.

1.025

d.

1.005

ANS: D

Sterile hemorrhagic cystitis is a side effect of chemical irritation to the bladder from chemotherapy or radiotherapy. It can be prevented by a liberal oral or parenteral fluid intake (at least one and a half times the recommended daily fluid requirement). The urine should be dilute so 1.005 is the expected specific gravity.

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35. A child, age 10 years, has a neuroblastoma and is in the hospital for additional chemotherapy treatments. What laboratory values are most likely this childs?

a.

White blood cell count, 17,000/mm3; hemoglobin, 15 g/dl

b.

White blood cell count, 3,000/mm3; hemoglobin, 11.5 g/dl

c.

Platelets, 450,000/mm3; hemoglobin, 12 g/dl

d.

White blood cell count, 10,000/mm3; platelets, 175,000/mm3

ANS: B

Chemotherapy is the mainstay of therapy for extensive local or disseminated neuroblastoma. The drugs of choice are vincristine, doxorubicin, cyclophosphamide, cisplatin, etoposide, ifosfamide, and carboplatin. These cause immunosuppression, so the laboratory values will indicate a low white blood cell count and hemoglobin.

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36. Calculate the absolute neutrophil count (ANC) for the following: WBC count of 5000 mm3; neutrophils (segs) of 10%; and nonsegmented neutrophils (bands) of 12%.

a.

110/mm3

b.

500/mm3

c.

1100/mm3

d.

5000/mm3

ANS: C

Determine the total percentage of neutrophils (polys, or segs, and bands). Multiply white blood cell (WBC) count by percentage of neutrophils.

WBC = 1000/mm3, neutrophils = 7%, and nonsegmented neutrophils (bands) = 7%

Step 1: 10% + 12% = 22%

Step 2: 0.22 5000 = 1100/mm3 ANC

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MSC: Client Needs: Physiological Integrity

37. A child has been diagnosed with a Wilms tumor. What should preoperative nursing care include?

a.

Careful bathing and handling

b.

Monitoring of behavioral status

c.

Maintenance of strict isolation

d.

Administration of packed red blood cells

ANS: A

Careful bathing and handling are important in preventing trauma to the Wilms tumor site.

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TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

38. What is appropriate mouth care for a toddler with mucosal ulceration related to chemotherapy?

a.

Mouthwashes with plain saline

b.

Lemon glycerin swabs for cleansing

c.

Mouthwashes with hydrogen peroxide

d.

Swish and swallow with viscous lidocaine

ANS: A

Administering mouth care is particularly difficult in infants and toddlers. A satisfactory method of cleaning the gums is to wrap a piece of gauze around a finger; soak it in saline or plain water; and swab the gums, palate, and inner cheek surfaces with the finger. Mouth rinses are best accomplished with plain water or saline because the child cannot gargle or spit out excess fluid. Avoid agents such as lemon glycerin swabs and hydrogen peroxide because of the drying effects on the mucosa. Lidocaine should be avoided in young children.

DIF: Cognitive Level: Applying REF: p. 1385

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

39. The nurse should expect to care for which age of child if the admitting diagnosis is retinoblastoma?

a.

Infant or toddler

b.

Preschool- or school-age child

c.

School-age or adolescent child

d.

Adolescent

ANS: A

The average age of the child at the time of diagnosis is 2 years, and bilateral and hereditary disease is diagnosed earlier than unilateral and nonhereditary disease.

DIF: Cognitive Level: Understanding REF: p. 1418

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

40. Postoperative positioning for a child who has had a medulloblastoma brain tumor (infratentorial) removed should be which?

a.

Trendelenburg

b.

Head of bed elevated above heart level

c.

Flat on operative side with pillows behind the head

d.

Flat, on either side with pillows behind the back

ANS: D

The child with an infratentorial procedure is usually positioned flat and on either side. Pillows should be placed against the childs back, not head, to maintain the desired position. The Trendelenburg position is contraindicated in both infratentorial and supratentorial surgeries because it increases intracranial pressure and the risk of hemorrhage.

DIF: Cognitive Level: Applying REF: p. 1410

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

41. A child is receiving vincristine (Oncovin). The nurse should monitor for which side effect of this medication?

a.

Diarrhea

b.

Photosensitivity

c.

Constipation

d.

Ototoxicity

ANS: A

Vincristine, and to a lesser extent vinblastine, can cause various neurotoxic effects. One of the more common neurotoxic effects is severe constipation caused from decreased bowel innervation.

DIF: Cognitive Level: Applying REF: p. 1412

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

42. What chemotherapeutic agent can cause an anaphylactic reaction?

a.

Prednisone (Deltasone)

b.

Vincristine (Oncovin)

c.

L-Asparaginase (Elspar)

d.

Methotrexate (Trexall)

ANS: C

A potentially fatal complication is anaphylaxis, especially from L-asparaginase, bleomycin, cisplatin, and etoposide (VP-16).

DIF: Cognitive Level: Understanding REF: p. 1383

TOP: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

43. A child with cancer being treated with chemotherapy is receiving a platelet transfusion. The nurse understands that the transfused platelets should survive the body for how many days?

a.

1 to 3 days

b.

4 to 6 days

c.

7 to 9 days

d.

10 to 12 days

ANS: A

Transfused platelets generally survive in the body for 1 to 3 days. The peak effect is reached in about 1 hour and decreased by half in 24 hours.

DIF: Cognitive Level: Understanding REF: p. 1392

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

44. Daily toothbrushing and flossing can be encouraged for the child on chemotherapy when the platelet count is above which?

a.

10,000/mm3

b.

20,000/mm3

c.

30,000/mm3

d.

40,000/mm3

ANS: D

Daily toothbrushing and flossing are encouraged in children with platelet counts above 40,000/mm3.

DIF: Cognitive Level: Analyzing REF: p. 1397 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

45. A parent of a hospitalized child on chemotherapy asks the nurse if a sibling of the hospitalized child should receive the varicella vaccination. The nurse should give which response?

a.

The sibling can get a varicella vaccination.

b.

The sibling should not get a varicella vaccination.

c.

The sibling should wait until the child is finished with chemotherapy.

d.

The sibling should get varicella-zoster immune globulin if exposed to chickenpox.

ANS: A

Siblings and other family members can receive the live measles, mumps, and rubella vaccine and the varicella vaccine without risk to the child who is immunosuppressed.

DIF: Cognitive Level: Applying REF: p. 1397

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

46. The nurse is collecting a 24-hour urine sample on a child with suspected diagnosis of neuroblastoma. What finding in the urine is expected with neuroblastomas?

a.

Ketones

b.

Catecholamines

c.

Red blood cells

d.

Excessive white blood cells

ANS: B

Neuroblastomas, particularly those arising on the adrenal glands or from a sympathetic chain, excrete the catecholamines epinephrine and norepinephrine. Urinary excretion of catecholamines is detected in approximately 95% of children with adrenal or sympathetic tumors.

DIF: Cognitive Level: Analyzing REF: p. 1412 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

47. A child with osteosarcoma is experiencing phantom limb pain after an amputation. What prescribed medication is effective for short-term phantom pain relief?

a.

Phenytoin (Dilantin)

b.

Gabapentin (Neurontin)

c.

Valproic Acid (Depakote)

d.

Phenobarbital (Phenobarbital)

ANS: B

A recent Cochrane review reported that various medications have been used for phantom limb pain but complete pain relief has been unsuccessful. Morphine, gabapentin, and ketamine are effective for short-term pain relief.

DIF: Cognitive Level: Applying REF: p. 1414

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse is precepting a new graduate nurse at an ambulatory pediatric hematology and oncology clinic. What cardinal signs of cancer in children should the nurse make the new nurse aware of? (Select all that apply.)

a.

Sudden tendency to bruise easily

b.

Transitory, generalized pain

c.

Frequent headaches

d.

Excessive, rapid weight gain

e.

Gradual, steady fever

f.

Unexplained loss of energy

ANS: A, C, F

The cardinal signs of cancer in children include a sudden tendency to bruise easily; frequent headaches, often with vomiting; and an unexplained loss of energy. Other cardinal signs include persistent, localized pain; excessive, rapid weight loss; and a prolonged, unexplained fever.

DIF: Cognitive Level: Applying REF: p. 1381

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

2. A child on chemotherapy has developed rectal ulcers. What interventions should the nurse teach to the child and parents to relieve the discomfort of rectal ulcers? (Select all that apply.)

a.

Warm sitz baths

b.

Use of stool softeners

c.

Record bowel movements

d.

Use of an opioid for discomfort

e.

Occlusive ointment applied to the area

ANS: A, B, C, E

If rectal ulcers develop, meticulous toilet hygiene, warm sitz baths after each bowel movement, and an occlusive ointment applied to the ulcerated area promote healing; the use of stool softeners is necessary to prevent further discomfort. Parents should record bowel movements because the child may voluntarily avoid defecation to prevent discomfort. Opioids would cause increased constipation.

DIF: Cognitive Level: Applying REF: p. 1394

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

3. What are favorable prognostic criteria for acute lymphoblastic leukemia? (Select all that apply.)

a.

Male gender

b.

CALLA positive

c.

Early preB cell

d.

2 to 10 years of age

e.

Leukocyte count ?7?50,000/mm3

ANS: B, C, D

Favorable prognostic criteria for acute lymphoblastic leukemia include CALLA positive, early preB cell, and age 2 to 10 years. Leukocyte count less, not greater, than 50,000/mm3 and female, not male, gender are favorable prognostic criteria.

DIF: Cognitive Level: Analyzing REF: p. 1400 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

4. The nurse should teach the family that which residual disabilities can occur for a child being treated for a brain tumor? (Select all that apply.)

a.

Ataxia

b.

Anorexia

c.

Dysphagia

d.

Sensory deficits

e.

Crania nerve palsies

ANS: A, C, D, E

Even with children who are long-term survivors after treatment for a brain tumor, residual disabilities, such as short stature, cranial nerve palsies, sensory defects, motor abnormalities (especially ataxia), intellectual deficits, dysphagia, dysgraphia, and behavioral problems, may occur. Anorexia is not a residual disability.

DIF: Cognitive Level: Applying REF: p. 1411

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

5. The nurse is caring for a child with retinoblastoma that was treated with an enucleation. What interventions should the nurse plan for care of an eye socket after enucleation? (Select all that apply.)

a.

Clean the prosthesis.

b.

Change the eye pad daily.

c.

Keep the opposite eye covered initially.

d.

Irrigate the socket daily with a prescribed solution.

e.

Apply a prescribed antibiotic ointment after irrigation.

ANS: B, D, E

Care of the socket is minimal and easily accomplished. The wound itself is clean and has little or no drainage. If an antibiotic ointment is prescribed, it is applied in a thin line on the surface of the tissues of the socket. To cleanse the site, an irrigating solution may be ordered and is instilled daily or more frequently if necessary before application of the antibiotic ointment. The dressing consists of an eye pad changed daily. The prosthesis is not placed until the socket has healed. The opposite eye is not covered.

DIF: Cognitive Level: Applying REF: p. 1420

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

6. What guidelines should the nurse follow when handling chemotherapeutic agents? (Select all that apply.)

a.

Use clean technique.

b.

Prepare medications in a safety cabinet.

c.

Wear gloves designed for handling chemotherapy.

d.

Wear face and eye protection when splashing is possible.

e.

Discard gloves and protective clothing in a special container.

ANS: B, C, D, E

Safe handling of chemotherapeutic agents includes preparing medications in a safety cabinet, wearing gloves designed for handling chemotherapy, wearing face and eye protection when splashing is possible, and discarding gloves and protective clothing in a special container. Aseptic, not clean, technique should be used.

DIF: Cognitive Level: Applying REF: p. 1384

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

7. What strategies should the nurse implement to increase nutritional intake for the child receiving chemotherapy? (Select all that apply.)

a.

Allow the child any food tolerated.

b.

Fortify foods with nutritious supplements.

c.

Allow the child to be involved in food selection.

d.

Encourage the parents to place pressure on the importance of eating.

e.

Encourage the child to eat favorite foods during infusion of chemotherapy medications.

ANS: A, B, C

To increase nutritional intake for the child receiving chemotherapy, the nurse should allow the child any food tolerated, fortify foods with nutritious supplements, and allow the child to be involved in food selection. The parents should be encouraged to reduce pressure placed on eating. Some children develop aversions to certain foods if they are eaten during chemotherapy. It is best to refrain from offering the childs favorite foods while the child is receiving chemotherapy.

DIF: Cognitive Level: Applying REF: p. 1389

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

COMPLETION

1. A health care provider prescribes ondansetron (Zofran) 0.15 mg/kg intravenously (IV) 30 minutes before chemotherapy for a child with acute lymphoblastic leukemia. The child weighs 22 kg. The medication label states: Ondansetron (Zofran) 2 mg/1 ml. The nurse prepares to administer the dose. How many milliliters will the nurse prepare to administer the dose? Fill in the blank. Round your answer to one decimal place.

________________

ANS:

1.7

Follow the formula for dosage calculation.

22 0.15 = 3.3 mg as the dose

Desired

Volume = ml per dose

Available

3.3 mg

1 ml = 1.65 ml round to 1.7 ml

2 mg

DIF: Cognitive Level: Applying REF: p. 1393

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

2. The health care provider prescribes ceftazidime (Fortaz) 75 mg per intravenous piggyback (IVPB) every 8 hours for a child with cancer admitted with fever and neutropenia. The pharmacy sends the medication to the unit in a 50-ml bag with directions to run the medication over 30 minutes. What milliliters per hour will the nurse set the intravenous pump to run the medication over 30 minutes? Fill in the blank and record your answer in a whole number.

_____________

ANS:

100

Perform the calculation.

50 ml

________ 60 minutes = 100 ml/hr

30 minutes

DIF: Cognitive Level: Applying REF: p. 1390

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

3. The health care provider prescribes vancomycin 200 mg per intravenous piggyback (IVPB) every 6 hours for a child with cancer admitted to the hospital for fever and neutropenia. The pharmacy sends the medication to the unit in a 240-ml bag with directions to run the medication over 120 minutes. What milliliters per hour will the nurse set the intravenous pump to run the medication over 120 minutes? Fill in the blank and record your answer in a whole number.

_____________

ANS:

120

Perform the calculation.

Convert the minutes to hours = 120/60 = 2 hours

240 ml

________ = 120 ml/hr

2 hours

DIF: Cognitive Level: Applying REF: p. 1390

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

4. A health care provider prescribes Osmitrol (mannitol) 0.25 g/kg intravenously (IV) every 6 hours for a child after a brain tumor removal. The child weighs 20 kg. The medication label states: Osmitrol (Mannitol) 250 mg/1 ml. The nurse prepares to administer the dose. How many milliliters will the nurse prepare to administer the dose? Fill in the blank. Record your answer in a whole number.

________________

ANS:

20

Calculate the dose.

0.25 g 20 = 5 g convert to mg = 5000 mg

Follow the formula for dosage calculation.

Desired

Volume = ml per dose

Available

5000 mg

1 ml = 20 ml

250 mg

DIF: Cognitive Level: Applying REF: p. 1410

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

5. Calculate the absolute neutrophil count for a child with a WBC = 3000/mm3, neutrophils = 10%, and nonsegmented neutrophils (bands) = 10%. Record your answer below in a whole number.

_____________

ANS:

600

Perform the calculation

Determine the total percentage of neutrophils (polys, or segs, and bands).

Multiply white blood cell (WBC) count by percentage of neutrophils.

WBC = 3000/mm3, neutrophils = 10%, and nonsegmented neutrophils (bands) = 10%

Step 1: 10% + 10% = 20%

Step 2: 0.2 3000 = 600/mm3 ANC

DIF: Cognitive Level: Applying REF: p. 1391 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

6. Calculate the absolute neutrophil count for a child with a WBC = 6000/mm3, neutrophils = 18%, and nonsegmented neutrophils (bands) = 20%. Record your answer below in a whole number.

____________

ANS:

2280

Perform the calculation

Determine the total percentage of neutrophils (polys, or segs, and bands).

Multiply white blood cell (WBC) count by percentage of neutrophils.

WBC = 6000/mm3, neutrophils = 18%, nonsegmented neutrophils (bands) = 20%

Step 1: 18% + 20% = 38%

Step 2: 0.38 6000 = 2280/mm3 ANC

DIF: Cognitive Level: Applying REF: p. 1391 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

7. Calculate the absolute neutrophil count for a child with a WBC = 10,000/mm3, neutrophils = 25%, and nonsegmented neutrophils (bands) = 22%. Record your answer in a whole number.

_____________

ANS:

4700

Perform the calculation

Determine the total percentage of neutrophils (polys, or segs, and bands).

Multiply white blood cell (WBC) count by percentage of neutrophils.

WBC = 10,000/mm3, neutrophils = 25%, and nonsegmented neutrophils (bands) = 22%

Step 1: 25% + 22% = 47%

Step 2: 0.47 10,000 = 4700/mm3 ANC

DIF: Cognitive Level: Applying REF: p. 1391 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

8. Calculate the absolute neutrophil count for a child with a WBC = 15,000/mm3, neutrophils = 29%, and nonsegmented neutrophils (bands) = 29%. Record your answer in a whole number.

_____________

ANS:

8700

Perform the calculation

Determine the total percentage of neutrophils (polys, or segs, and bands).

Multiply white blood cell (WBC) count by percentage of neutrophils.

WBC = 3000/mm3, neutrophils = 10%, and nonsegmented neutrophils (bands) = 10%

Step 1: 29% + 29% = 58%

Step 2: 0.58 15,000 = 8700/mm3 ANC

DIF: Cognitive Level: Applying REF: p. 1391 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

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