Chapter 48: The Child with Cancer My Nursing Test Banks

Chapter 48: The Child with Cancer

Test Bank

MULTIPLE CHOICE

1. The nurse notes that a childs gums bleed easily and he has bruising and petechiae on his extremities. What laboratory values are 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

Feedback

A

The normal platelet count is 150,000 to 400,000/mm3. This finding is very low, indicating an increased bleeding potential. The child should be monitored closely for signs of bleeding.

B

The prothrombin time of 11 to 15 seconds is within normal limits.

C

The normal hematocrit is 35 to 45 and, although this finding is low, it would not create the symptoms presented.

D

This value indicates the probable presence of infection, but it is not a reflection of bleeding tendency.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1278

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

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

a.

Gastrointestinal upset

b.

Bone marrow suppression

c.

Decreased creatinine level

d.

Alopecia

ANS: B

Feedback

A

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.

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.

C

A decreased creatinine level is consistent with renal pathologic conditions, not chemotherapy.

D

Not all chemotherapeutic agents cause alopecia. No precautions are taken to prevent alopecia.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1268

OBJ: Nursing Process: Assessment

MSC: Client Needs: 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 the knowledge that

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

Feedback

A

With the majority of children surviving 5 years or longer, it is inappropriate to refer to leukemia as a fatal disease.

B

This statement is true, but it does not address the parents concern.

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%.

D

About 95% of children achieve remission within the first month of chemotherapy. If a significant number of blast cells are still present in the bone marrow after a month of chemotherapy, a new and stronger regimen is begun.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1267

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

4. Hematopoietic stem cell transplantation (HSCT) is the standard treatment for a child in his or her first remission with what cancer?

a.

ALL

b.

Non-Hodgkin lymphoma

c.

Wilms tumor

d.

Acute myeloblastic leukemia (AML)

ANS: D

Feedback

A

The standard treatment for ALL is combination chemotherapy.

B

Standard treatment for non-Hodgkin lymphoma is chemotherapy. Bone marrow transplantation is used to treat non-Hodgkin lymphoma that is resistant to conventional chemotherapy and radiation.

C

The treatment for Wilms tumor consists of surgery and chemotherapy alone or in combination with radiation therapy.

D

HSCT is often used interchangeably with bone marrow transplantation and is currently standard treatment for children in their first remission with AML.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1271

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

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

a.

Ewing sarcoma

b.

Wilms tumor

c.

Neuroblastoma

d.

Leukemia

ANS: D

Feedback

A

Symptoms of Ewing sarcoma involve pain and soft tissue swelling around the affected bone.

B

Wilms tumor usually manifests as an abdominal mass with abdominal pain and may include renal symptoms, such as hematuria, hypertension, and anemia.

C

Neuroblastoma manifests primarily as an abdominal, chest, bone, or joint mass. Symptoms are dependent on the extent and involvement of the tumor.

D

These symptoms reflect bone marrow failure and organ infiltration, which occur in leukemia.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1274

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

6. Which clinical finding is an overt sign of retinoblastoma in children?

a.

Whitish reflex in the eye

b.

Lymphadenopathy

c.

Bone pain

d.

Change in gait

ANS: A

Feedback

A

A whitish reflex in the eye, leukocoria, is a common finding of retinoblastoma. It is an overt sign of cancer in children.

B

Persistent lymphadenopathy is a manifestation of several forms of childhood cancer. It is a covert sign of cancer in children.

C

Bone pain is a covert symptom of cancer in children.

D

A change in gait may be a sign of a brain tumor. It is considered a covert sign of cancer in children.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1292

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

7. What is a priority nursing diagnosis 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

Feedback

A

This nursing diagnosis applies to a child with non-Hodgkin lymphoma or any cancer involving the chest area.

B

Leukemia is characterized by the proliferation of immature white blood cells, which lack the ability to fight infection.

C

This 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.

D

Radiation therapy is not a treatment for leukemia.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1277

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic 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

Feedback

A

A CBC may show blast cells that would raise suspicion of leukemia. It is not a confirming diagnostic study.

B

A lumbar puncture is done to check for central nervous system involvement in the child who has been diagnosed with leukemia.

C

The confirming test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspiration and biopsy.

D

A CT scan may be done to check for bone involvement in the child with leukemia. It does not confirm a diagnosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1274

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

9. Which statement, if made by a nurse to the parents of a child with leukemia, indicates an understanding of teaching related to home care associated with the disease?

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 involvement.

c.

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

d.

Your sons temperature should be taken frequently.

ANS: D

Feedback

A

The childs temperature must be taken daily because of the risk for infection, but it is not necessary to take a blood pressure daily.

B

Fluid is never withheld as a precaution against increased intracranial pressure. If a child had confirmed CNS involvement with increased intracranial pressure, this intervention might be more appropriate.

C

Children who are immunosuppressed should not receive any live virus vaccines.

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 as often as necessary.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1277

OBJ: Nursing Process: Evaluation MSC: Client Needs: 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.

ANS: D

Feedback

A

In a child with neutropenia, a reddened area may be the only sign of an infection. The area should never be massaged.

B

The forearm is not a typical pressure area; therefore the likelihood of the redness being related to pressure is very small.

C

The observation should be documented, but because it may be a sign of an infection and immunosuppression, the physician must also be notified.

D

Skin is the first line of defense against infection. Any signs of infection in a child who is immunosuppressed must be reported to the physician. When a child is neutropenic, pus may not be produced and the only sign of infection may be redness.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1278

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic 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 boys 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

Feedback

A

The goal is to relieve the mothers guilt and build trust so that she can talk about her feelings. This statement will only reinforce her guilt.

B

This response is flippant and reinforces that the mother was negligent, which will only increase her guilt.

C

This statement 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.

D

This statement shows a total lack of empathy and would increase the mothers feelings of guilt.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1279

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

12. What 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

Feedback

A

Fluids are not routinely limited in a child with a Wilms tumor. However, intake and output are important because of the kidney involvement.

B

Excessive manipulation of the tumor area can cause seeding of the tumor and spread of the malignant cells.

C

Fluids are not forced on a child with a Wilms tumor. Normal intake for age is usually maintained.

D

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.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1291

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

13. Children with non-Hodgkin lymphoma are at risk for complications resulting from tumor lysis syndrome (TLS). The nurse should assess for

a.

Liver failure

b.

CNS deficit

c.

Kidney failure

d.

Respiratory distress

ANS: C

Feedback

A

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.

B

TLS does not affect the CNS.

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.

D

TLS does not affect the lungs and cause respiratory distress.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1283

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

14. While completing an assessment on a 6-month-old infant, which finding should the nurse recognize as 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

Feedback

A

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.

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.

C

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.

D

Increased intracranial pressure resulting from a brain tumor is manifested as a headache but could not be verbalized by an infant.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1276

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

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

a.

Protuberant, firm abdomen

b.

Enlarged, painless, firm cervical lymph nodes

c.

Soft tissue swelling

d.

Soft to hard, nontender mass in pelvic area

ANS: B

Feedback

A

A protuberant, firm abdomen is present in many cases of neuroblastoma.

B

Painless, firm, movable adenopathy (enlarged lymph nodes) palpated in the cervical region is an expected assessment finding in Hodgkin disease. Other systemic symptoms include unexplained fevers, weight loss, and night sweats.

C

Soft tissue swelling around the affected bone is a manifestation of Ewing sarcoma.

D

A soft to hard, nontender mass can be palpated when rhabdomyosarcoma is present.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1285

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic 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.

Place the child in Trendelenburg position.

b.

Perform neurologic assessments.

c.

Assess dressings for drainage.

d.

Monitor temperature.

ANS: A

Feedback

A

The child is never placed in the Trendelenburg position because it increases intracranial pressure and the risk of bleeding.

B

Increased intracranial pressure is a risk in the postoperative period. The nurse would assess the childs neurologic status frequently.

C

Hemorrhage is a risk in the postoperative period. The childs dressing would be inspected frequently for bleeding.

D

Temperature is monitored closely because the child is at risk for infection in the postoperative period.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1282

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

17. A child with non-Hodgkin lymphoma will be starting chemotherapy. What 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 Haemophilus influenzae type B vaccines

ANS: B

Feedback

A

A central venous catheter is placed to assist in delivering chemotherapy.

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.

C

An externalized VP shunt may be placed to relieve intracranial pressure caused by a brain tumor.

D

If a splenectomy is necessary for a child with Hodgkin disease, the pneumococcal andHaemophilus influenzae vaccines are administered before the surgery.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1284

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

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

a.

Osteogenic sarcoma

b.

Rhabdomyosarcoma

c.

Neuroblastoma

d.

Non-Hodgkin lymphoma

ANS: C

Feedback

A

Osteogenic sarcoma is a bone tumor. Bone tumors typically affect older children.

B

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.

C

Neuroblastoma is found exclusively in infants and children. In most cases of neuroblastoma, a primary abdominal mass and protuberant, firm abdomen are present.

D

Non-Hodgkin 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1286

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

19. 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. This type of BMT is termed

a.

Autologous

b.

Allogeneic

c.

Syngeneic

d.

Stem cell

ANS: A

Feedback

A

In an autologous transplant, the childs own marrow or previously harvested and banked cord blood is used.

B

In an allogeneic BMT, histocompatibility has been matched with a related or an unrelated donor.

C

In a syngeneic transplant, the child receives bone marrow from an identical twin.

D

A stem cell transplantation uses a unique immature cell present in the peripheral circulation.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1271

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

20. 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

Feedback

A

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.

B

Mouthwashes containing alcohol may be drying to oral mucosa, thus breaking down the protective barrier of the skin.

C

The childs mouth is inspected regularly for ulcers. At the first sign of ulceration, an antifungal drug is initiated.

D

Oral hygiene should be performed four times a day.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1269

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

21. What fluid 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

Feedback

A

A hot beverage can be irritating to mouth ulcers.

B

Citrus products may be very painful to an ulcerated mouth.

C

Cool liquids are soothing and ice pops are usually well tolerated.

D

Citrus products may be very painful to an ulcerated mouth.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1277

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

1. When an adolescent with a new diagnosis of Ewing sarcoma asks the nurse about treatment, the nurses response is based on the knowledge that (select all that apply)

a.

This type of tumor invades the bone.

b.

Management includes chemotherapy, surgery, and radiation.

c.

Ewing 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.

e.

Is the most common bone tumor seen in children.

ANS: A, B, D

Feedback

Correct

Ewing 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 Ewing 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.

Incorrect

Ewing sarcoma is responsive to both chemotherapy and radiation. Osteosarcoma is the most common primary bone malignancy in children. The second most common bone tumor seen in children is Ewing sarcoma.

PTS: 1 DIF: Cognitive Level: Analysis REF: pp. 1289-1290

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

2. What should the nurse recognize as symptoms of a brain tumor in a school-age child for whom she is caring? Select all that apply.

a.

Blurred vision

b.

Increased head circumference

c.

Vomiting when getting out of bed

d.

Intermittent headache

e.

Declining academic performance

ANS: A, C, D, E

Feedback

Correct

Visual changes such as nystagmus, diplopia, and strabismus are manifestations of a brain tumor. 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. Increased intracranial pressure resulting from a brain tumor is manifested as a headache. School-age children may exhibit declining academic performance, fatigue, personality changes, and symptoms of vague, intermittent headache. Other symptoms may include seizures or focal neurologic deficits.

Incorrect

Manifestations of brain tumors vary with tumor location and the childs age and development. Infants with brain tumors may have increased head circumference with a bulging fontanel. School-age children have closed fontanels and therefore their head circumferences do not increase with brain tumors.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 1276

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

3. A child with a brain tumor is undergoing radiation therapy. What should the nurse include 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

Feedback

Correct

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.

Incorrect

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.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1271

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

COMPLETION

1. In recent years the use of _____________ stem cell transplantation has become the accepted therapy for the treatment of several hematologic and oncologic disorders.

ANS:

hematopoietic

HSCT allows extremely high doses of chemotherapy, with or without radiation, to be given without regard for bone marrow recovery because hematopoiesis will be restored through transplantation. Stem cells are harvested from bone marrow, peripheral blood, and umbilical cord blood. HSCT is often used interchangeably with bone marrow transplantation in the clinical setting.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1271

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

2. A less common malignancy of muscle or striated tissue is known as ______________.

ANS:

rhabdomyosarcoma

This sarcoma occurs periorbitally or in the head and neck of younger children and in the trunk and extremities of older children. Long-term survival rates are variable based upon the age of the child.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 1290

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

TRUE/FALSE

1. Complementary and alternative medical therapies (CAM) are those that are scientifically proven or are not proven; however, they are deemed to be useful as an adjunct to treatment. It is not uncommon for families to try CAM without disclosing this information to the health care team. Is this statement true or false?

ANS: T

Families should be asked about CAM therapies by the nurse in a nonthreatening manner. This is important information because some therapies can potentially decrease the efficacy of chemotherapy (such as folate in a child receiving methotrexate).

PTS: 1 DIF: Cognitive Level: Application REF: p. 1273

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

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