Chapter 48: The Child with Cancer – Flashcards

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.

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.

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 parent's 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.

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.

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.

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.

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.

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.

ANS: D Feedback A The child's 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 child's temperature as often as necessary.

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.

ANS: C Feedback A The goal is to relieve the mother's 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 mother's feelings of guilt.

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.

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 tumor's intracellular contents are dumped into the child's 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.

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 child's 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.

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.

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 child's neurologic status frequently. C Hemorrhage is a risk in the postoperative period. The child's dressing would be inspected frequently for bleeding. D Temperature is monitored closely because the child is at risk for infection in the postoperative period.

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 and Haemophilus influenzae vaccines are administered before the surgery.

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.

ANS: A Feedback A In an autologous transplant, the child's 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.

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 child's 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.

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

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 child's 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.

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 child's 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.

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.

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.

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.

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).