Chapter 48: The Child with Cancer

Test Bank

MULTIPLE CHOICE

1. The nurse notes that a child’s 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 parent’s 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 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.

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 son’s blood pressure must be taken daily while he is on chemotherapy.”
b. “Limit your son’s 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 son’s temperature should be taken frequently.”
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.

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 nurse’s 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
boy’s 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 children’s
health.”
d. “I hope this delay does not affect the treatment plan.”
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.

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 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.

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 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.

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 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.

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 and Haemophilus 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 child’s 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 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.

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 child’s 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 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.

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 nurse’s 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 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.

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 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.

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 child’s 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