Silvestri Chapter 37 Ed#561

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 037 (edited file)—"Hematological Disorders" 10/14/08, Page 1 of 9, 0 Figure(s), 1 Table(s) , 7 Box(es)

37: Hematological Disorders PRACTICE QUESTIONS 1. A pediatric nursing instructor asks a nursing student to describe the cause of the clinical manifestations that occur in sickle cell disease. Which of the following is the correct response by the nursing student? 1. “Sickled cells increase the blood flow through the body and cause a great deal of pain.” 2. “The sickled cells mix with the unsickled cells and cause the immune system to become depressed.” 3. “Bone marrow depression occurs because of the development of sickled cells.” 4. “Sickled cells are unable to flow easily through the microvasculature and their clumping obstructs blood flow.” Answer: 4 Rationale: All the clinical manifestations of sickle cell disease are a result of the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With reoxygenation, most of the sickled red blood cells resume their normal shape. Options 1, 2, and 3 are inaccurate. Test-Taking Strategy: Use the process of elimination. Recalling that sickled cells clump will assist in directing you to the correct option. Review the pathophysiology associated with sickle cell disease if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 138. 2. A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. A nurse checks the laboratory results, knowing that which of the following would be increased in this disease? 1. Platelet count 2. Hematocrit level 3. Reticulocyte count 4. Hemoglobin level Answer: 3 Rationale: A diagnosis is established on the basis of a complete blood count, examination for sickled red blood cells (RBCs) in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, an increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with SCD because the life span of their sickled RBCs is shortened. Test-Taking Strategy: Use the process of elimination. Recalling that the life span of the sickled RBCs is shortened in SCD and noting the relationship between this concept and the reticulocytes will direct you to the correct option. Review the laboratory tests that are diagnostic for this

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disorder if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: James, S., Ashwill, J., & Droske, S. (2002). Nursing care of children: Principles and practice (2nd ed.). Philadelphia: W.B. Saunders, p. 747. 3. A nurse instructs the mother of a child with sickle cell disease regarding the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions? 1. Infection 2. Trauma 3. Fluid overload 4. Stress Answer: 3 Rationale: Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or general stress. The mother of a child with sickle cell disease should encourage fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration. Test-Taking Strategy: Note the key words, need for further instructions. These words indicate a false response question and that you need to select the incorrect item. Recalling that fluids is a main component of treatment in sickle cell disease to prevent dehydration and pain crisis will direct you to option 3. Review the precipitating factors of pain crisis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 140. 4. Oral iron supplements are prescribed for the 6-year-old child with iron deficiency anemia. The nurse instructs the mother to administer the iron with which best food item? 1. Water 2. Milk 3. Apple juice 4. Orange juice Answer: 4 Rationale: Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or juice high in vitamin C. Test-Taking Strategy: Use the process of elimination. Recalling that vitamin C increases the absorption of iron will assist in eliminating options 1 and 2. From the remaining options, select option 4, because this food item contains the highest amount of vitamin C. Review the procedure for administering oral iron if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance

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Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 137. 5. A nurse caring for a child with aplastic anemia reviews the laboratory results and notes a white blood cell (WBC) count of 6000/µL and a platelet count of 27,000/mm3. Which nursing intervention will the nurse suggest to incorporate into the plan of care? 1. Maintain strict isolation precautions 2. Encourage naps 3. Encourage a diet high in iron 4. Encourage quiet play activities Answer: 4 Rationale: Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, use of a soft toothbrush, and abstinence from contact sports or activities that could cause an injury. Strict isolation would be required if the WBC count were low. Options 2 and 3 are unrelated to the risk of bleeding. Test-Taking Strategy: Use the process of elimination. Note that the WBC count is normal and that the platelet count is low. Recall that a low platelet count places the client at risk for bleeding. This will assist in eliminating options 1, 2, and 3. Review normal WBC and platelet counts if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 1324-1325. Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1565. 6. A nurse reinforces instructions regarding home care to the parents of a 3-year-old child hospitalized with hemophilia. Which statement by a parent indicates a need for further instructions? 1. “I will supervise my child closely.” 2. “I will pad corners of the furniture.” 3. “I will remove household items that can easily fall over.” 4. “I will avoid immunizations being administered and dental hygiene treatments for my child.” Answer: 4 Rationale: The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate statements. The parents are also provided instructions regarding measures to take in the event of blunt trauma, especially trauma involving the joints, and are instructed to apply prolonged pressure to superficial wounds until the bleeding has stopped. Test-Taking Strategy: Use the process of elimination and note the key words, need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that bleeding is a concern in this disorder will assist in

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eliminating options 1, 2, and 3 because they include measures of protection and safety for the child. Review home care measures for the child with hemophilia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 235. 7. A nurse is reinforcing home care instructions to the mother of a 10-year-old child with hemophilia. Which activity would the nurse suggest that the child could safely participate in with peers? 1. Basketball 2. Swimming 3. Soccer 4. Field hockey Answer: 2 Rationale: Children with hemophilia need to avoid contact sports and need to take precautions, such as wearing elbow and knee pads and helmets, when participating in other sports. The safest activity that will prevent injury is swimming. Test-Taking Strategy: Note the key word, safely. Recalling that bleeding is a major concern in this condition will assist in directing you to option 2. Also, note that the activities in options 1, 3, and 4 present the potential for injury. Review home care instructions for the child with hemophilia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 235. 8. A nursing student is presenting a clinical conference and discusses the causative factors related to β-thalassemia. The student informs the group that the child at greatest risk of developing this disorder is: 1. A child whose intake of iron is extremely poor 2. A child breast-fed by a mother with chronic anemia 3. A child of Mediterranean descent 4. A child of Mexican descent Answer: 3 Rationale: β-Thalassemia is an autosomal recessive disorder. This disorder is found primarily in individuals of Mediterranean descent. The disease has also been reported in Asian and African populations. Test-Taking Strategy: Knowledge regarding the causative factors associated with this disorder is required to answer this question. Remember that this disorder is found primarily in individuals of Mediterranean descent. Review this disorder if you had difficulty with this question.

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Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 638. 9. A nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates a need for further instructions? 1. “I need to use proper hand washing techniques.” 2. “I need to take a rectal temperature daily on my child.” 3. “I need to inspect my child’s skin daily for redness.” 4. “I need to inspect my child’s mouth daily for lesions.” Answer: 2 Rationale: The risk of injury to fragile mucous membranes is so great in the child with leukemia that only oral, axillary, or tympanic temperatures should be taken. Rectal abscesses can easily occur in damaged rectal tissue. No rectal temperatures should be taken. Additionally, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, and 4 are appropriate teaching measures. Test-Taking Strategy: Use the process of elimination and note the key words, need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Option 1 and 3 can be easily eliminated first. From the remaining options, note the word “rectal” in option 2. Recalling that rectal temperatures should be avoided will direct you to this option. Review home care instructions related to infection in the leukemic child if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 644. 10. A 6-year-old child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. The nurse makes which appropriate response to the grandmother? 1. “I have a vase in the utility room and I will get it for you.” 2. “The flowers from your garden are beautiful, but should not be placed in the child’s room at this time.” 3. “I will get the vase and wash it well before you put the flowers in it.” 4. “When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible.” Answer: 2 Rationale: For the hospitalized neutropenic child, flowers or plants should not be kept in the

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room because standing water and damp soil harbor Aspergillus and Pseudomonas organisms, to which these children are very susceptible. Additionally, fruits and vegetables that are not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. Test-Taking Strategy: Use the process of elimination and knowledge regarding protective isolation procedures for a neutropenic child. Note that options 1 and 3 are similar and should be eliminated first. From the remaining options, select option 2, because this nursing response maintains the procedure required. Review protective isolation procedures for the neutropenic child if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Communication and Documentation Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 1339-1340. 11. A nurse is reviewing the health record of a 10-year-old child suspected of having Hodgkin’s disease. Which of the following would the nurse expect to note documented in the record that is most characteristic of this disease? 1. Painful, enlarged inguinal lymph nodes 2. Fever and malaise 3. Painless, firm, and movable adenopathy in the cervical area 4. Anorexia and weight loss Answer: 3 Rationale: Clinical manifestations specifically associated with Hodgkin’s disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas. Hepatosplenomegaly is also noted. Although anorexia, weight loss, fever, and malaise are associated with Hodgkin’s disease, these manifestations are seen in many disorders. Test-Taking Strategy: Note the key words, most characteristic. Eliminate options 2 and 4 first because these symptoms are general and vague. Recalling that painless adenopathy is associated with Hodgkin’s disease will direct you to option 3. Review the clinical manifestations related to Hodgkin’s disease if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 325. 12. A 4-year-old child is hospitalized with a suspected diagnosis of Wilms’ tumor. The nurse assists in developing a plan of care and suggests avoiding which of the following? 1. Palpating the abdomen for a mass 2. Checking the urine for the presence of hematuria 3. Monitoring the temperature for the presence of fever 4. Monitoring the blood pressure for the presence of hypertension Answer: 1 Rationale: A Wilms’ tumor is a tumor of the kidney. If Wilms’ tumor is suspected, the mass

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should not be palpated. Excessive manipulation can cause seeding of the tumor and cause the spread of the cancerous cells. Fever, hematuria, and hypertension are clinical manifestations associated with Wilms’ tumor. Test-Taking Strategy: Use the process of elimination and note the key word, avoiding. This word indicates a false response question and that you need to select the incorrect intervention. Knowledge that this tumor is located in the kidney will assist in eliminating options 2, 3, and 4 because of the relationship of these options to renal function. Review nursing interventions for the child with Wilms’ tumor if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 205. 13. A nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease? 1. “The symptoms of the disease in the early stage are almost always attributed to normal growing pains.” 2. “The femur is the most common site of this sarcoma.” 3. “Limping, if a weight bearing limb is affected, is a clinical manifestation.” 4. “The child does not experience pain at the primary tumor site.” Answer: 4 Rationale: A clinical manifestation of osteogenic sarcoma is progressive, insidious, intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 2, and 3 are accurate regarding osteogenic sarcoma. Test-Taking Strategy: Note the key words, need to further research. Recalling that osteogenic sarcoma is a malignant tumor of the bone will direct you to option 4. Review the clinical manifestations associated with osteogenic sarcoma if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 580. Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1627. 14. A 13-year-old child is diagnosed with Ewing’s sarcoma of the femur. Following a course of chemotherapy, it has been decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. The nurse makes which statement to assist in alleviating the child’s fear? 1. “This aching and cramping is normal and temporary and will subside.” 2. “This always occurs after the surgery and we will teach you ways to deal with it.” 3. “The pain medication that I give you will take these feelings away.”

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4. “This pain is not real pain and relaxation exercises will help it go away.” Answer: 1 Rationale: Following amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of aching or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to answer this question. Note that the issue of the question relates to alleviating the child’s fear. Option 1 is the only option that will alleviate fear. Options 2, 3, and 4 infer that this pain may be permanent. Also, option 2 contains the absolute word “always.” Review care of the child following amputation if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 580. Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1628. 15. A nurse is monitoring for bleeding in a child following surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. The nurse takes which appropriate action? 1. Circles the area of drainage and continues to monitor 2. Reinforces the dressing 3. Notifies the registered nurse (RN) 4. Documents the findings and continue to monitor Answer: 3 Rationale: Colorless drainage on the dressing would indicate the presence of cerebrospinal fluid and should be reported to the RN immediately. The RN would then contact the physician. Options 1, 2, and 4 delay required immediate interventions. Test-Taking Strategy: Use the process of elimination. Note the key words, colorless drainage. This should quickly alert you to the possibility of the presence of cerebrospinal fluid. Therefore, eliminate options 1, 2, and 4. Review care of the child with a brain tumor if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1623. 16. A nurse is reviewing a physician's orders for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Select the orders that the nurse would expect to note written in the client’s chart. ____Increase oral fluid intake.

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____Intravenous (IV) fluids of normal saline at 50 mL/hour. ____Administer oxygen at 2 L/ minute. ____Elevate the head of the bed 60 degrees at all times. ____Administer meperidine (Demerol) 25 mg intramuscular for pain. Answers: Increase oral fluid intake Intravenous (IV) fluids of normal saline at 50 mL/hour Administer oxygen at 2 L/minute Rationale: Vaso-occlusive crisis is caused by stasis of blood, with clumping of the cells in the microcirculation, ischemia, and infarction. Signs include fever, pain, and tissue engorgement. Increased fluids and oxygen are used to treat vaso-occlusive crisis. Although analgesics are prescribed, meperidine (Demerol) is not recommended for the child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The head of the bed is elevated no more than 30 degrees to prevent flexion of joints and strain on painful areas. Test-Taking Strategy: Focus on the pathophysiology associated with vaso-occlusive crisis. Recall that this type of crisis is caused by stasis of blood, with clumping of the cells in the microcirculation, ischemia, and infarction. This will assist in identifying the expected physician’s orders. Review care of the child with sickle cell disease experiencing a crisis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 138; 140.