Chapter 30

The nurse is discussing disorders of the hematopoietic system when a client asked about erythrocytosis. What disease will the nurse mention with a primary characteristic of erythrocytosis? polycythemia vera sickle cell disease aplastic anemia pernicious anemia

polycythemia vera Polycythemia vera is associated with a rapid proliferation of blood cells produced by the bone marrow. In sickle cell disease, HbS causes RBCs to assume a sickled shape under hypoxic conditions. Aplastic anemia has a deficiency of erythrocytes. Sickle cell disease and the anemias do not have the characteristics of erythrocytosis.

A client with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever? Pancytopenia Thrombocytopenia Anemia Neutropenia

Neutropenia Fever and infection result from a decrease in neutrophils (neutropenia). Decreased red blood cells (anemia) cause weakness, fatigue, dyspnea on exertion, and pallor in AML. Pancytopenia, an overall decrease in all blood components, is not cause of fever in clients with AML. Decreased platelet count (thrombocytopenia) causes petechiae and bruising in AML.

What assessment finding best indicates that the client has recovered from induction therapy? Neutrophil and platelet counts within normal limits Vital signs within normal ranges No evidence of edema Absence of bone pain

Neutrophil and platelet counts within normal limits Recovery from induction therapy is indicated when the neutrophil and platelet counts have returned to normal and any infection has resolved. Stable vital signs, lack of edema, and absence of pain are not indicative of recovery from induction therapy.

Clients with multiple myeloma have abnormal plasma cells that proliferate in the bone marrow where they release osteoclast-activating factor, resulting in the formation of osteoclasts. What is the most common complication of the pathology resulting from this process? Pathologic fractures Osteoporosis Calcified bones Increased mobility

Pathologic fractures Osteoclasts are cells that break down and remove bone cells, which results in increased blood calcium and pathologic fractures.

The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing intervention to help prevent fractures in the client? Increase mobility. Provide adequate hydration. Promote safety. Encourage adequate nutrition.

Promote safety. Safety is paramount because any injury, no matter how slight, can result in a fracture. Mobility, hydration, and nutrition are important, but will not prevent fractures.

The nurse is teaching a client who is undergoing diagnostic tests for multiple myeloma. What clinical findings support the client's diagnosis of multiple myeloma? serum creatinine level 0.5 mg/dL serum calcium level of 7.5 mg/dL serum albumin level of 2.0 g/dL serum protein level 5.8 g/dL

serum albumin level of 2.0 g/dL Albumin is a protein found in the blood and low levels can be seen in myeloma. Normal albumin level is 3.4 to 5.4 g/dL. Serum creatinine level may be increased (above 1.2 mg/dL in men and 0.9 mg/dL in women). Serum calcium levels exceed 10.2 mg/dL in multiple myeloma because calcium is lost from the bone and reabsorbed in the serum. The serum protein level is increased in multiple myeloma, not decreased.

A client with multiple myeloma reports severe paresthesia in the feet. When planning care for the client, which priority nursing diagnosis will the nurse choose? Acute pain Risk for falls Impaired tissue integrity Sensory-perception disturbance

Risk for falls A client with paresthesia in the feet is at risk for falls due to impaired sensation. Acute pain, impaired tissue integrity, and sensory-perception disturbance are all nursing diagnoses that are appropriate for the client; however, risk for falls is priority.

A client is newly diagnosed with Hodgkin lymphoma. The nurse understands that the client's treatment will be based on what concept? Histology of tissue Staging of disease Involvement of lymph nodes Total blood cell count

Staging of disease Treatment of Hodgkin lymphoma is based on the stage of the disease, not the histology of tissue, involvement of lymph nodes, or total blood cell count.

The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma? The client with painful lymph nodes under the arm. The client with painful lymph nodes in the groin. The client with enlarged lymph nodes in the neck. The client with a painful sore throat.

The client with enlarged lymph nodes in the neck. Lymph node enlargement in Hodgkin lymphoma is not painful. The client with enlarged lymph nodes in the neck is most likely to have Hodgkin lymphoma if the enlarged nodes are painless. Sore throat is not a sign for this disorder.

A client is being tested for acute myeloid leukemia (AML). The nurse knows that which diagnostic test will be used as the hallmark for the diagnosis? Clotting factors Bone marrow analysis Complete blood count Alkaline phosphatase level

Bone marrow analysis To confirm the diagnosis of AML, laboratory studies need to be performed. A bone marrow analysis shows an excess or more than 20% of blast cells which is the hallmark of the diagnosis. Clotting factors are not used to diagnose AML. The complete blood count (CBC) commonly shows a decrease in both erythrocytes and platelets but is not as specific as the bone marrow analysis. The alkaline phosphatase level measures a liver enzyme.

The nurse cares for a client with acute myeloid leukemia with severe bone pain. What pathophysiological concept does the nurse understand is the reason for the client's pain? Abnormal blood cells deposit in small vessels. Bone marrow expands. Lymph nodes expand. Abnormal blood cells crystalize.

Bone marrow expands. In acute myeloid leukemia, bone pain is caused when the bone marrow expands.

A nurse cares for a client with early Hodgkin lymphoma. While assessing the client, the nurse will most likely find painless enlargement of which lymph node? Axillary Cervical Inguinal Popliteal

Cervical Non painful swelling of the cervical lymph nodes is the earliest symptom of Hodgkin lymphoma.

The nurse is teaching a client about the development of leukemia. What statement should be included in the teaching plan? "Acute leukemia develops slowly." "Chronic leukemia develops slowly." "In chronic leukemia, the minority of leukocytes are mature." "In acute leukemia there are not many undifferentiated cells."

"Chronic leukemia develops slowly." Chronic leukemia develops slowly, and the majority of leukocytes produced are mature. Acute leukemia develops quickly and the majority of leukocytes are undifferentiated cells.

The nurse is caring for a patient who will begin taking long-term biphosphate therapy. Why is it important for the nurse to encourage the patient to receive a thorough evaluation of dentition, including panoramic dental x-rays? The patient is at risk for tooth decay. The patient will develop gingival hyperplasia. The patient can develop osteonecrosis of the jaw. The patient can develop loosening of the teeth.

The patient can develop osteonecrosis of the jaw. Osteonecrosis of the jaw is an infrequent but serious complication that can arise in patients treated long-term with bisphosphonates; the mandible or maxilla are affected. Careful assessment for this complication should be conducted and a thorough evaluation of the patient's dentition should be performed prior to initiating bisphosphonate therapy, including panoramic dental x-rays.

Which statement indicates the client understands teaching about induction therapy for leukemia? "I will start slowly with medication treatment." "I will need to come every week for treatment." "I will be in the hospital for several weeks." "I know I can never be cured."

"I will be in the hospital for several weeks." Induction therapy involves high doses of several medications and the client is usually admitted to the hospital for several weeks. The treatment is started quickly and the goal is to cure or put the disease into remission.

The nurse is interacting with a family that has been caring for a client with cancer for several months. What are the best interventions to assist in relieving caregiver stress in this family? Select all that apply. Educate the family about medications and side effects. Allow family members to express feelings. Suggest support for household maintenance. Suggest the prescription of antianxiety medications. Suggest the family go to church more often.

Educate the family about medications and side effects. Allow family members to express feelings. Suggest support for household maintenance. Family members benefit from increased education on what to expect. Allowing family members to express their feelings has also been shown to relieve stress. Supporting the caregiver and family with help in household duties will also help the overburdened family. Antianxiety medications and church attendance have not been shown to reduce caregiver stress.

The nurse is teaching the client about consolidation. What statement should be included in the teaching plan? "Consolidation therapy is administered to reduce the chance of leukemia recurrence." "Consolidation occurs as a side effect of chemotherapy." "Consolidation of the lungs is an expected effect of induction therapy." "Consolidation is the term used when a client does not tolerate chemotherapy."

"Consolidation therapy is administered to reduce the chance of leukemia recurrence." Consolidation therapy is administered to eliminate residual leukemia cells that are not clinically detectable and reduce the chance for recurrence. It is also termed post-remission therapy. It is not a side effect of chemotherapy, but the administration of chemotherapy.

The nurse is teaching a client with acute lymphocytic leukemia (ALL) about therapy. What statement should be included in the plan of care? "Treatment is simple and consists of single-drug therapy." "Intrathecal chemotherapy is used primarily as preventive therapy." "The goal of therapy is palliation." "Side effects are rare with therapy."

"Intrathecal chemotherapy is used primarily as preventive therapy." Intrathecal chemotherapy is a key part of the treatment plan to prevent invasion of the central nervous system. The therapy uses multiple drugs, with many side effects. The goal of therapy is remission.

A client is being evaluated for a diagnosis of chronic myeloid leukemia (CML). What diagnostic indicator will the nurse assess? An enlarged liver A leukocyte count >100,000/mm3 Lymphadenopathy Increased number of blast cells

A leukocyte count >100,000/mm3 Although there is an increase in the production of blast cells and the client may have an enlarged liver and tender spleen, it is the high leukocyte count that is diagnostic. Lymphadenopathy is rare.

A client who is undergoing chemotherapy for AML reports pain in the low back. What is the nurse's first action? Refer the client to a chiropractor. Place heating pads on the client's back. Administer pain medication, as ordered. Assess renal function.

Assess renal function. Chemotherapy results in the destruction of cells and tumor lysis syndrome. Uric acid and phosphorus concentrations increase, and the client is susceptible to renal failure. The nurse should assess renal function if the client complains of low-back pain, as this could be indicative of kidney stone formation. Heating pads, pain medication, and referrals could be instituted once the cause of the pain is determined. The priority is further assessment to rule out important problems.

What interventions are most appropriate for the nurse to include in the plan of care for a client at risk for infection? Select all that apply. Assess skin and mucus membranes every shift. Auscultate lung sounds every shift and as needed. Place fresh flowers on a shelf on the opposite wall from the client. Encourage the client to take deep breaths every 4 hours while awake. Provide oral hygiene once daily.

Assess skin and mucus membranes every shift. Auscultate lung sounds every shift and as needed. Encourage the client to take deep breaths every 4 hours while awake. Interventions for risk for infection include assessing skin and mucus membranes every shift, auscultating lung sounds every shift and as needed, and encouraging deep breaths every 4 hours while the client is awake. No fresh flowers are allowed in the room because of germs found in stagnant water. Oral hygiene should be provided after meals and every 4 hours while the client is awake.

A client is receiving radiation therapy for lesions in the abdomen from non-Hodgkin's lymphoma. Because of the effects of the radiation treatments, what will the nurse assess for? Adventitious lung sounds Hair loss Diarrheal stools Laryngeal edema

Diarrheal stools Side effects of radiation therapy are limited to the area being irradiated. Clients who have abdominal radiation therapy may experience diarrhea. If the lesions were in the upper chest, then the client may experience adventitious lung sounds or laryngeal edema as side effects. Hair loss is associated more with chemotherapy than radiation therapy.

A client with Hodgkin lymphoma is planning to receive the Stanford V treatment protocol. Which medication teaching will the nurse prepare for this client? Select all that apply. Etoposide Vinblastine Adriamycin Doxorubicin Mechlorethamine

Etoposide Vinblastine Doxorubicin Mechlorethamine Treatment guidelines for classical Hodgkin lymphoma divide the clients into groups. Clients with early disease may receive the Stanford V treatment which includes etoposide, vinblastine, doxorubicin, and mechlorethamine in addition to vincristine, bleomycin and prednisone. Adriamycin is a part of the ABVD treatment protocol.

A client who is being treated for AML has bruises on both legs. What is the nurse's most appropriate action? Ask the client whether they have recently fallen. Evaluate the client's INR. Keep the client on bed rest. Evaluate the client's platelet count.

Evaluate the client's platelet count. Complications of AML include bleeding. The risk of bleeding correlates with the level and duration of platelet deficiency. Major hemorrhages may develop when the platelet count drops to less than 10,000/mm3. The bleeding is usually unrelated to falling. Keeping the client on bed rest will not prevent bleeding when the client has a low platelet count. Assessment for other areas of bleeding is also a priority intervention.

A nurse prepares a client for a bone marrow biopsy who is suspected of having acute myeloid leukemia. What results from the bone marrow biopsy does the nurse expect? Excess of immature leukocytes Excess of immature erythrocytes Deficiency of neutrophils Deficiency of erythrocytes

Excess of immature leukocytes The bone marrow biopsy of a client with acute myeloid leukemia will reveal an excess of immature leukocytes.

Which term refers to a form of white blood cell involved in immune response? Granulocyte Lymphocyte Spherocyte Thrombocyte

Lymphocyte Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.

The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? Osteopathic tumors destroy bone causing fractures. Osteoclasts break down bone cells so pathologic fractures occur. Osteolytic activating factor weakens bones producing fractures. Osteosarcomas form producing pathologic fractures.

Osteoclasts break down bone cells so pathologic fractures occur. The abnormal plasma cells proliferate in the bone marrow, where they release osteoclast-activating factor. This, in turn, causes osteoclasts to break down bone cells, resulting in increased blood calcium and pathologic fractures. The plasma cells also form single or multiple osteolytic (bone-destroying) tumors that produce a "punched-out" or "honeycombed" appearance in bones such as the spine, ribs, skull, pelvis, femurs, clavicles, and scapulae. Weakened vertebrae lead to compression of the spine accompanied by significant pain. The other options are distractors for this question.

The nurse recognizes the clinical assessment of a patient with acute myeloid leukemia (AML) includes observing for signs of infection early. What nursing action will most likely help prevent infection? Monitor the client's temperature every shift. Maintain contact precautions. Encourage increased fluid consumption. Practice vigilant handwashing.

Practice vigilant handwashing. Infection prevention is best handled by vigilant handwashing. Monitoring the client's temperature once a shift is not often enough. The client will take precautions, but precautions are enough to prevent infections. Encouraging increased fluid consumption will not prevent infection.

A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client? Monitoring respiratory status Balancing rest and activity Restricting fluid intake Preventing bone injury

Preventing bone injury When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict fluid intake.

A client is awaiting test results to diagnose Hodgkin lymphoma. The nurse knows that which result is the hallmark for the diagnosis of this condition? Increased basophils Reed-Sternberg cells Elevated platelet count Misshaped red blood cells

Reed-Sternberg cells The malignant cell of Hodgkin lymphoma is the Reed-Sternberg cell, a gigantic tumor cell that is morphologically unique and thought to be of immature lymphoid origin. These cells arise from the B lymphocyte. They may have more than one nucleus and often have an owl-like appearance. The presence of Reed-Sternberg cells is the pathologic hallmark and essential diagnostic criterion. Basophils, platelets, or red blood cells are not used to diagnose Hodgkin lymphoma.

A client with multiple myeloma presents to the emergency department and reports excessive thirst and constipation. Family members report that the client has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms? Platelet count 300,000/mm3 Serum calcium level 13.8 mg/dl Serum sodium level of 133 mEq/L Hemoglobin of 9.8 g/dl

Serum calcium level 13.8 mg/dl Excessive thirst, constipation, dehydration, confusion, and altered mental state are possible signs of hypercalcemia. Hypercalcemia is common in multiple myeloma because of the increased bone destruction. A platelet count of 300,000/mm3 is normal and wouldn't cause the client's symptoms. A sodium level of 133 mEq/L is slightly decreased but wouldn't cause confusion and excessive thirst. A hemoglobin of 9.8 g/dl level is slightly low but isn't likely responsible for the client's symptoms.

The nurse is caring for a client with acute lymphocytic leukemia (ALL) who is Philadephia chromosome negative. Which medications will the nurse anticipate providing to the client during initiation of pharmacological therapies? Select all that apply. Fludarabine Vincristine Dexamethasone Adalimumab Imatinib

Vincristine Dexamethasone Lymphoid blast cells are typically very sensitive to vinca alkaloids and corticosteroids; therefore, these medications are an integral part of the initial induction therapy in ALL. Fludarabine is commonly prescribed in the treatment of chronic lymphocytic leukemia (CLL). Monoclonal antibodies are used in the treatment of CLL.TKIs are used to treat chronic myeloid leukemia (CML) and chronic lymphocyte leukemia (CML).

The nurse in the oncology clinic is caring for a 42-year-old female client receiving chemotherapy with fludarabine for acute myeloid leukemia who has developed petechiae, epistaxis, and ecchymosis. Complete the following sentence by choosing from the lists of options. The nurse anticipates that the client has developed Select...hemorrhage infection deep vein thrombosis hyperkalemia Select...and that the laboratory results will reveal Select...thrombocytopenia leukocytosis electrolyte imbalances abnormal renal function tests Select....

hemorrhage thrombocytopenia This client has manifestations of hemorrhage, including petechiae (pinpoint bleeding in the skin), epistaxis (nosebleeds), and ecchymosis (bruises) due to a low platelet count (thrombocytopenia) secondary to chemotherapy. Chemotherapy with fludarabine may cause bone marrow suppression with neutropenia (low neutrophil count) and thrombocytopenia (low platelet count). When the platelet count is low, the client is at risk for hemorrhage as evidenced by petechiae, epistaxis, and ecchymosis. Chemotherapy with fludarabine may cause bone marrow suppression, leading to thrombocytopenia (low platelet count) and hemorrhage. Although the client is at risk for infection, the assessment findings of petechiae, epistaxis, and ecchymoses are indicators of a low platelet count. The assessment findings do not support a diagnosis of deep vein thrombosis (DVT). Manifestations of DVT include calf pain, leg swelling, and warmth, and pain over the thrombosis. Hyperkalemia does not cause signs and symptoms of hemorrhage. Leukocytosis (a low white count) may occur following treatment with fludarabine, but it does not cause petechiae, epistaxis, and ecchymosis. Electrolyte imbalances and abnormal renal function also do not cause petechiae, epistaxis, and ecchymosis.

A client with suspected multiple myeloma is reporting back pain. What is the priority nursing action? Have the client lie on a hard surface. Have the client rest. Encourage ambulation. Send the client for a spinal x-ray study.

Send the client for a spinal x-ray study. The client with myeloma can have bone pain, especially in the back and ribs. The pain will decrease with rest and increase with activity. Lying on a hard surface will not relieve the pain. The priority action is to make certain the client does not have a fractured spine, as the bone destruction in this disease is sufficiently severe to cause vertebral collapse.

A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host? Acute respiratory distress syndrome Graft-versus-host disease Remission Bone marrow depression

Graft-versus-host disease Patients who undergo HSCT have a significant risk of infection, graft-versus host disease (in which the donor's lymphocytes [graft] recognize the patient's body as "foreign" and set up reactions to attack the foreign host), and other complications.

The nurse is caring for a client with acute myeloid leukemia (AML) with high uric acid levels. What medication does the nurse anticipate administering that will prevent crystallization of uric acid and stone formation? Allopurinol Filgrastim Hydroxyurea Asparaginase

Allopurinol Massive leukemic cell destruction from chemotherapy results in the release of intracellular electrolytes and fluids into the systemic circulation. Increases in uric acid levels, potassium, and phosphate are seen; this process is referred to as tumor lysis (cell destruction) syndrome. The increased uric acid and phosphorus levels make the client vulnerable to renal stone formation and renal colic, which can progress to acute renal failure. Patients require a high fluid intake, and prophylaxis with allopurinol or rasburicase to prevent crystallization of uric acid and subsequent stone formation

A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms? Hemolytic anemia Polycythemia vera Leukemia Multiple myeloma

Multiple myeloma The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease progresses, the pain becomes more severe and localized. The pain intensifies with activity and is relieved by rest. When tumors replace bone marrow, pathologic fractures develop. Hemolytic anemia does not result in pathologic fractures nor does polycythemia vera or leukemia.

The nurse cares for an older adult client with unprovoked back pain and increased serum protein. Which hematologic neoplasm does the nurse suspect the client has? Chronic myeloid leukemia Multiple myeloma Hodgkin lymphoma Non-Hodgkin lymphoma

Multiple myeloma Any older adult with unprovoked or unexplained back pain and increased protein in the serum should be assessed for multiple myeloma. Bone pain occurs because of bone breakdown and the malignant cells of multiple myeloma increase the serum protein levels.

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? Pancytopenia Anemia Leukopenia Thrombocytopenia

Pancytopenia Pancytopenia may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.

A client has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal? Address issues of negative body image. Place the client in reverse isolation. Administer pain medication. Maintain nutrition.

Maintain nutrition. Maintaining nutrition is the most important goal after induction therapy because the client experiences severe diarrhea and can easily become nutritionally deficient and develop fluid and electrolyte imbalance. The client is most likely not in pain at this point, and this is an intervention, not a goal.

When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? Health history, such as bleeding, fatigue, or fainting Menstrual history Age and gender Lifestyle assessments, such as exercise routines

Health history, such as bleeding, fatigue, or fainting When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Age, gender, menstrual history, or lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.

A patient with AML is having aggressive chemotherapy to attempt to achieve remission. The patient is aware that hospitalization will be necessary for several weeks. What type of therapy will the nurse explain that the patient will receive? Induction therapy Supportive therapy Antimicrobial therapy Standard therapy

Induction therapy Despite advances in understanding of the biology of AML, substantive advances in treatment response rates and survival rates have not occurred for decades, with the exception of advances made in treating APL (see later discussion). Even for patients with subtypes that have not benefited from advances in treatment, cure is still possible. The overall objective of treatment is to achieve complete remission, in which there is no evidence of residual leukemia in the bone marrow. Attempts are made to achieve remission by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks.

The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple areas of ecchymosis and petechiae. What laboratory study should the nurse be concerned about? WBC count of 4,200 cells/uL Hematocrit of 38% Platelet count of 9,000/mm3 Creatinine level of 1.0 mg/dL

Platelet count of 9,000/mm3 Complications of AML include bleeding and infection, which are the major causes of death. The risk of bleeding correlates with the level and duration of platelet deficiency (thrombocytopenia). The low platelet count can cause ecchymoses (bruises) and petechiae. Major hemorrhages also may develop when the platelet count drops to less than 10,000/mm3.

The nurse is reviewing the long-term treatment plan with a client diagnosed with Hodgkin lymphoma. Which recommendations will the nurse provide to reduce the client's risk of developing secondary malignancies? Select all that apply. Avoid excessive sunlight. Restrict use of tobacco. Reduce intake of alcohol. Limit the intake of citrus fruits. Avoid foods high in carbohydrates.

Avoid excessive sunlight. Restrict use of tobacco. Reduce intake of alcohol. The potential development of a second malignancy should be addressed with the client when initial treatment decisions are made. The nurse should encourage clients to reduce factors that increase the risk of developing second cancers, such as avoiding excess sunlight, restricting the use of tobacco, and reducing the intake of alcohol. Citrus foods and carbohydrates will not increase the client's risk of developing a secondary malignancy after treatment for Hodgkin lymphoma.

The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for? Debilitating fatigue Bone pain in the back of the ribs Gradual muscle paralysis Severe thrombocytopenia

Bone pain in the back of the ribs Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma is bone pain, usually in the back or ribs. Unlike arthritic pain, the bone pain associated with myeloma increases with movement and decreases with rest; clients may report that they have less pain on awakening but the pain intensity increases during the day.