Chapter 34: Malignant Neoplasms
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? a) Hypermagnesemia b) Hypernatremia c) Hyperkalemia d) Hypercalcemia
d) Hypercalcemia Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.
Which of the following are complications related to polycythemia vera (PV)? Select all that apply. a) Ulcers b) CVA c) MI d) Splenomegaly e) Hematuria
a) Ulcers b) CVA c) MI e) Hematuria Patients with PV are at increased risk for thromboses resulting in a CVA or myocardial infarction. Bleeding can be significant and can occur in the form of nosebleeds, ulcers, frank gastrointestinal bleeding, and intracranial hemorrhage. Splenomegaly is a clinical manifestation of PV, not a complication.
A client is receiving chemotherapy for acute myeloid leukemia and has poor nutritional intake. The first action of the nurse is to a) Provide mouth care before each meal. b) Ask, "Are you experiencing nausea?" c) Caution the client to chew carefully after administration of the prescribed lidocaine (Xylocaine Viscous). d) Provide nutritional supplements in addition to a diet that has a soft texture and moderate temperature.
b) Ask, "Are you experiencing nausea?" All these options are things the nurse can do to assist the client to obtain better nutrition. The nurse first needs to assess the reason for poor nutritional intake. It could be because of nausea, in which case the nurse would implement interventions to address the client's nausea.
The nurse practitioner suspects that a patient has multiple myeloma based on his major presenting symptom and the analysis of his laboratory results. Select the classic symptom for this disease. a) Gradual muscle paralysis b) Bone pain in the back of the ribs c) Debilitating fatigue d) Severe thrombocytopenia
b) 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; patients may report that they have less pain on awakening but the pain intensity increases during the day.
Which of the following is the hallmark of polycythemia vera (PV)? a) Splenomegaly b) Headache c) Ruddy complexion d) Blurred vision
a) Splenomegaly Splenomegaly is the hallmark of PV. Patients typically have a ruddy complexion and splenomegaly. Symptoms result from increased blood volume (headache, dizziness, tinnitus, fatigue, paresthesias, and blurred vision).
Which assessment findings support the client's diagnosis of AML (acute myeloid leukemia)? Select all that apply. a) Weakness and fatigue b) Enlarged heart c) Enlarged lymph nodes d) Bone pain e) Petechiae
a) Weakness and fatigue c) Enlarged lymph nodes d) Bone pain e) Petechiae Clients with AML may present with petechiae, enlarged lymph nodes, weakness, fatigue, and bone pain. An enlarged heart is not a typical finding with this disorder.
A patient is being evaluated for a diagnosis of chronic myeloid leukemia (CML). The nurse understands that a diagnostic indicator is: a) A leukocyte count >100,000/mm3. b) Lymphadenopathy. c) Increased number of blast cells. d) An enlarged liver.
a) A leukocyte count >100,000/mm3. Although there is an increase in the production of blast cells, and the patient may have an enlarged liver and tender spleen, it is the high leukocyte count that is diagnostic. Lymphadenopathy is rare.
A patient with polycythemia vera is complaining of severe itching. What triggers does the nurse know can cause this distressing symptom? (Select all that apply.) a) Alcohol consumption b) Allergic reaction to the red blood cell increase c) Temperature change d) Exposure to water of any temperature e) Aspirin
a) Alcohol consumption c) Temperature change d) Exposure to water of any temperature Pruritus is very common, occurring in up to 70% of patients with polycythemia vera (Saini, Patnaik & Tefferi, 2010) and is one of the most distressing symptoms of this disease. It is triggered by contact with temperature change, alcohol consumption, or, more typically, exposure to water of any temperature but seems to be worse with exposure to hot water.
A nurse has established for a client the nursing diagnosis of risk for infection. Which of the following interventions would the nurse include in the plan of care for this client? Select all answers that apply. a) Encourage the client to take deep breaths every 4 hours while awake. b) Place fresh flowers on a shelf on the opposite wall from the client. c) Auscultate lung sounds every shift and prn. d) Assess skin and mucus membranes every shift. e) Provide oral hygiene once daily.
a) Encourage the client to take deep breaths every 4 hours while awake. c) Auscultate lung sounds every shift and prn. d) Assess skin and mucus membranes every shift. Interventions for risk for infection include assessing skin and mucus membranes every shift, auscultating lung sounds every shift and prn, 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 patient with polycythemia vera has a high red blood cell (RBC) count and is at risk for the development of thrombosis. What treatment is important to reduce blood viscosity and to deplete the patient's iron stores? a) Phlebotomy b) Blood transfusions c) Radiation d) Chelation therapy
a) Phlebotomy The objective of management is to reduce the high RBC count and reduce the risk of thrombosis. Phlebotomy is an important part of therapy (Fig. 34-5). It involves removing enough blood (initially 500 mL once or twice weekly) to reduce blood viscosity and to deplete the patient's iron stores, thereby rendering the patient iron deficient and consequently unable to continue to manufacture hemoglobin excessively.
Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)? a) A 24-year-old female taking oral contraceptives b) A 72-year-old patient with a history of cancer c) A 40-year-old patient with a history of hypertension d) A 52-year-old patient with acute kidney injury
b) A 72-year-old patient with a history of cancer Primary MDS tends to be a disease of people older than 70 years. Because the initial findings are so subtle, the disease may not be diagnosed until later in the illness trajectory, if at all. Thus, the actual incidence of MDS is not known.
A client has been diagnosed with multiple myeloma. Which of the following laboratory values should the nurse expect to find in a client with multiple myeloma? a) Polycythemia vera b) Decreased serum protein c) Increased urinary protein d) Decreased calcium level
b) Decreased serum protein A characteristic finding in multiple myeloma is protein in the urine. Other laboratory findings include increased serum protein, hypercalcemia, anemia, and hyperuricemia. Polycythemia vera is not found in multiple myeloma.
A client is receiving radiation therapy for lesions in the abdomen from non-Hodgkin's lymphoma. Because of the effects of the radiation treatments, the nurse now assesses for a) Hair loss b) Diarrheal stools c) Adventitous lung sounds d) Laryngeal edema
b) Diarrheal stools Side effects of radiation therapy are limited to the area being irradiated. Clients who have abdominal radiation therapy may experience diarrhoea. If the lesions were in the upper chest, then the client may experience adventitious lung sounds or laryngeal oedema as side effects. Hair loss is associated more with chemotherapy than radiation therapy.
Which of the following is the only curative treatment for chronic myeloid leukemia (CML)? a) Idarubicin b) Imatinib c) Allogeneic stem cell transplant d) Cytarabine
c) Allogeneic stem cell transplant Allogeneic stem cell transplantation remains the only curative treatment for CML. The efficacy of Imatinib as first-line treatment and the treatment-related mortality of stem cell transplant limits use of transplant to patients with high risk or relapsed disease, or in those patients who did not respond to therapy with TKI. Cytarabine and idarubicin are part of induction therapy for acute myeloid leukemia (AML).
A nurse is caring for an asymptomatic client with acute myelogenous leukemia. The client has a total white blood cell (WBC) count of 0 ?l, a platelet count of 3,000 mm2, and a hemoglobin level of 9 mg/dl. He has a single lumen central venous catheter in place and the physician has ordered the nurse to administer imipenem cilastatin (Primaxin) 500 mg every 8 hours, transfuse 1 unit packed red blood cells (RBCs), give amphotericin B (Fungizone) 40 mg I.V. over 4 hours, and transfuse 2 pheresis units of platelets. In what order should the nurse infuse these medications and blood products? a) Platelets, imipenem cilastatin, amphotericin B, packed RBCs b) Packed RBCs, platelets, imipenem cilastatin, amphotericin B c) Amphotericin B, imipenem cilastatin, platelets, packed RBCs d) Packed RBCs, amphotericin B, imipenem cilastatin, platelets
a) Platelets, imipenem cilastatin, amphotericin B, packed RBCs Although the client is currently asymptomatic, a platelet count of 3,000 mm2 puts him at risk for spontaneous hemorrhage, the most immediate and serious risk he faces. A WBC count of 0 clearly indicates neutropenia; the client needs an antibiotic and antifungal therapy to prevent infection. Although the client is anemic, he's currently asymptomatic. The absence of clinical manifestations makes his need for a transfusion less urgent.
Following bone marrow aspiration of a 19-year-old client, analysis reveals more than 20% immature blast cells. Platelet counts are 9000/mm³. What nursing interventions should the nurse employ for the care of this client? Select all answers that apply. a) Recommend taking ibuprofen for mild aches and pains. b) Administer prescribed docusate (Colace) daily. c) Assess for mental state changes. d) Apply pressure to venipuncture sites for 1 to 2 minutes. e) Discuss the withholding of oral contraceptives.
b) Administer prescribed docusate (Colace) daily. c) Assess for mental state changes. The client has leukemia with immature blast cells and an extremely low platelet count. The client is at increased risk for bleeding. Interventions that would address bleeding include assessing for mental status changes (because bleeding could occur in the brain) and administering stool softeners to prevent constipation (which would increase the risk of bleeding from the rectum). Oral contraceptives would be administered to induce amenorrhea. Ibuprofen would be avoided because this medication inhibits platelet function. The nurse is to apply pressure to venipuncture sites for 5 minutes.
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? a) Hemolytic anemia b) Leukemia c) Multiple myeloma d) Polycythemia vera
c) 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.
A client has been diagnosed with multiple myeloma. Which of the following laboratory values should the nurse expect to find in a client with multiple myeloma? a) Decreased serum protein b) Increased urinary protein c) Polycythemia vera d) Decreased calcium level
b) Increased urinary protein A characteristic finding in multiple myeloma is protein in the urine. Other laboratory findings include increased serum protein, hypercalcemia, anemia, and hyperuricemia. Polycythemia vera is not found in multiple myeloma.
A patient with AML has pale mucous membranes and bruises on his legs. What is the primary nursing intervention? a) Assess the patient's pulses and blood pressure. b) Check the patient's history. c) Assess the patient's hemoglobin and platelets. d) Assess the patient's skin.
c) Assess the patient's hemoglobin and platelets. Patients with AML may develop pallor from anemia and bleeding tendencies from low platelet counts. Assessing the patient's hemoglobin and platelets will help to determine if this is the cause of the symptoms. This would be the priority above assessing pulses, blood pressure, history, or skin.
A nurse assesses a patient who has been diagnosed with DIC. Which of the following indicators are consistent with this diagnosis? Select all that apply. a) Capillary fill time <3 seconds b) Polyuria c) Increased blood urea nitrogen (BUN) and creatinine d) Cyanosis in the extremities e) Dyspnea and hypoxia f) Increased breath sounds
c) Increased blood urea nitrogen (BUN) and creatinine d) Cyanosis in the extremities e) Dyspnea and hypoxia Urine output would be decreased in DIC, and capillary fill time would be more than 3 seconds; breath sounds would be decreased. Refer to Table 20-4 in the text.
A patient is taking hydroxyurea for the treatment of primary myelofibrosis. While the patient is taking this medication, what will the nurse monitor to determine effectiveness? a) Blood urea nitrogen (BUN) and creatinine levels b) Leukocyte and platelet count c) Aspartate aminotransferase (AST) and alanine transaminase (ALT) levels d) Hemoglobin and hematocrit
b) Leukocyte and platelet count Hydroxyurea is often used in patients with primary myelofibrosis to control high leukocyte and platelet counts and to reduce the size of the spleen.
What type of cancer is the most common type of secondary malignancy in patients with Hodgkin's disease? a) Breast b) Lung c) Colon d) Bone
b) Lung Lung cancer is the most common type of secondary malignancy in patients with Hodgkin's disease, particularly following combination chemotherapy and radiation. Breast, colon, and bone are not the most common type of secondary malignancy.
A patient has completed induction therapy and has diarrhoea and severe mucositis. What is the appropriate nursing goal? a) Place client in reverse isolation. b) Maintain nutrition. c) Address issues of negative body image. d) Administer pain medication.
b) Maintain nutrition. Maintaining nutrition is the most important goal after induction therapy because the patient experiences severe diarrhea and can easily become nutritionally deficient as well as develop fluid and electrolyte imbalance. The patient is most likely not in pain at this point, and this is an intervention not a goal.
An elderly client is hospitalized for induction of chemotherapy to treat leukemia. The client reports fatigue to the nurse. What nursing intervention would best address the client's fatigue? a) Talk to the family about not visiting so the client can obtain rest. b) Provide sedentary activities only, such as watching television. c) Assist the client to sit in a chair for meals. d) Have the client maintain complete bedrest.
c) Assist the client to sit in a chair for meals. Fatigue is a common symptom with clients who have leukemia. Despite the fatigue, clients still need to maintain some physical activity. An example of physical activity is having the client sit in a chair for meals. The nurse does not want to encourage complete bedrest or sedentary activities, such as watching television, due to possible deconditioning. The nurse has not discussed with the client about limiting family visits. The client may want some family to visit.
You are caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? a) Osteolytic activating factor weakens bones producing fractures. b) Osteopathic tumors destroy bone causing fractures. c) Osteoclasts break down bone cells so pathologic fractures occur. d) Osteosarcomas form producing pathologic fractures.
c) 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. Options A, C, and D are distractors for this question.
The hospitalized client is experiencing gastrointestinal bleeding. Laboratory test results show that the client's platelets are 9000/mm³. The client is receiving prednisone and azathioprine (Imuran). The nurse a) Teaches the client to vigorously floss the teeth to prevent infections b) Requests a prescription of diphenoxylate/atropine (Lomotil) for loose stools c) Performs a neurologic assessment with vital signs d) Uses contact precautions with this client
c) Performs a neurologic assessment with vital signs With platelets less than 10,000/mm³ there is a risk for spontaneous bleeding, including within the cranial vault. The nurse performs a neurologic examination to assess for this possibility. Though the client is receiving immunosuppressants, it is not necessary to use contact precautions with this client. Contact precautions are used with clients who have known or suspected transmittable illnesses. Diphenoxylate/atropine can cause constipation and inhibit accurate assessment of the client's gastrointestinal bleeding. If the client strains when having a bowel movement, the client could bleed even more. The client is not to floss vigorously; doing so can cause bleeding.
Clinical assessment of a patient with AML includes observing for signs of infection, the major cause of death for AML. The nurse should assess for indicators of: a) Neutropenia. b) Thrombocytopenia. c) Bone marrow expansion. d) Splenomegaly.
d) Splenomegaly. Acute myeloid leukemia starts inside the bone marrow and prevents the formation of white blood cells. A bone marrow analysis that shows greater than 30% of immature blast cells is indicative of an AML diagnosis.