Chapter 32 Hematologic Disorders

A 67-year-old male is admitted to your unit with a suspected diagnosis of acute myeloid leukemia (AML). The patient asks you how much time he has left. What would you tell this patient?

"The 5-year survival rate for those older than 65 years of age is 4%."

A 16-year-old female comes into the clinic complaining of fatigue. Blood work shows an increased bilirubin concentration and an increased reticulocyte count. What would the nurse suspect the patient has? A) A hypoproliferative anemia B) A leukemia C) A bleeding disorder D) A hemolytic anemia

A hemolytic anemia

You are caring for a patient with a hematologic disorder. The patient asks you where the body forms blood cells. Where would you tell the patient that blood cells are formed? A) In the spleen B) In the kidneys C) In the bone marrow D) In the liver

In the bone marrow Feedback: Bone marrow is the primary site for hematopoiesis. The liver and spleen may be involved during embryonic development or when marrow is destroyed. The kidneys release erythropoietin, which stimulates the marrow to increase production of RBCs. Blood cells are not formed in the spleen, kidneys, or liver.

A patient comes to the clinic complaining of fatigue and pica. Laboratory findings reveal a low serum iron level and a low ferritin level. What would the nurse suspect that the patient will be diagnosed with? A) Iron deficiency anemia B) Pernicious anemia C) Sickle cell anemia D) Hemolytic anemia

Iron deficiency anemia Feedback: A low serum iron level, a low ferritin level, and symptoms of pica are associated with iron deficiency anemia. TIBC may also be elevated. None of the other anemias are associated with pica.

You are the nurse caring for a patient with acute leukemia. What would you do to assess the risk for infection? a) Monitor creatinine levels b) Monitor hepatic function tests c) Monitor electrolyte levels d) Monitor WBC count

Monitor WBC count

A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A) Safe transfusion for patients with a history of transfusion reactions B) Prevention of viral infections from another person's blood C) Avoidance of complications in patients with alloantibodies D) Prevention of alloimmunization

Prevention of viral infections from another person's blood Feedback: The primary advantage of autologous transfusions is the prevention of viral infections from another person's blood. Other advantages include safe transfusion for patients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in

A 12-year-old on the oncology unit at children's hospital tells the nurse that they have discovered there are different kinds of leukemia. The child asks the nurse to explain what makes them all "leukemia." What would the nurse reply a)The different leukemias all have unregulated production of white blood cells. b)The different leukemias all have unregulated production of red blood cells. c)The different leukemias all have a decrease in production of white blood cells. d)The different leukemias all have a decrease in production of red blood cells.

The different leukemias all have unregulated proliferation of white blood cells.

You are doing patient teaching with a patient newly diagnosed with primary thrombocythemia. While teaching the patient about the signs and symptoms of thrombosis, what neurologic manifestations would you include? A) Ecchymosis B) Visual changes C) Pain D) Fatigue

Visual changes Feedback: The patient is informed about signs and symptoms of thrombosis, particularly the neurologic manifestations, such as visual changes, numbness, tingling, and weakness. Neurologic manifestations of thrombosis do not generally include ecchymosis, pain, or fatigue

A patient with non-Hodgkin's lymphoma is receiving information from the oncology nurse. The patient asks the nurse why she should stop drinking and smoking and stay out of the sun. What would be the nurse's best response? A)"Everyone should do these things because they're health promotion activities that apply to everyone." B)"You don't want to develop a second cancer, do you?" C)"You need to do this just to be on the safe side." D)"It's important to reduce other factors that increase the risk of second cancers."

"You need to reduce other factors that increase the risk of developing second cancers."

A patient with renal failure has decreased erythropoietin production. Upon analysis of the patient's complete blood count, the nurse will expect which of the following complete blood count results? A) An increased hemoglobin and hematocrit B) A decreased hemoglobin and hematocrit C) A decreased MCV and MCH D) An increased MCV and MCH

A decreased hemoglobin and hematocrit Feedback: The decreased production of erythropoietin will result in a decreased hemoglobin and hematocrit. The patient will have normal MCV and MCH values. This makes options A, C, and D incorrect

A 35-year-old male is admitted to the hospital complaining of severe headaches, vomiting, and testicular pain. His blood work shows reduced numbers of platelets, leukocytes, and erythrocytes with a high proportion of immature cells. The nurse caring for this patient suspects a diagnosis of what? A) AML B) CML C) MDS D) ALL

ALL- Acute Lymphotic Leukemia Feedback: In acute lymphocytic leukemia, manifestations of leukemic cell infiltration into other organs are more common than with other forms of leukemia, and include pain from an enlarged liver or spleen and bone pain. The central nervous system is frequently a site for leukemic cells; thus, patients may exhibit headache and vomiting because of meningeal involvement. Other extranodal sites include the testes and breasts.

A student asks the physiology instructor about the clotting cascade. The instructor explains that plasminogen is a component necessary in the clotting cascade. Where in the body is plasminogen present? A) Myocardial muscle tissue B) All body fluids C) Cerebral tissue D) Renal tissue

All body fluids Feedback: Plasminogen, which is present in all body fluids, circulates with fibrinogen. Plasminogen is found in body fluids, not tissue.

A patient with advanced leukemia is responding poorly to treatment. You find the patient tearful and trying to express his feelings, but he is having difficulty. What would be your first nursing action? B) Offer to call pastoral care. C) Ask if he would like you to sit with him while he collects his thoughts. D) Tell him that you can understand how he's feeling.

Ask if he would like you to sit with him while he collects his thoughts. Feedback: Providing emotional support and discussing the uncertain future are crucial. Option A is incorrect because leaving the patient doesn't show acceptance of his feelings. Option B is incorrect because offering to call pastoral care may be helpful for some patients but should be done after the nurse has spent time with the patient. Option D is incorrect because telling the patient that you understand how he's feeling is inappropriate because it doesn't help him express his feelings

A patient with leukemia has developed stomatitis and is not eating. An oral anesthetic has been prescribed. What would you warn the patient about? A) Chew with extreme care to avoid inadvertently biting the tongue. B) Use the oral anesthetic 1 hour prior to meal time. C) Brush the teeth before and after eating. D) Swallow slowly.

Chew with extreme care to avoid inadvertently biting the tongue. Feedback: If oral anesthetics are used, the patient must be warned to chew with extreme care to avoid inadvertently biting the tongue or buccal mucosa. An oral anesthetic would be metabolized by the time the patient eats if it is used 1 hour prior to meals. You would not warn the patient about brushing the teeth or swallowing slowly because an oral anesthetic has been used.

A patient is admitted to the hospital with pernicious anemia. What possible complications would the nurse caring for this patient know to monitor for? a) Confusion b) Ascites c) Peripheral edema d) Pulmonary edema

Confusion

The nurse on the pediatric unit is caring for a 10-year-old boy with a diagnosis of hemophilia. The nurse knows that a priority nursing diagnosis for a patient with hemophilia is what?

Coping

A patient diagnosed with leukemia has just been admitted to the oncology unit. You are helping to write this patient's care plan. You know that potential complications for patients with leukemia include what? A) Pancreatitis B) DIC C) Nutritional excess D) Liver dysfunction

DIC Feedback: Based on the assessment data, potential complications that may develop include infection, bleeding/DIC, renal dysfunction, tumor lysis syndrome, nutritional depletion, mucositis, depression, and anxiety. Pancreatitis and liver dysfunction are generally not complications of leukemia

A patient is admitted to the ICU with a diagnosis of bleeding esophageal varices. The patient has a comorbidity of cirrhosis. An attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect to have ordered for this patient? A) Fresh frozen plasma B) Vitamin K C) Oral anticoagulants D) Heparin drip

Fresh frozen plasma Feedback: Patients with liver dysfunction may also have life-threatening hemorrhage from peptic ulcers or esophageal varices. In these cases, replacement with fresh frozen plasma, PRBCs, and platelets is usually required. Oral drugs would not work fast enough for bleeding esophageal varicies; besides, an anticoagulant would not be ordered for this patient. Vitamin K may be ordered once the bleeding is stopped, but that is not what is needed to stop the bleeding of the varices.

A patient, 25 years of age, comes to the emergency department complaining of excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged PT but a vitamin K deficiency is ruled out. When assessing the patient, areas of ecchymosis are noted on other areas of the body. The nurse caring for this patient suspects what? A) Lymphoma B) Leukemia C) Hemophilia D) Hepatic dysfunction

Hepatic dysfunction Feedback: Prolongation of the PT, unless it is caused by vitamin K deficiency, may indicate severe hepatic dysfunction. Option C is incorrect as the majority of hemophiliacs are diagnosed as children. The scenario does not describe signs or symptoms of lymphoma or leukemia

The nursing instructor is talking with the students about the care of a patient with multiple myeloma who is experiencing bone destruction. What would the instructor tell the students the patient should be assessed for signs of? A) Hypercalcemia B) Hyperproteinemia C) Elevated serum viscosity D) Elevated RBC count

Hypercalcemia Feedback: Hypercalcemia may occur when bone destruction occurs due to the disease process. Elevated serum viscosity occurs because plasma cells excrete excess immunoglobulin. RBC count will be decreased. Hyperproteinemia would not be present

A student nurse is caring for a patient who is receiving chemotherapy for cancer. The student nurse reviews the laboratory data with his preceptor and notes that the patient has thrombocytopenia. Which nursing diagnosis should the nurse give the highest priority? A) Activity intolerance B) Impaired tissue integrity C) Impaired oral mucous membranes D) Ineffective tissue perfusion (cerebral, cardiopulmonary, GI)

Ineffective tissue perfusion (cerebral, cardiopulmonary, GI) Feedback: These are all appropriate nursing diagnoses for the client with thrombocytopenia (reduced platelet count). However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the client's physiologic integrity.

A patient has come to the OB/GYN clinic with complaints of a heavy menstrual flow. The nurse knows that red blood cell production will be increased in the patient's body. Because of this, the nurse is aware that the patient may need to increase her daily intake of what? A) Vitamin C B) Vitamin D C) Iron D) Magnesium

Iron Feedback: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins C and D and magnesium do not need to be increased when red blood cell production is increased.

The nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron supplements. What will the nurse include in her teaching? A. Take the iron with dairy products to enhance absorption. B. Increase the intake of vitamin E to enhance absorption. C. Iron will cause the stools to darken in color. D. Limit foods high in fiber due to the risk for diarrhea.

Iron will cause the stools to darken in color. Feedback: The nurse will inform the patient that iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Patients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy.

You are caring for a patient with a diagnosis of hypoproliferative anemia. You are aware that this type of anemia is due to what? 1. Loss of RBCs 2. Abnormality of RBCs 3. Lack of production of RBCs 4. Injury to the RBCs in circulation

Lack of production of RBCs Hypoproliferative anemia is usually a result of inadequate numbers of RBCs being produced by the bone marrow. Loss of RBCs is usually a result of blood loss. Hemolytic anemia can be a result of injury to the RBCs in circulation, possibly due to heart valve hemolysis. Abnormality of RBCs can occur in sickle cell anemia.

In the process of hematopoiesis stem cells differentiate into either myeloid or lymphoid stem cells. What do myeloid stem cells further differentiate into? (Mark all that apply.) A) Leukocytes B) Mast cells C) Thrombocytes D) Platelets E) Erythrocyte

Leukocytes, platelets, and erythrocytes Feedback: Myeloid stem cells differentiate into three broad cell types: erythrocytes, leukocytes, and platelets

You are caring for a patient whose bone marrow has been replaced by scar tissue in many of the areas that produce blood cells for the body. What organs can become active in blood cell production by the process of extramedullary hematopoiesis? A) Spleen and kidneys B) Kidneys and pancreas C) Pancreas and liver D) Liver and spleen

Liver and spleen Feedback: In adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen can also resume production of blood cells by a process known as extramedullary hematopoiesis. The kidneys and pancreas do not produce blood cells for the body

You are assessing a new patient with complaints of a sore, red, and smooth tongue. Based upon your assessment findings, you know that the patient is demonstrating symptoms associated with what? A) Sickle cell anemia B) Hemolytic anemia C) Megaloblastic anemia D) Aplastic anemia

Megaloblastic anemia Feedback: A red, smooth, sore tongue is a symptom associated with meagloblastic anemia. Iron deficiency anemia may be characterized by a smooth, red tongue. Sickle cell and hemolytic anemia do not have symptoms involving the tongue

You are triaging patients in the walk-in clinic. A 77-year-old man comes in complaining of fatigue and back pain. What should be closely evaluated in this patient? A) Hodgkin's disease B) Non-Hodgkin's lymphoma C) Multiple myeloma D) Acute thrombocythemia

Multiple myeloma Feedback: Back pain, which is often a presenting symptom in multiple myeloma, should be closely investigated in older patients. The lymphomas and bleeding disorders do not present with the primary symptom of back pain.

The home health nurse is caring for a patient with multiple myeloma. What does the nurse know is a priority issue to be managed in a patient with multiple myeloma? A) Nutrition B) Stress C) Coping D) Pain

Pain Feedback: Pain management is very important in patients with multiple myeloma. Nutrition, stress, and coping may be issues the home health nurse addresses, but the priority management issue is pain

You are the nurse assessing a patient with multiple myeloma. What should you keep in mind that patients with multiple myeloma are at risk for? A) Chronic liver failure. B) Acute heart failure. C) Pathologic bone fractures. D) Hypoxemia

Pathologic bone fractures. Feedback: Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Also, clients are at risk for renal failure secondary to myeloma proteins by causing renal tubular obstruction. Liver failure and heart failure are not usually sequelae of multiple myeloma. Hypoxemia is not usually related to multiple myeloma

The nurse is caring for a patient with severe anemia. The patient is tachycardic and complains of dizziness and exertional dyspnea. The nurse knows that in an effort to deliver more blood to hypoxic tissue the workload on the heart is increased. What signs and symptoms might develop if this patient goes into heart failure? A) Peripheral edema B) Nausea and vomiting C) Migraine D) Fever

Peripheral edema Hepatomegaly Cardiomegaly Cardiac status should be carefully assessed in patients with anemia. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly), and by peripheral edema. Nausea, migraine, and fever are not associated with heart failure.

When a human body receives an injury that causes blood loss, there are several processes involved in maintaining hemostasis. When a blood clot is no longer needed, what digests the fibrinogen and fibrin? A) Plasminogen B) Thrombin C) Prothrombin D) Plasmin

Plasmin Feedback: The substance plasminogen is required to lyse (break down) the fibrin. Plasminogen, which is present in all body fluids, circulates with fibrinogen and is therefore incorporated into the fibrin clot as it forms. When the clot is no longer needed (eg, after an injured blood vessel has healed), the plasminogen is activated to form plasmin. Plasmin digests the fibrinogen and fibrin. Prothrombin is converted to thrombin , which in turn catalyzes the conversion of fibrinogen to fibrin so a clot can form

A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnoses? A) Activity intolerance B) Risk for infection C) Disturbed processes D) Risk for spiritual distress

Risk for infection Feedback: Induction therapy places the patient at risk for infection, and this is the priority nursing diagnosis. During the time of induction therapy, the patient is very ill, with bacterial, fungal, and occasional viral infections; bleeding and severe mucositis, which causes diarrhea; and marked decline in the ability to maintain adequate nutrition. Supportive care consists of administering blood products and promptly treating infections. Options A, C, and D are valid nursing diagnosis for this patient but they are not the highest priority.

You are caring for a patient with Hodgkin's lymphoma at the oncology clinic. While doing patient teaching you know you need to stress what? A) Risk of infection B) Need for nutritious diet C) Need for adequate sleep D) Risk of losing support network

Risk of infection Feedback: Patients need to be taught to minimize the risks of infection, to recognize signs of possible infection, and to contact their health care provider if such signs develop. A nutritious diet and adequate sleep may be included in the teaching but will not be stressed like the risk of infection. Option D is a distracter for this question.

A nurse is caring for a 16-year-old who has sickle cell anemia. The nurse is concerned about substance abuse in this patient. What would the nurse encourage the patient to do to prevent substance abuse of analgesics in this patient?

Seek care from a single provider for pain relief. The patient should be encouraged to use a single primary health care provider to address health care concerns. Emergency department visits should be reported to the primary health care provider to achieve optimal management of the disease.

An elderly man trips over his dog and receives an injury to the skin, which causes minor blood loss. Primary hemostasis is activated in this patient. What occurs in primary hemostasis? A) Severed blood vessels constrict. B) Thromboplastin is released. C) Prothrombin is converted to thrombin. D) Fibrin is lysed.

Severed blood vessels constrict Feedback: Primary hemostasis involves the severed vessel constricting and platelets collecting at the injury site. Secondary hemostasis occurs when thromboplastin is released, prothrombin converts to thrombin, and fibrin is lysed.

A critical care nurse is caring for a patient with autoimmune hemolytic anemia. The patient is not responding to conservative treatments, and his condition is now becoming life threatening. The nurse is aware that a treatment option in this case may include what? A) Hepatectomy B) Vitamin K administration C) Platelet transfusion D) Splenectomy

Splenectomy Feedback: A splenectomy may be the course of treatment if autoimmune hemolytic anemia does not respond to conservative treatment. Vitamin K administration is treatment for vitamin K deficiency. Platelet transfusion may be the course of treatment for some bleeding disorders. Hepatectomy would not help the patient.

The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (RBCs) has begun, the patient is having difficulty breathing and chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patient's physician. B) Stop the transfusion immediately. C) Remove the patient's intravenous access. D) Assess the patient's chest sounds and vital signs

Stop the transfusion immediately. Feedback: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the patient's vital signs, and notify the physician. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. You do not remove the patient's IV access.

A nurse is admitting a patient with idiopathic thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that alter platelet function? A) Antihypertensives B) Penicillins C) Sulfa-containing medications D) Aspirin-based drugs E) NSAIDs

Sulfa-containing medications, aspirin-based drugs, and NSAIDs Feedback: The nurse must be alert for sulfa-containing medications and others that alter platelet function (eg, aspirin-based or other NSAIDs). The antihypertensive drugs and the penicillins do not alter platelet function.

A patient newly diagnosed with thrombocytopenia is admitted to your unit. After the admission assessment, the patient asks you to explain the disease to her. What would you explain to the patient about this condition? A) There could be an attack on the platelets by the antibodies. B) There could be decreased production of platelets. C) There could be elevated platelet production. D) There could be decreased white blood cell production

There could be decreased production of platelets. Feedback: Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or increased consumption of platelets. Increased production of platelets is associated with thrombocythemia, and decreased white blood cell production is associated with leukopenia.