NSG 330 Ch 34- Management Hematologic Neoplasms
What assessment finding best indicates that the client has recovered from induction therapy?
Neutrophil and platelet counts within normal limits Explanation: 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.
An oncology nurse is providing health education for a patient who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia?
The different leukemias all involve unregulated proliferation of white blood cells. Leukemia commonly involves unregulated proliferation of white blood cells. Decreased production of red blood cells is associated with anemias. Decreased production of white blood cells is associated with leukopenia. The leukemias are not characterized by their involvement with the lymphatic system.
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?
Bone pain in the back of the ribs Explanation: 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.
A client with polycythemia vera reports gouty arthritis symptoms in the toes and fingers. What is the nurse's best understanding of the pathophysiological reason for this symptom?
The dead red blood cells release excess uric acid. Explanation: There is a rapid proliferation of red blood cells from the marrow in polycythemia vera. However, these red blood cells die sooner than normal and the dead red blood cells release potassium and uric acid. This build up of uric acid in the blood leads to gouty arthritis symptoms.
A nurse is caring for a patient who has a diagnosis of acute leukemia. What assessment most directly addresses the most common cause of death among patients with leukemia?
Monitoring for infection In patients with acute leukemia, death typically occurs from infection or bleeding. Compromised nutrition, electrolyte imbalances, and impaired liver function are all plausible, but none is among the most common causes of death in this patient population.
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?
Reed-Sternberg cells Explanation: 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 nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions?
Risk for Ineffective Tissue Perfusion Patients with ET are at risk for hypercoagulation and consequent ineffective tissue perfusion. Fluid volume, breathing, and thermoregulation are not normally affected.
A nurse is assessing a client with multiple myeloma. Due to this condition, what will this client be at risk for?
pathologic bone fractures. Explanation: 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 aren't usually sequelae of multiple myeloma. Hypoxemia isn't usually related to multiple myeloma.
An oncology nurse recognizes a patients risk for fluid imbalance while the patient is undergoing treatment for leukemia. What relevant assessments should the nurse include in the patients plan of care? Select all that apply
Monitoring the patients electrolyte levels Measuring the patients weight on a daily basis Measuring and recording the patients intake and output Auscultating the patients lungs frequently Assessments that relate to fluid balance include monitoring the patients electrolytes, auscultating the patients chest for adventitious sounds, weighing the patient daily, and closely monitoring intake and output. Liver function is not directly relevant to the patients fluid status in most cases.
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?
Bone marrow analysis Explanation: 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.
A nurse is caring for a patient with Hodgkin lymphoma at the oncology clinic. The nurse should be aware of what main goal of care?
Cure of the disease The goal in the treatment of Hodgkin lymphoma is cure. Palliation is thus not normally necessary. Quality of life and symptom control are vital, but the overarching goal is the cure the disease.
The nurse is teaching a client with acute lymphocytic leukemia (ALL) about therapy. What statement should be included in the plan of care?
"Intrathecal chemotherapy is used primarily as preventive therapy." Explanation: 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 nurse is teaching a client with multiple myeloma about the therapeutic benefits of radiation therapy. Which statements will the nurse include in the teaching? Select all that apply.
"It helps to strengthen the bone." "It helps to decrease bone pain." Explanation: Radiation therapy is useful in strengthening the bone at a specific lesion, particularly a bone at risk for fracture or spinal cord compression. It is also extremely useful in relieving bone pain. Radiation therapy is not effective in decreasing bone malignancy, decreasing excess calcium, or activating an immune response.
A nurse is providing teaching to a client who will undergo chemotherapy and radiation prior to hematopoietic stem cell transplantation (HSCT) for acute myeloid leukemia (AML). What statement will the nurse use to describe the purpose of the chemotherapy and radiation?
"These therapies destroy the ability of your body to produce blood cells inside your bone marrow." Explanation: The treatment goal of chemotherapy and radiation therapy is the destruction of hematopoietic function of the client's bone marrow. The client is then "rescued" with the infusion of the donor stem cells to reinitiate blood cell production. AML is a cancer of the blood and does not have a mass effect/tumor that other cancers may cause. Also, these therapies are not used to decrease a client's pain or to decrease the risk of allergic reaction.
The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures?
Osteoclasts break down bone cells so pathologic fractures occur. Explanation: 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.
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 Explanation: Osteoclasts are cells that break down and remove bone cells, which results in increased blood calcium and pathologic fractures.
A client with AML has pale mucous membranes and bruises on the legs. What is the primary nursing intervention?
Assess the client's hemoglobin and platelets. Explanation: Clients with AML may develop pallor from anemia and a tendency to bleed because of a low platelet count. Assessing the client's hemoglobin and platelets will help to determine whether this is the cause of the symptoms. This would be the priority above assessing pulses, blood pressure, history, or skin.
An oncology nurse is caring for a patient with multiple myeloma who is experiencing bone destruction. When reviewing the patients most recent blood tests, the nurse should anticipate what imbalance?
Hypercalcemia Hypercalcemia may result 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 client with chronic lymphocytic leukemia (CLL) wants to have treatment for the condition. Which medication will the nurse question for this client?
Heparin Explanation: Commonly prescribed pharmacological therapies for chronic lymphocytic leukemia (CLL) include immunotherapy agents (ipilimumab), corticosteroids (dexamethasone), and chemotherapeutic agents (vincristine). Clients with CLL are at risk of bleeding, and therefore the use of anticoagulants (heparin) is contraindicated.
A client with suspected multiple myeloma is reporting back pain. What is the priority nursing action?
Send the client for a spinal x-ray study. Explanation: 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.
Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)?
A 72-year-old patient with a history of cancer Explanation: 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.
After receiving a diagnosis of acute lymphocytic leukemia, a patient is visibly distraught, stating, I have no idea where to go from here. How should the nurse prepare to meet this patients psychosocial needs?
Assess the patients specific needs for education and support. In order to meets the patients needs, the nurse must first identify the specific nature of these needs. According to the nursing process, assessment must precede interventions. The plan of medical care is important, but not central to the provision of support. The patients previous health care is not a primary consideration, and the nurse cannot assure the patient of successful treatment.
Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets?
Pancytopenia Explanation: 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.
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?
Practice vigilant handwashing. Explanation: 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 aren't enough to prevent infections. Encouraging increased fluid consumption will not prevent infection.
A patient has a diagnosis of multiple myeloma and the nurse is preparing health education in preparation for discharge from the hospital. What action should the nurse promote?
Close monitoring of urine output and kidney function Renal function must be monitored closely in the patient with multiple myeloma. Excessive weight- bearing can cause pathologic fractures. There is no direct indication for anticoagulation or supplementary oxygen
A nurse is writing the care plan of a patient who has been diagnosed with myelofibrosis. What nursing diagnoses should the nurse address? Select all that apply
Disturbed Body Image Impaired Mobility Imbalanced Nutrition: Less than Body Requirements Risk for Infection The profound splenomegaly that accompanies myelofibrosis can impact the patients body image and mobility. As well, nutritional deficits are common and the patient is at risk for infection. Cognitive effects are less common.
A client is newly diagnosed with Hodgkin lymphoma. The nurse understands that the client's treatment will be based on what concept?
Staging of disease Explanation: 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.
Which statement best describes the function of stem cells in the bone marrow?
They produce all blood cells. Explanation: All blood cells are produced from undifferentiated precursors called pluripotent stem cells in the bone marrow. Other cells produced from the pluripotent stem cells help defend against bacterial infection, produce antibodies against foreign antigens, and are active against hypersensitivity reactions.
The clinical nurse educator is presenting health promotion education to a patient who will be treated for non-Hodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions?
Avoiding highly crowded public places The risk of infection is significant for these patients, not only from treatment-related myelosuppression but also from the defective immune response that results from the disease itself. Limiting infection exposure is thus necessary. The need to avoid grapefruit is dependent on the patients medication regimen. Sun exposure and the use of razors are not necessarily contraindicated.
A nurse is caring for patient whose diagnosis of multiple myeloma is being treated with bortezomib. The nurse should assess for what adverse effect of this treatment?
Peripheral neuropathy A significant toxicity associated with the use of bortezomib for multiple myeloma is peripheral neuropathy. Stomatitis, cognitive changes, and nephropathy are not noted to be adverse effects of this medication.
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia?
Apply prolonged pressure to needle sites or other sources of external bleeding. Explanation: For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.
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?
Assist the client to sit in a chair for meals. Explanation: 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.
A client diagnosed with polycythemia vera has come into the clinic because he has developed a nighttime cough, fatigue, and shortness of breath. What complication would you suspect in this client?
Congestive heart failure Explanation: The symptoms exhibited by this client are indicative of congestive heart failure. Complications include hypertension, congestive heart failure, stroke, tissue and organ infarction, and hemorrhage. Stroke would present with headache, aphasia, and/or numbness in extremities. Tissue infarction would involve extremity discoloration or an organ failure. Pulmonary embolism would be associated with chest pain.
A young adult patient has received the news that her treatment for Hodgkin lymphoma has been deemed successful and that no further treatment is necessary at this time. The care team should ensure that the patient receives regular health assessments in the future due to the risk of what complication?
Hematologic cancers Survivors of Hodgkin lymphoma have a high risk of second cancers, with hematologic cancers being the most common. There is no consequent risk of anemia or hemophilia, and hematologic cancers are much more common than GU cancers.
A patient has completed the full course of treatment for acute lymphocytic leukemia and has failed to respond appreciably. When preparing for the patients subsequent care, the nurse should perform what action?
Identify the patients specific wishes around end-of-life care. Should the patient not respond to therapy, it is important to identify and respect the patients choices about treatment, including measures to prolong life and other end-of-life measures. The patient may or may not be open to pursuing CAM. Unsuccessful treatment is not necessarily the result of failure to adhere to the treatment plan. Assessment should precede meetings with a chaplain, which may or may not be beneficial to the patient and congruent with the familys belief 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 Explanation: 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.
An emergency department nurse is triaging a 77-year-old man who presents with uncharacteristic fatigue as well as back and rib pain. The patient denies any recent injuries. The nurse should recognize the need for this patient to be assessed for what health problem?
Multiple myeloma 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 typically present with the primary symptom of back pain or rib pain
A nurse is caring for a patient who is being treated for leukemia in the hospital. The patient was able to maintain her nutritional status for the first few weeks following her diagnosis but is now exhibiting early signs and symptoms of malnutrition. In collaboration with the dietitian, the nurse should implement what intervention?
Provide the patient with several small, soft-textured meals each day. For patients experiencing difficulties with oral intake, the provision of small, easily chewed meals may be beneficial. This option would be trialed before resorting to tube feeding or TPN. The family should be encouraged to participate in care, but should not be assigned full responsibility.
An adult patients abnormal complete blood count (CBC) and physical assessment have prompted the primary care provider to order a diagnostic workup for Hodgkin lymphoma. The presence of what assessment finding is considered diagnostic of the disease?
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. It is the pathologic hallmark and essential diagnostic criterion. Schwann cells exist in the peripheral nervous system and Lewy bodies are markers of Parkinson disease. Loops of Henle exist in nephrons
A 60-year-old patient with chronic myeloid leukemia will be treated in the home setting and the nurse is preparing appropriate health education. What topic should the nurse emphasize?
The importance of adhering to the prescribed drug regimen Nurses need to understand that the effectiveness of the drugs used to treat CML is based on the ability of the patient to adhere to the medication regimen as prescribed. Adherence is often incomplete, thus this must be a focus of health education. Vaccinations normally would not be administered during treatment and daily physical activity may be impossible for the patient. Dietary restrictions are not normally necessary
A home health nurse is caring for a patient with multiple myeloma. Which of the following interventions should the nurse prioritize when addressing the patients severe bone pain?
Helping the patient manage the opioid analgesic regimen For severe pain resulting from multiple myeloma, opioids are likely necessary. NSAIDs would likely be ineffective and are associated with significant adverse effects. Hot and cold packs as well as distraction would be insufficient for severe pain.
The nurse is teaching a client about the development of leukemia. What statement should be included in the teaching plan?
"Chronic leukemia develops slowly." Explanation: Chronic leukemia develops slowly, and the majority of leukocytes produced are mature. Acute leukemia develops quickly and the majority of leukocytes are undifferentiated cells.
A client with leukemia is being discharged from the hospital to hospice care. Which statement by the client indicates the client is not appropriately dealing with spiritual distress?
"I do not understand why this happened to me." Explanation: The statement "I do not understand why this happened to me" indicates that the client is not accepting of the consequences of his health problems and impending death. The other statements indicate the client has plans that would result in spiritual well-being or harmony.
A client is being evaluated for a diagnosis of chronic myeloid leukemia (CML). What diagnostic indicator will the nurse assess?
A leukocyte count >100,000/mm3 Explanation: 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.
The clinic nurse is caring for a client diagnosed with leukopenia. What does the nurse know this client has?
A general reduction in all white blood cells Explanation: Leukopenia is a general reduction in all WBCs. Leukopenia does not have anything to do with erythrocytes.
A clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the patients disease?
Follow the trends of the patients hematocrit. The course of polycythemia vera can be best ascertained by monitoring the patients hematocrit, which should remain below 45%. Erythropoietin injections would exacerbate the condition. Skin tone should be observed, but is a subjective assessment finding. The patients ESR is not relevant to the course of the disease.
A patient diagnosed with acute myelogenous leukemia has just been admitted to the oncology unit. When writing this patients care plan, what potential complication should the nurse address?
Hemorrhage Pancreatitis, arteritis, and liver dysfunction are generally not complications of leukemia. However, the patient faces a high risk of hemorrhage.
A nurse practitioner is assessing a patient who has a fever, malaise, and a white blood cell count that is elevated. Which of the following principles should guide the nurses management of the patients care?
Infection is the most likely cause of the patients change in health status. Leukocytosis is most often the result of infection. It is only considered pathologic (and suggestive of leukemia) if it is persistent and extreme. Multiple myeloma and lymphoma are not likely causes of this constellation of symptoms.
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?
Cervical Explanation: Non painful swelling of the cervical lymph nodes is the earliest symptom of Hodgkin lymphoma.
A client with acute myeloid leukemia (AML) is scheduled to begin induction therapy. Which treatments will the nurse expect to be prescribed to prevent life-threatening effects of this therapy? Select all that apply.
Platelets Antibiotics Packed red blood cells Granulocytic growth factors Explanation: During induction therapy, chemotherapy not only destroys leukemic cells, but also healthy cells, requiring clients to be hospitalized for several weeks (typically 4 to 6 weeks) due to severe and potentially life-threatening side effects, such as neutropenia. Management consists of blood products such as platelets. Antibiotics are used to treat bacterial infections that occur because of the neutropenia. Packed red blood cell infusions may also be used especially for clients that need a large volume of blood. The use of granulocytic growth factors may be used during the induction phase only for clients who have a life-threatening infection in order to shorten the neutropenic period. Hematopoietic stem cell transplant (HSCT) is routinely done following induction and consolidation therapy. In certain instances it may be performed following induction but not during induction.
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?
Promote safety. Explanation: 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 assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma?
The client with enlarged lymph nodes in the neck. Explanation: 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.
The nurse is assessing a client admitted with a deep vein thrombosis with an elevated red blood cell count. The admitting diagnosis is polycythemia vera. What is the hallmark clinical sign of PV?
splenomegaly Explanation: Splenomegaly is the hallmark of PV. Patients typically have a ruddy complexion and splenomegaly. Symptoms result from increased blood volume (headache, dizziness, tinnitus, fatigue, weight loss, paresthesias, and blurred vision). Edema, pale body color, and weight gain are not classic symptoms of PV.
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?
ALL In acute lymphocytic leukemia (ALL), 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, as well as 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. This particular presentation is not closely associated with acute myeloid leukemia (AML), chronic myeloid leukemia (CML), or myelodysplastic syndromes (MDS).
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 Explanation: 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. Clients require a high fluid intake, and prophylaxis with allopurinol (Zyloprim) to prevent crystallization of uric acid and subsequent stone formation.
A nurse is planning the care of a patient who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the patients care plan, the nurse has identified a diagnosis of Risk for Injury. What pathophysiologic effect of multiple myeloma most contributes to this risk?
Decreased bone density Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Labyrinthitis is uncharacteristic, and patients do not normally experience hypercoagulation or cardiac hypertrophy.
Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia?
Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing. Explanation: Neutropenia occurs when the absolute neutrophil count falls below 1,000/mm3, reflecting a severe risk of infection. The nurse should provide a low-bacterial diet, which means eliminating fresh fruits and vegetables, avoiding invasive procedures such as enemas, and practicing frequent hand washing. Using a soft toothbrush, avoiding straight-edged razors and enemas, and monitoring for bleeding are precautions for clients with thrombocytopenia. Putting on a mask, gown, and gloves when entering the client's room are reverse isolation measures. A neutropenic client doesn't need a clear liquid diet or sodium restrictions.
The nurse is caring for a client with myelodysplastic syndrome (MDS). Which interventions will the nurse implement for this client? Select all that apply.
Energy conservation techniques Tylenol as ordered for fever Monitoring for spontanous bleeding Explanation: The MDS are a group of clonal disorders of the myeloid stem cell that cause dysplasia in one or more types of cell lines. These disorders commonly result in low blood cell counts, with the tendency to develop into acute leukemia The manifestations of MDS can vary widely. Symptoms include fatigue, recurrent pneumonia, and other infections that cause fever. Bleeding can also occur. MDS is not associated with muscle cramps or transient confusion.
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 Explanation: 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 nurse at a long-term care facility is amending the care plan of a resident who has just been diagnosed with essential thrombocythemia (ET). The nurse should anticipate the administration of what medication?
Hydroxyurea Hydroxyurea is effective in lowering the platelet count for patients with ET. Dalteparin, allopurinol, and HCTZ do not have this therapeutic effect.
A client with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever?
Neutropenia Explanation: 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.
The nurse is reviewing the health history of a client with essential thrombocythemia. Which findings increase the client's risk of developing a complication? Select all that apply.
Obesity Smoking Diabetes Hypertension Explanation: Complications of essential thrombocythemia include hemorrhage. Clients with cardiovascular risk factors, specifically obesity, smoking, diabetes, and hypertension, are at a higher risk for thrombotic complications. Osteoarthritis is not associated with complications from essential thrombocythemia.
A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client?
Preventing bone injury Explanation: 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.
An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurses most appropriate response to the patients complaint?
Promptly refer the patient for medical assessment. Hodgkin lymphoma usually begins as an enlargement of one or more lymph nodes on one side of the neck. The individual nodes are painless and firm but not hard. Prompt medical assessment is necessary if a patient has this presentation. However, there is no acute need to call 911. Delaying care for 1 week could have serious consequences and x-rays are not among the common diagnostic tests.
A patient has been found to have an indolent neoplasm. The nurse should recognize what implication of this condition?
The patient faces a significant risk of malignancy. Indolent neoplasms have the potential to develop into a neoplasm, but this is not always the case. The patient does not necessary have, or go on to develop, leukemia. Indolent neoplasms are unrelated to the pathophysiology of hemophilia.
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?
Hypercalcemia Explanation: Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.
Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult patient who is otherwise healthy. The patient and the care team have collaborated and the patient will soon begin induction therapy. The nurse should prepare the patient for which of the following?
An aggressive course of chemotherapy Attempts are made to achieve remission of AML by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks. Induction therapy is not synonymous with radiation, stem cell transplantation, or targeted therapies.
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." Explanation: 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 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 Explanation: 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 patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurses most appropriate action?
Ask if he would like you to sit with him while he collects his thoughts Providing emotional support and discussing the uncertain future are crucial. Leaving is incorrect because leaving the patient doesnt show acceptance of his feelings. Offering to call pastoral care may be helpful for some patients but should be done after the nurse has spent time with the patient. Telling the patient that you understand how hes feeling is inappropriate because it doesnt help him express his feelings.
The nurse is administering packed red blood cell (RBC) transfusions for a patient with myelodysplastic syndrome (MDS). The patient has had several transfusions and is likely to receive several more. What is a priority for the nurse to monitor related to the transfusions?
Iron levels Explanation: For most patients with MDS, transfusions of RBCs may be required to control the anemia and its symptoms. These patients can develop iron overload from the repeated transfusions; this risk can be diminished with prompt initiation of chelation therapy (see following Nursing Management section).
A patient with non-Hodgkins 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 nurses best response?
Its important to reduce other factors that increase the risk of second cancers The nurse should encourage patients to reduce other factors that increase the risk of developing second cancers, such as use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight. The other options do not answer the patients question, and also make light of the patients question.
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?
Risk for falls Explanation: 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.
The nurse is assessing a patent with polycythemia vera. What skin assessment data would the nurse determine is a normal finding for this patient?
Ruddy complexion Explanation: Polycythemia vera (sometimes called P vera), or primary polycythemia, is a proliferative disorder of the myeloid stem cells. Patients typically have a ruddy complexion and splenomegaly.
A client with multiple myeloma is complaining about pain. What instructions will the nurse give the client to help to reduce pain during activity?
Do not lift more than 10 pounds. Explanation: The client with multiple myeloma needs education about activity instructions, such as lifting no more than 10 pounds and using proper body mechanics. Braces may be needed. The client should be active and would not be instructed to stay in bed or limit activity, as he or she would become very stiff. Limiting fluids would be contraindicated; the client needs to remain well hydrated.
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?
Bone marrow expands. Explanation: In acute myeloid leukemia, bone pain is caused when the bone marrow expands.
A client with a new onset of rib and spine pain is being evaluated for multiple myeloma. For which manifestations will the nurse assess this client? Select all that apply.
Anemia Hypercalcemia Renal dysfunction Bone destructions Explanation: Clinical manifestations of multiple myeloma result not only from the malignant cells themselves, but also from the abnormal protein they produce. The classic clinical manifestations of multiple myeloma are referred to as the CRAB features and include anemia, hypercalcemia, renal dysfunction, and bone destruction. Lymph enlargement is associated with lymphomas, but not with multiple myeloma.
A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention?
Assess for signs of injury. Explanation: A client with hypoesthesia of the feet will have decreased sensation and numbness. The nurse should assess for signs of injury. If the client is injured, he or she will not be able to feel it; this could lead to the development of infection. Ambulation will not help the client, and elevating the legs may make the problem worse, as blood flow to the feet would be decreased. Keeping the feet cold will also decrease blood flow.
The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take?
Perform a neurologic assessment with vital signs. Explanation: 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 and 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.
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?
Platelet count of 9,000/mm3 Explanation: 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.
A patient with a myelodysplastic syndrome is being treated on the medical unit. What assessment finding should prompt the nurse to contact the patients primary care provider?
The patient has an oral temperature of 37.5C (99.5F). Because the patient with MDS is at a high risk for infection, any early signs of infection must be reported promptly. The nurse should address each of the listed assessment findings, but none is as direct a threat to the patients immediate health as an infection
A client who is undergoing chemotherapy for AML reports pain in the low back. What is the nurse's first action?
Assess renal function. Explanation: 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.
A patient who is undergoing consolidation therapy for the treatment of leukemia has been experiencing debilitating fatigue. How can the nurse best meet this patients needs for physical activity?
Assist the patient to a chair during awake times, as tolerated. Sitting is a chair is preferable to bed rest, even if a patient is experiencing severe fatigue. A patient who has debilitating fatigue would not likely be able to perform stair exercises. Teaching about mobility may be necessary, but education must be followed by interventions that actually involve mobility. Deep breathing and coughing reduce the risk of respiratory complications but are not substitutes for physical mobility in preventing deconditioning.
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. Explanation: 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.
A nurse is caring for a patient who has been diagnosed with leukemia. The nurses most recent assessment reveals the presence of ecchymoseson the patients sacral area and petechiae in her forearms. In addition to informing the patients primary care provider, the nurse should perform what action?
Check the patients most recent platelet level. The patients signs are suggestive of thrombocytopenia, thus the nurse should check the patients most recent platelet level. VTE is not a risk and this does not constitute a need for isolation. Ambulation and activity may be contraindicated due to the risk of bleeding.
A 77-year-old male is admitted to a unit with a suspected diagnosis of acute myeloid leukemia (AML). When planning this patients care, the nurse should be aware of what epidemiologic fact?
Five-year survival for patients over 75 years old is less than 2%. The 5-year survival rate for patients with AML who are 50 years of age or younger is 43%; it drops to 19% for those between 50 and 64 years, and drops to1.6% for those older than 75 years. Early diagnosis is beneficial, but is nonetheless not associated with good outcomes or high survival rates. Preillness health is significant, but not the most important variable
A client who is being treated for AML has bruises on both legs. What is the nurse's most appropriate action?
Evaluate the client's platelet count. Explanation: 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 patient with leukemia has developed stomatitis and is experiencing a nutritional deficit. An oral anesthetic has consequently been prescribed. What health education should the nurse provide to the patient?
Chew with care to avoid inadvertently biting the tongue. 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. There is no specific need to warn the patient about brushing teeth or swallowing slowly because an oral anesthetic has been used.
A client has been diagnosed with polycythemia vera. What is the best instruction for the nurse to give to this client?
Maintain adequate blood pressure control Explanation: The client with polycythemia vera needs to control blood pressure, because of the increased risk for thrombosis or hemorrhage. Iron supplements can stimulate red blood cell production. Ingestion of alcohol may cause bleeding. Bathing in cool or tepid water may control itching, but this is not as high a priority as preventing thrombosis or hemorrhage.
A client has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal?
Maintain nutrition. Explanation: 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.
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?
Risk for Infection Induction therapy places the patient at risk for infection, thus 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. Immobility, confusion, and spiritual distress are possible, but infection is the patients most acute physiologic threat.
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?
Graft-versus-host disease Explanation: 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 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. Explanation: 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.
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?
Serum calcium level 13.8 mg/dl Explanation: 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.
For a client with Hodgkin lymphoma, who is at a risk for ineffective airway clearance and impaired gas exchange, the nurse places the client in a high Fowler's position to
increase lung expansion. Explanation: For a client with Hodgkin disease who is at a risk for ineffective airway clearance and impaired gas exchange, the nurse keeps the neck in the midline and places the client in a high Fowler's position if respiratory distress develops. Avoiding unnecessary pressure on the trachea and positioning for increased lung expansion improve air exchange. The nurse administers oxygen, per the physician's orders, to reduce deficits in the blood oxygen concentration. The nurse assesses the client's respiratory status during each shift to detect compromised ventilation. The nurse places an endotracheal tube, a laryngoscope, and a bag-valve mask at the bedside for intubation if the need for the airway management arises.
A nurse is preparing health education for a patient who has received a diagnosis of myelodysplastic syndrome (MDS). Which of the following topics should the nurse prioritize?
Emergency management of bleeding episodes Because of patients risks of hemorrhage, patients with MDS should be taught techniques for managing emergent bleeding episodes. Bronchodilators are not indicated for the treatment of MDS and lymphedema is not normally associated with the disease. Energy conservation techniques are likely to be useful, but management of hemorrhage is a priority because of the potential consequences.
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 Doxorubicin Mechlorethamine Explanation: 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.
Which statement indicates the client understands teaching about induction therapy for leukemia?
"I will be in the hospital for several weeks." Explanation: 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.
A clinic patient is being treated for polycythemia vera and the nurse is providing health education. What practice should the nurse recommend in order to prevent the complications of this health problem?
Avoiding tight and restrictive clothing on the legs Because of the risk of DVT, patients with polycythemia vera should avoid tight and restrictive clothing. There is no need to avoid foods with vitamin K or to avoid higher altitudes. Activity levels should be maintained, but there is no specific need for ROM exercises.
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?
Multiple myeloma Explanation: 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.
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 Explanation: The bone marrow biopsy of a client with acute myeloid leukemia will reveal an excess of immature leukocytes.
A nurse cares for a client with multiple myeloma who reports severe back pain that worsens throughout the day. What additional clinical symptoms will the nurse associate with the pathophysiology of the client's disease?
Excessive thirst Explanation: Bone pain in multiple myeloma results from bone breakdown. As a result of the breakdown, ionized calcium is released into the blood causing hypercalcemia. Symptoms of hypercalcemia include excessive thirst, dehydration, and constipation.
An older adult patient is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). What assessment finding is certain to be present if the patient has CLL?
Increased lymphocyte levels An increased lymphocyte count (lymphocytosis) is always present in patients with CLL. Each of the other listed symptoms may or may not be present, and none is definitive for CLL.
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?
Multiple myeloma Explanation: 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 patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the patients care plan?
Protective isolation and vigilant use of standard precautions Induction therapy causes neutropenia and a severe risk of infection. This risk must be addressed directly in order to ensure the patients survival. For this reason, infection control would be prioritized over nutritional interventions, family care, and pain, even though each of these are important aspects of nursing care.
Following an extensive diagnostic workup, an older adult patient has been diagnosed with a secondary myelodysplastic syndrome (MDS). What assessment question most directly addresses the potential etiology of this patients health problem?
Were you ever exposed to toxic chemicals in any of the jobs that you held? Secondary MDS can occur at any age and results from prior toxic exposure to chemicals, including chemotherapeutic medications. Family history, sun exposure, and previous infections are unrelated to the pathophysiology of secondary MDS.
