NURS405 Ch30: Management of Patients with Hematologic Neoplasms

A client who is undergoing chemotherapy for AML reports pain in the low back. What is the nurse's first action?

Assess renal function

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.

What assessment finding best indicates that the client has recovered from induction therapy?

Neutrophil and platelet counts within normal limits

polycythemia vera

general increase in red blood cells

The nurse is caring for a client with erythematous fingers and renal calculi. Which assessment findings help determine if the client is experiencing polycythemia vera? Select all that apply.

Enlarged spleen Body mass index 33 Received erythropoietin injections History of receiving blood transfusions The diagnosis of polycythemia vera is based upon the evaluation of clinical symptoms and laboratory values. An abdominal symptom of polycythemia vera is an enlarged spleen. Obesity is a cardiovascular risk factor for the condition. A history of receiving erythropoietin injections and receiving blood transfusion are both risk factors for the condition. Difficulty swallowing is not a symptom of polycythemia vera.

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

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?

Hypercalcemia Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

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

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 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 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 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.

A nurse reviews the laboratory results of a client with polycythemia vera. Which findings will the nurse find? Select all that apply.

Decreased erythropoietin Increased hemoglobin Explanation: Polycythemia vera causes increased hemoglobin and decreased erythropoietin. Additionally, polycythemia vera causes an increase in platelets and leukocytes as well.

A client with leukemia has developed a cough and increased fatigue. What is the primary nursing intervention?

Evaluate the client for potential infection.

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

The nurse is teaching a client about the development of leukemia. What statement should be included in the teaching plan?

"Chronic leukemia develops slowly."

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."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.

Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)?

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 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 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 (Zyloprim) 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 (see Chapter 15). The increased uric acid and phosphorus levels make the patient vulnerable to renal stone formation and renal colic, which can progress to acute renal failure. Patients require a high fluid intake, and prophylaxis with allopurinol (Zyloprim) to prevent crystallization of uric acid and subsequent stone formation.

A client is receiving chemotherapy for acute myeloid leukemia and has poor nutritional intake. What is the first action the nurse should take?

Ask, "Are you experiencing nausea?"

paresthesia

abnormal sensation of numbness and tingling without objective cause

erythrocytosis

increase in the number of red blood cells

mucositis

inflammation of the mucous membrane

MDS

myelodysplastic syndrome-preleukemic condition (anemia, cytopenias, and possible transformation to AML)

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

Following bone marrow aspiration of a 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 that apply.

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

The nurse cares for a client with acute myeloid leukemia with severe bone pain. What pathophysiological concept does the nurse understand is the reason for the client's pain?

Bone marrow expands.

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

Cervical

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 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.

A client has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal?

Maintain nutrition.

The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list 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. The other options do not have the characteristics of erythrocytosis.

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.

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.

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. 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.

The nurse in the oncology clinic is caring for a 42-year-old female client receiving chemotherapy with fludarabine for acute myeloid leukemia who has developed petechiae, epistaxis, and ecchymosis.

The nurse anticipates that the client has developed a hemorrhage and that the laboratory results will reveal leukocytosis

A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention?

Assess for signs of injury. 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 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. Options A, C, and D are distractors for this question.

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. 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 caring for a patient who will begin taking long-term biphosphate therapy. Why is it important for the nurse to encourage the patient to receive a thorough evaluation of dentition, including panoramic dental x-rays?

The patient can develop osteonecrosis of the jaw.

Which statement best describes the function of stem cells in the bone marrow?

They produce all blood cells. 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.

A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client?

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

A client is awaiting test results to diagnose Hodgkin lymphoma. The nurse knows that which result is the hallmark for the diagnosis of this condition?

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