Patho - Ch. 21

A nurse is caring for an adult client who has the most common type of adult leukemia. The nurse is caring for which client?

A client with chronic lymphocytic leukemia (CLL) CLL and AML (35% and 29% of adult leukemias, respectively) are the most common types in adults. The most common leukemia in children is ALL. CML accounts for about 11% of adult leukemias.

A client has hemorrhage and thrombosis simultaneously. The nurse is caring for which client?

A client with disseminated intravascular coagulation Disseminated intravascular coagulation is a pathosis that is associated with simultaneous hemorrhage and thrombosis. An embolus is a moving clot, circulating in the bloodstream. Burkitt lymphoma is a B cell tumor with unique clinical and epidemiologic features that accounts for 30% of childhood lymphomas worldwide. Hereditary hemochromatosis is a common autosomal recessive disorder of iron metabolism and is characterized by increased gastrointestinal iron absorption with subsequent tissue iron deposition.

A nurse is assessing a client using the criteria from the triad of Virchow. The nurse is assessing which client?

A client with potential for a thrombus The triad of Virchow includes the factors that predispose to thrombus formation, which are injury to the endothelium, abnormalities of blood flow, and hypercoagulability of the blood. Anemia would be low numbers of red blood cells. Leukemia would be excessive production of white blood cells. Lymphomas would involve enlarged lymph nodes.

A nurse is caring for a client that has decreased platelets. The nurse is caring for which client?

A client with thrombocytopenia Thrombocytopenia is defined as a platelet count below 150,000 cells/mm3, although it is not usually considered significant until the platelet count drops below 100,000 cells/mm3. Thrombocytosis or thrombocythemia is defined as a platelet count greater than 400,000 cells/mm3 and is an example of thromboproliferation. A thrombosis is a blood clot attached to the blood vessel wall.

Which information indicates a nurse has an accurate understanding of the difference between anemia in a client and polycythemia in a client?

Anemia is a decrease in erythrocytes, but polycythemia is increased concentration of erythrocytes Anemia is a decrease in erythrocytes, but polycythemia is increased concentration of erythrocytes. Polycythemia can damage tissue. The statement that anemia can lead to disseminated intravascular coagulation but that polycythemia can lead to idiopathic thrombocytopenic purpura is not true. Polycythemia can be caused by a problem that arises in bone marrow.

A client has acute lymphocytic leukemia. Which cell line most likely is affected?

B lymphocytes About 85% of acute lymphocytic leukemias (ALL) arise from the B lymphocyte cell line and about 15% from T lymphocytes. Monocytes are not affected. A very small group of ALL cases arise from neither B nor T lymphocytes and are called null cells.

A client's anemia most commonly is classified using which criteria?

Changes that affect the cell's size and hemoglobin content The most common classification of anemias is based on the changes that affect the cell's size and hemoglobin content. While anemias can be classified by their cause or by the changes that affect shape, this is not the most common criteria. Classification does not relate to treatment.

A nurse is caring for a client with disseminated intravascular coagulation (DIC). During the planning of care, which pathophysiologic mechanism should the nurse consider?

Clotting that leads to bleeding DIC is a result of widespread clot formation that consumes platelets and clotting factors, which leaves the client at risk for serious bleeding. As the result of extensive clotting, platelet and fibrinogen levels are decreased, not increased. Loss of red blood cells leads to anemia, not to DIC. Mast cell degranulation is not relevant to DIC, but it is relevant in allergic reactions.

A client has impaired hemostasis. Which factor should the nurse consider when planning care for this client?

Dietary deficiency of vitamin K Impaired hemostasis, or the inability to promote coagulation and the development of a stable fibrin clot, is commonly associated with liver dysfunction, which may be caused by either specific liver disorders or lack of vitamin K, not an excess. A deficiency of dietary iron leads to iron deficiency anemia, whereas an excess leads to iron overload.

A nurse is caring for a client with thrombosis in the microcirculation throughout the body. Which diagnosis will the nurse observe written on the chart?

Disseminated intravascular coagulation Systemic derangement in coagulation takes place in disseminated intravascular coagulation, resulting in thrombosis in the microcirculation throughout the body. A stroke results from the obstruction of blood flow in or to the brain by a clot. Atherosclerosis is a circulatory condition that results in the inability of vessels to regulate blood flow as a result of the plaque buildup in their walls. A myocardial infarction is a result of obstructed blood flow in a vessel supplying the heart muscle itself.

The adult client is undergoing a second round of chemotherapy for metastatic cancer. When the nurse checks the indwelling intravenous line, there is oozing from the central line site, bleeding from the nose and gums, and ecchymotic lesions on the hip. Which condition is most likely the cause of these clinical signs?

Disseminated intravascular coagulation (DIC) Acute DIC presents rapidly with oozing from venipuncture sites and arterial sites, as well as ecchymotic lesions. Approximately 15% of clients with metastatic cancer or acute leukemia have symptoms of DIC. Iron deficiency anemia occurs gradually and presents with koilonychia, glossitis, and fatigue; it does not present with bleeding. The acute form of idiopathic thrombocytopenic purpura is frequently observed in children and typically lasts 1 to 2 months with a complete remission. The familial type of thrombotic thrombocytopenic purpura is the rarer type and is usually chronic, usually relapsing, and usually seen in children.

A client has multiple myeloma. According to the area where multiple myeloma forms tumor masses, which type of tissue will the nurse monitor?

bones In multiple myeloma, the malignant plasma cells form tumor masses in the bones. In multiple myeloma, the malignant cells do not form tumor masses in the brain or lungs. Malignant melanoma principally affects the skin.

A nurse is reviewing objective data from the physical examination of a 17-year-old teenager who is suspected of having infectious mononucleosis. Which assessment finding would be of greatest concern?

Enlarged spleen Enlarged spleen and liver, which occurs in 25% to 75% of those infected with infectious mononucleosis, can lead to splenic rupture. Although rare, it can occur spontaneously or as a result of mild trauma and is the most common cause of death related to infectious mononucleosis. Sore throat, manifested as inflamed mouth and throat, enlarged tonsils, and generalized lymph node enlargement are expected clinical manifestations with infectious mononucleosis and should not cause concern.

A client develops drug-induced thrombocytopenia. Which drug is the most common cause of this condition?

Heparin Heparin-induced thrombocytopenia is the most common form of drug-induced thrombocytopenia, occurring in approximately 4% of individuals treated with unfractionated heparin. Thiazide, estrogen, quinine-containing medications, chemotherapeutic agents, and ethanol are also implicated in drug-induced thrombocytopenia, but not as commonly as heparin.

A nurse observes Reed-Sternberg cells on a laboratory report. The nurse is caring for a client with which disease?

Hodgkin's lymphoma Reed-Sternberg cells are characteristic of Hodgkin lymphoma. Reed-Sternberg cells are not characteristic of other white blood cell malignancy. Multiple myeloma has malignant plasma cells. Leukemias affect white blood cells.

A client has lymphoblastic lymphoma. Which is the characteristic cell or cell state associated with lymphoblastic lymphoma?

Immature malignant T cells Lymphoblastic lymphoma arises from a clone of relatively immature T cells that becomes malignant in the thymus. Heterophilic antibodies are a group of heterogenous IgM antibodies that are agglutinins against animal erythrocytes and are found in infectious mononucleosis. Bence- Jones protein is a free immunoglobulin light chain present in the blood and urine of an individual with multiple myeloma that contributes to renal tubular cell damage. The Reed-Sternberg cell is a definitive diagnostic marker for Hodgkin lymphoma.

A nurse closely monitors a client who had gastric bypass surgery for the development of pernicious anemia. What is the rationale for the nurse's actions?

Intrinsic factor production by the gastric epithelium is reduced. Pernicious anemia is caused by vitamin B12 deficiency from lack of intrinsic factor. Vitamin B12 absorption in the distal ileum requires intrinsic factor, which is secreted by parietal cells in the stomach. Removal of gastric tissue decreases intrinsic factor production. Vitamin B12 is water soluble, rather than fat soluble. Pernicious anemia does not involve antibodies to intrinsic factor.

Which factor increases a client's risk for leukemia?

Ionizing radiation Increased risk has been linked to cigarette smoke, exposure to benzene, and ionizing radiation. Large doses of ionizing radiation particularly result in an increased incidence of myelogenous leukemia. Infections with human immunodeficiency virus (HIV) or hepatitis C, not A, virus increase the risk for leukemia. Alcohol intake and sedentary lifestyle have not been identified as risk factors for leukemia.

A client presents with pica. Which diagnosis will the nurse observe documented on the chart?

Iron deficiency anemia Pica (eating nonfood substances) is associated with iron deficiency anemia. Pica is not commonly associated with thalassemia (inherited autosomal recessive disorders), hemolytic anemias (acquired or hereditary), or folate deficiency anemia (alcoholics and malnourished individuals).

A nurse is teaching a health class about anemia. Which type of anemia should the nurse include in the teaching session that is the most common worldwide?

Iron deficiency anemia (IDA)

Which statement by the client indicates that teaching was successful regarding the best definition of anemia?

It is a decreased number of circulating red blood cells. All types of anemia involve a decreased number of circulating erythrocytes. Increased production of platelets is thrombocytosis. Increased excretion of potassium causes hypokalemia. A decreased amount of circulating plasma volume occurs in dehydration; anemia involves decreased amounts of hemoglobin.

A client is newly diagnosed with non-Hodgkin lymphoma. Which clinical manifestation will the nurse observe on assessment?

Lymphadenopathy

Which pathophysiologic mechanism occurs in a client with chronic lymphocytic leukemia (CLL)?

Malignant transformation of B cells The pathophysiologic mechanisms in CLL are malignant transformation of B cells and failure of normal programmed cell death or apoptosis (not an increase), giving these cells an extended life and making the condition chronic. Null cell occurs in a small percentage of acute lymphocytic leukemia, not chronic.

A nurse notices a shift to the left in the laboratory reports. Which action is most appropriate for the nurse to take?

Monitor the client's temperature every 4 hours During infection, inflammation, or leukemia, premature release of the immature neutrophils is responsible for the phenomenon known as a shift-to-the-left or leukemoid reaction. Discharge is not appropriate at this time, because an infection, inflammation, or leukemia is present. Infection, inflammation, and leukemia do not respond to blood pressure medication or weighing.

A nurse is reviewing objective data from the annual physical examination of a client. Which assessment finding does the nurse recognize as abnormal?

Mucous membrane finding (pale mucous membranes) Manifestations of anemia may be seen in other parts of the body. The skin, mucous membranes, lips, nail beds, and conjunctivae can become pale because of reduced hemoglobin concentration. The respiration findings and the absence of poikilocytosis and anisocytosis are all normal.

A client has malignant plasma cells with tumor masses all throughout the skeletal system. While giving report, which term can the nurse use to describe this condition?

Multiple Myeloma Multiple myeloma is a B cell cancer characterized by the proliferation of malignant plasma cells that infiltrate the bone marrow and aggregate into tumor masses throughout the skeletal system. Hodgkin lymphoma is characterized by its progression from one group of lymph nodes to another and the presence of Reed-Sternberg cells. Natural killer cell neoplasm is a form of non-Hodgkin lymphoma. Acute lymphocytic leukemia affects white blood cells.

A client was admitted to the burn unit with deep partial thickness burns over 20% of the body and has been stabilized. What would be an expected finding of laboratory blood tests?

Neutrophilia An increase in neutrophils (neutrophilia or granulocytosis) occurs to protect the body from infection following severe burns. Eosinopenia, not eosinophilia, is observed in the stress response for burns, trauma, shock, surgery, and mental distress. Lymphocytopenia can occur in immunodeficiency syndrome, radiation, or chemotherapy. Monocytopenia occurs in hairy cell leukemia and prednisone therapy.

A client is recovering from a life-threatening motor vehicle accident in which massive crushing injuries occurred 10 days ago. Three hours into the shift, the nurse notes acrocyanosis and hematuria and finds that all previous puncture sites and wounds are now oozing blood and will not stop bleeding. What is the nurse's most appropriate response at this time?

Notify the primary healthcare provider immediately The most appropriate response is to notify the primary healthcare provider now because this is a new development classic of disseminated intravascular coagulation (DIC), which is a medical emergency. Pressure dressings will not help in this situation, because the bleeding will not stop and affects internal as well as external sites. The total picture is that of DIC, and a complete blood count will not let the nurse know the clotting factors or bleeding times. Vitamin K is not given in DIC. The treatment of choice for DIC is fresh frozen plasma and possibly heparin because the client is not septic at this time.

After an assessment the nurse suspects the client with sepsis is developing disseminated intravascular coagulation (DIC). What did the nurse find during the assessment?

Oozing blood from an intravenous needle site Acute DIC presents with rapid development of hemorrhaging (oozing) from venipuncture sites, arterial lines, or surgical wounds or development of ecchymotic lesions (purpura, petechiae) and hematomas. Brittle, spoon-shaped nails occur with iron deficiency anemia. The term macrocytic refers to red blood cells that are larger than normal and occur with certain anemias. Ascites can occur with non-Hodgkin lymphoma.

A client has low platelet levels, low red blood cell levels, and low white blood cell levels. Which term should the nurse use to describe this condition during report?

Pancytopenia Pancytopenia is a reduction in all cellular components of the blood. Anisocytosis is excessive variation in the size of red blood cells. Hypoxemia is reduced oxygen level in the blood. Glossitis occurs in iron deficiency anemia.

Which type of anemia is associated with the presence of macrocytic-normochromic erythrocytes?

Pernicious anemia Macrocytic-normochromic erythrocytes occur in pernicious anemia due to a lack of vitamin B12. When abnormal genetic matter forms in erythroblasts, it leads to large, abnormal-shaped erythrocytes. Hemolytic anemia occurs as a result of the premature breakdown of the erythrocyte cell membrane, leading to normocytic-normochromic anemia. Sickle cell anemia occurs due to abnormal hemoglobin synthesis and abnormal shape of erythrocytes. Sideroblastic anemia occurs due to lack of iron uptake by erythroblasts and due to defective porphyrin and hemoglobin synthesis, leading to microcytic-hypochromic anemia.

A nurse notices that a Schilling test is prescribed by the primary healthcare provider. The nurse suspects the client has which anemia?

Pernicious anemia Pernicious anemia is diagnosed with a variety of tests, including serologic studies, gastric biopsy, bone marrow aspiration, clinical findings, and the Schilling test. The Schilling test does not diagnose sickle cell (sickle shaped eyrthrocytes), iron deficiency (low iron levels), or folate deficiency (low folate levels) anemias.

Which type of anemia most likely causes nervous system manifestations?

Pernicious anemia Pernicious anemia occurs due to lack of vitamin B12 and leads to degeneration of myelin and loss of nerve fiber in the spinal cord, thereby resulting in numbness, gait disturbance, and abnormal reflexes. Thalassemia leads to iron overload. Aplastic anemia leads to thrombocytopenia, reticulocytopenia, and leukopenia, whereas hemolytic anemia causes jaundice.

Which client is most predisposed to severe bleeding?

Platelet count less than 10,000 cells/mm3 Severe bleeding results if the thrombocyte count falls below 10,000 cells/mm3 and can be fatal if it occurs in the gastrointestinal tract, respiratory tract, or central nervous system. Spontaneous bleeding without apparent trauma can occur with counts between 10,000 and 15,000 cells/mm3. Most clinicians do not consider the decrease significant unless it falls below 100,000 cells/mm3, and the risk for hemorrhage associated with minor trauma does not appreciably increase until the count falls below 50,000 cells/mm3.

A client has the absolute primary form of polycythemia. Which term should the nurse use in report to describe this condition?

Polycythemia vera The absolute primary form of polycythemia is referred to as polycythemia vera. Polycythemia exists in two forms: relative and absolute. Relative polycythemia results from hemoconcentration of the blood associated with dehydration. Hereditary hemochromatosis is a common, inherited, autosomal recessive iron metabolism disorder that has increased absorption and deposition of iron in tissues. Normocytic-normochromic anemias have a deficiency of erythrocytes with a normal size and hemoglobin content.

A client has chronic idiopathic thrombocytopenic purpura. What is the primary pathophysiologic mechanism that occurs?

Presence of autoantibodies against platelet-associated antigens Chronic idiopathic thrombocytopenic purpura (ITP) is the primary form of the disease; it is associated with the presence of autoantibodies against platelet-associated antigens and tends to get progressively worse. Acute, not chronic, ITP often occurs secondary to viral infections and some medications. Lymphoblastic lymphoma arises from a clone of relatively immature T cells that becomes malignant in the thymus.

Which are the major organ systems that undergo the compensation effect during anemia? Select all that apply.

Respiratory system and Cardiovascular system Compensation generally involves the respiratory, cardiovascular, and hematologic systems. Anemia occurs when the total number of red blood cells and hemoglobin count is reduced. A low level of hemoglobin relates to low-oxygen carrying capacity of the blood. Therefore the workload on the heart and blood vessels increases to pump more blood. Anemia indirectly affects the nervous system, digestive system, and urinary system, which may cause an individual to have fatigue, low concentration, and low appetite.

A client has Hodgkin disease, and the spread of lymphoma has reached multiple extralymphatic organs and tissues. Which stage will the nurse observe written on the chart?

Stage IV Stage IV carries a poor prognosis and means that there is spread to one or more extralymphatic organs or tissues. In stage I, only a single area of lymph nodes is involved. In stage II, there are two or more areas of lymph nodes involved, all on the same side of the diaphragm. Dissemination to lymph nodes both above and below the diaphragm is stage III.

The laboratory analysis conducted on a client with acute-onset fever and malaise reveals an elevated neutrophil count. How should the nurse interpret this finding?

The client has a bacterial infection. During an acute infection, neutrophilia, or an increase in the number of circulating neutrophils, occurs as the bone marrow releases stored neutrophils. Neutrophils are early responders to an acute bacterial infection and arrive in large numbers very quickly. Viral and protozoal infections usually cause a decrease in neutrophils. Parasitic infections do not generally result in an increase in neutrophils but do cause an increase in eosinophils.

A nurse notices on a client's laboratory report that a "shift-to-the-left" phenomenon occurred. How should the nurse interpret this finding?

The demand for circulating mature neutrophils exceeds the supply. When the demand for circulating mature neutrophils exceeds the supply, immature, not mature, neutrophils and other leukocytes are released from the bone marrow resulting in the phenomenon known as a leukemoid reaction or "shift-to-the-left" phenomenon. An increased number of red blood cells is termed polycythemia while a lack of red blood cells is anemia.

Which pathophysiologic process should the nurse remember when planning care for a client with mononucleosis?

This is an acute infection of B lymphocytes with Epstein-Barr virus. Infectious mononucleosis is an acute infection of B lymphocytes (B cells) with Epstein-Barr virus. Leukemia is a clonal malignant disorder of the blood and blood-forming organs. Acute leukemia is characterized by undifferentiated or immature cells, usually a blast cell. Suppression of normal antibody production is the most significant effect in chronic lymphoid leukemia.

While planning care for a client with anemia, which principle should the nurse remember?

Tissue hypoxia is the primary alteration The fundamental alteration of anemia is a reduced oxygen-carrying capacity of the blood resulting in tissue hypoxia. Triad of Virchow is associated with thromboembolic disorders. Vitamin K is needed for clotting; a lack of Vitamin B12 is associated with anemia. Multiple myeloma is a B cell cancer characterized by the proliferation of malignant plasma cells that infiltrate the bone marrow and aggregate into tumor masses throughout the skeletal system.

A client has a higher-than-normal white blood cell count. Which term should the nurse use to describe this condition?

leukocytosis Leukocytosis is an increase in the number of leukocytes (white blood cells) in the blood. A decrease in the number of white blood cells is termed leukopenia. The neutrophil is the most numerous of the granulocytes, and the term granulocytosis is often used in place of the term neutrophilia. Granulocytosis is an increase in the number of granulocytes (neutrophils, eosinophils, basophils) in the blood.

A nurse is caring for a client with chronic lymphocytic leukemia (CLL). Which action by the nurse is most appropriate?

monitor for infection Suppression of normal antibody production is the most significant effect in CLL. Individuals are thus at risk for recurrent bacterial and other infections that are commonly sensitive to antibodies. Anemia (erythrocytopenia), thrombocytopenia, and neutropenia are typically present with overt CLL, not erythrocytosis or thrombocytosis. Hypernatremia (elevated sodium) is not associated with CLL.

A client with folate deficiency anemia has cheilosis. Which area should the nurse assess primarily for cheilosis?

mouth A specific manifestation of folate deficiency anemia includes cheilosis (scales and fissures of the mouth). Although pallor can be identified in the eyelids, it cannot identify cheilosis. Jaundice, sallowness, and cyanosis can be observed in the skin, but cheilosis cannot be observed in the skin. Spoon shaped nails (koilonychias) can be observed with iron deficiency anemia, but cheilosis does not involve the nails.

A nurse is assessing lymph nodes. Which finding is normal?

nonpalpable lymph nodes Normally, lymph nodes are not palpable or are barely palpable. Painful, enlarged lymph nodes are abnormal. Generalized lymphadenopathy is also abnormal.

A client is newly diagnosed with Hodgkin lymphoma. On assessment, what will the nurse typically find?

painless enlargement of lymph nodes Hodgkin lymphoma (HL) is first characterized by painless enlargement of lymph nodes. In people with infectious mononucleosis, early flulike symptoms, such as headache, malaise, joint pain, and fatigue, may appear during the first 3 to 5 days, although some individuals are without symptoms. Anemia (not polycythemia) is often found in individuals with HL accompanied by a low serum iron level and reduced iron-binding capacity. In non-African Burkitt lymphoma the most common presentation is abdominal swelling.

A client has a partial gastrectomy. Based on the surgery, the nurse recognizes that the client has lost which specialized cell that helps produce a substance needed for absorption of vitamin B12?

parietal Parietal cells produce hydrochloric acid and a substance called intrinsic factor, which is needed for adequate intestinal absorption of vitamin B12. Chief cells produce pepsinogen, the inactive form of the enzyme pepsin. Plasmin is the primary component of fibrinolysis (dissolving clots). Folate is a vitamin that is needed for red blood cell synthesis, not a type of cell that produces intrinsic factor.

Which of these people should the nurse recognize as being at the highest risk for developing a folate deficiency anemia?

people who abuse alcohol People who abuse alcohol are at high risk for folate deficiency anemia. Vegetables are an excellent source of folate. Menstruating women are at risk for iron deficiency anemia; pregnant women are predisposed to folate deficiency anemia. Lack of intrinsic factor causes pernicious anemia.

What are the causes of development of iron deficiency anemia? Select all that apply.

pica, menorrhagia, gastric bypass Iron deficiency anemia (IDA) is a common type of anemia with low levels of erythrocytes and hemoglobin. Pica involves the craving and eating of nonnutritional substances such as chalk, dirt, or paper and leads to IDA. In females, menorrhagia is a common cause of IDA. An individual who undergoes gastric surgery may have IDA due to reduced absorption of iron. Drinking hot tea causes pernicious anemia in a patient. Copper deficiency causes sideroblastic anemia.

A nurse is teaching an adult health community class about the most common causes of iron deficiency anemia. Which conditions should the nurse include? Select all that apply.

pregnancy and chronic bleeding In developed countries, pregnancy and a continuous loss of blood are the most common causes of iron deficiency anemia. End-stage renal disease causes anemia from lack of erythropoietin. Genetic autoimmune disease is not associated with iron deficiency anemia. Acute inflammatory diseases are not common causes of iron deficiency anemia; however, there can be anemia of chronic inflammatory diseases that is not related to iron deficiency.

The nurse is assessing a pregnant client admitted to obstetrics for severe preeclampsia. Which clinical findings might suggest disseminated intravascular coagulation (DIC)?

spontaneous bleeding from the gums Spontaneous bleeding from the gums is associated with DIC. DIC may occur in pregnant women with severe preeclampsia. Acute DIC presents with rapid development of hemorrhaging or oozing from venipuncture sites and other wounds, as well as the development of ecchymotic lesions, such as purpura, petechiae, and hematomas. The eyes, nose, and gums are sites of bleeding. The client had spontaneous bleeding of the gums and palatal petechiae, both signs of DIC. Hypotension occurs with DIC, not hypertension. Clear yellow urine is normal. A pulse of 96 is also normal.

A client has problems with insufficient clotting. Which vitamin should the nurse encourage the client to consume?

vitamin K Vitamin K is required for normal clotting factor synthesis by the liver. Vitamin A helps with night vision. Vitamin B helps with metabolism. Vitamin E acts as an antioxidant. Vitamins B, C, and E do not help with clotting.