Chapter 30: Management of Patients with Hematologic Neoplasms

Which statement indicates the client understands teaching about induction therapy for leukemia?

"I will be in the hospital for several weeks." -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.

polycythemia vera

condition characterized by too many erythrocytes; blood becomes too thick to flow easily through blood vessels

Which assessment findings support the client's diagnosis of acute myeloid leukemia? Select all that apply.

- Petechiae - Enlarged lymph nodes - Weakness and fatigue - Bone pain

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 -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 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 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 -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.

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 -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 assisting the client with multiple myeloma to ambulate. What is the most important nursing intervention to help prevent fractures in the client?

Promote safety. -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.

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.

multiple myeloma

malignant tumor of bone marrow cells

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

Neutrophil and platelet counts within normal limits -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.

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 -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.

acute myeloid leukemia (AML)

the most common form of leukemia in adults; develops when the bone marrow produces too many myeloblasts

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 -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.

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

Assess renal function. -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.

myelodysplastic syndrome (MDS)?

a type of cancer in which there is insufficient production of one or more types of blood cells due to dysfunction of the bone marrow

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

Hodgkin lymphoma

malignant tumor of lymphoid tissue in the spleen and lymph nodes

A nurse prepares teaching for a group of clients with chronic myeloid leukemia (CML). When planning the teaching on medication adherence, which factors associated with lower oral therapy adherence will the nurse keep in mind? Select all that apply.

- Living alone - Low socioeconomic status - Not participating in a clinical trial - Taking medication - independent of meals

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

"Chronic leukemia develops slowly."

induction therapy

Intense combination of chemotherapy and radiation give at time of diagnosis with the goal of achieving remission (99%)

A client receiving treatment for acute myeloid leukemia (AML) develops elevated potassium, uric acid, and phosphate levels. Which treatments will the nurse anticipate being prescribed to reduce this client's risk for kidney stone formation? Select all that apply.

- Allopurinol - Intravenous fluids

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

Maintain nutrition.

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.

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 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.

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

The nurse is providing teaching to a client diagnosed with chronic myeloid leukemia (CML). Which statement will the nurse include in the teaching on the pathophysiology of the disease?

"Uncontrolled growth of blood cells causes the marrow to expand to organs." -Because there is an uncontrolled proliferation of cells, the marrow expands into the cavities of long bones, such as the femur, and cells are also formed in the liver and spleen (extramedullary hematopoiesis), resulting in enlargement of these organs that is sometimes painful.

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."

A nurse assesses a client who has been diagnosed with DIC. Which indicators are consistent with this diagnosis? Select all that apply.

- Cyanosis in the extremities - Dyspnea and hypoxia - Increased blood urea nitrogen (BUN) and creatinine -Urine output would be decreased in DIC, and capillary fill time would be more than 3 seconds; breath sounds would be decreased.

A nurse plans care for a client with multiple myeloma. Using the CRAB acronym for symptoms associated with this disease, which clinical features does the nurse expect to find upon assessment of the client? Select all that apply.

- Hypercalcemia - Renal insufficiency - Anemia - Bone lesions

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 -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 client with suspected multiple myeloma is reporting back pain. What is the priority nursing action?

Send the client for a spinal x-ray study. -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.

A client is receiving radiation therapy for lesions in the abdomen from non-Hodgkin's lymphoma. Because of the effects of the radiation treatments, what will the nurse assess for?

Diarrheal stools -Side effects of radiation therapy are limited to the area being irradiated. Clients who have abdominal radiation therapy may experience diarrhea. If the lesions were in the upper chest, then the client may experience adventitious lung sounds or laryngeal edema as side effects. Hair loss is associated more with chemotherapy than radiation therapy.

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. -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.

A client who is being treated for AML has bruises on both legs. What is the nurse's mostappropriate action?

Evaluate the client's platelet count. -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 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.

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 -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.

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 -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.

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. -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 -Osteoclasts are cells that break down and remove bone cells, which results in increased blood calcium and pathologic fractures.

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 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 -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 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.

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 -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.

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. -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.

Chronic lymphocytic leukemia

a form of leukemia characterized by the accumulation of abnormal, mature lymphocytes lymphocytes are a type of white blood cell important for immunity)

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 -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 client with leukemia is experiencing recurrent fevers. Which actions will the nurse take to improve this client's comfort? Select all that apply.

- Sponge with cool water. - Change bed clothes frequently. - Provide acetaminophen as prescribed.

The nurse is caring for a client with acute lymphocytic leukemia (ALL) who is Philadephia chromosome negative. Which medications will the nurse anticipate providing to the client during initiation of pharmacological therapies? Select all that apply.

- Vincristine - Dexamethasone

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." -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.

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 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 -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 48-year-old female recently diagnosed with leukemia presents with increased immature lymphocytes, decreased granulocytes, and normal erythrocytes. The client most likely has which type of leukemia?

Chronic lymphocytic leukemia -Clients with CLL are typically older than 40 years of age, have increased immature lymphocytes, normal or decreased granulocytes, but erythrocyte and platelet counts may be normal or low. Clients with ALL are younger than 5 years of age; uncommon after 15 years of age. Clients with AML have a decrease in all myeloid formed cells: monocytes, granulocytes, erythrocytes, and platelets. Clients with CML are similar to those with AML but greater number of normal cells than in acute form.

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 -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 assessing a patent with polycythemia vera. What skin assessment data would the nurse determine is a normal finding for this patient?

Ruddy complexion -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 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 -Non painful swelling of the cervical lymph nodes is the earliest symptom of Hodgkin lymphoma.

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.

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. -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 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 -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.

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.

A client with AML has pale mucous membranes and bruises on the legs. What is the primarynursing intervention?

Assess the client's hemoglobin and platelets. -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.

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. -In acute myeloid leukemia, bone pain is caused when the bone marrow expands.

A patient is taking hydroxyurea for the treatment of primary myelofibrosis. While the patient is taking this medication, what will the nurse monitor to determine effectiveness?

Leukocyte and platelet count -Hydroxyurea is often used in patients with primary myelofibrosis to control high leukocyte and platelet counts and to reduce the size of the spleen.

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.