(1340) PREP U ch 32 Caring for Clients with Disorders of the Lymphatic System

An oncology nurse is caring for a client with multiple myeloma who is experiencing bone destruction. When reviewing the client's 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 has lymphedema in the leg. The nurse measures the affected leg's circumference as 8 cm more than the unaffected leg and has cellulitis. When documenting findings, what stage would the nurse grade the lymphedema?

Grade III Characteristics of Grade III (Severe) lymphedema is that the circumference of affected limb is 8 cm greater than the unaffected limb, involves the entire limb, or is accompanied by infection or cellulitis (inflammation of connective tissue in or close to the skin).

A nurse is planning the care of a client who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the client's care plan, the nurse has identified a diagnosis of Risk for Injury, which should be attributed to what factor?

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.

A client who is undergoing consolidation therapy for the treatment of leukemia has been experiencing debilitating fatigue. How can the nurse best meet this client's needs for physical activity?

Assist the client to a chair during awake times, as tolerated. Sitting up in a chair is preferable to bed rest, even if a client is experiencing severe fatigue. A client 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 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 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 client who is a breast cancer survivor is battling secondary lymphedema. How many women are affected by secondary lymphedema after cancer treatment?

more than one-fourth Lymphedema affects more than one fourth of women who have received treatment for breast cancer; this accounts for an appreciable number of the 2 to 3 million Americans affected by this condition (Holcomb, 2006).

A client presents with weeping lower extremity edema and skin that is thickened and brawny. This condition has been present for 4 weeks. The physician would likely order:

symptomatic treatment. In lymphedema, treatment is usually symptomatic.

The nurse is managing care for a client with respiratory distress secondary to Hodgkin's disease. What equipment should the nurse have available? Select all that apply.

Endotracheal tube Laryngoscope Bag-valve mask The nurse should place an endotracheal tube, laryngoscope, and bag-valve mask at the bedside for intubation. Anticipation of the need for airway management ensures that medical intervention and emergency assistance are not delayed.

After receiving a diagnosis of acute lymphocytic leukemia, a client is visibly distraught, stating, "I have no idea where to go from here." How should the nurse prepare to meet this client's psychosocial needs?

Assess the client's specific needs for education and support. In order to meets the client's 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 client's previous health care is not a primary consideration, and the nurse cannot assure the client of successful treatment.

A client with lymphedema is struggling with negative emotions related to her appearance. Which of the following suggestions from the nurse would be most effective in helping the client address the problem?

"Let's discuss some clothing styles that can help conceal the problem while you are being treated." Extensive emotional support is necessary when the edema is severe. The client's self-esteem often is decreased, which can lead to social withdrawal. The nurse supports the client's self-image by suggesting certain styles of clothing that conceal abnormal enlargement of an arm or leg. Telling the client not to dwell on the problem is dismissive and inappropriate; also, sometimes lymphedema does not go away. The nurse should not automatically suggest spiritual counseling to assist with a client's practical problem, unless a client specifically initiates interest in such a referral. While it might be helpful for the client to spend the most time with the people with whom she feels most comfortable, this may increase her isolation. It also may not be practical if a client must return to work or other activities.

A 70-year-old client has recently been diagnosed with lymphoma and asks what may have contributed to this illness. Which of the following statements from the nurse would be most accurate?

"Lymphoma incidence increases with age because of cumulative exposures to carcinogens and a decline in immune functioning." The risk of lymphoma is increased in older adults, primarily because of the immunologic changes of aging and prolonged exposure to carcinogens. This age group has a higher risk than others for lymphomas. Development of lymphoma has no connection to previous history of infection with varicella. Lymphoma is a problem of the lymphatic system, not of circulatory or blood-vessel functioning.

A public health nurse is planning community teaching for a group of older adults regarding aging and hematological conditions. What condition will the nurse identify as most common among this population?

Anemia Anemia is the most common hematological condition in older adults, particularly those admitted to hospitals and long-term care facilities.

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.

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 nurse is documenting skin findings in a client with lymphedema. Which of the following descriptions would be most consistent with the expected presentation?

Brawny The skin of the client with lymphedema can appear thickened, rough, and discolored; it is described as brawny (orange). Rubor means a red appearance; cyanotic is a bluish skin tone when oxygenation to tissues is impaired; and jaundice is a yellow skin tone that develops in client with liver problems.

A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. In addition to informing the client's primary care provider, the nurse should perform what action?

Check the client's most recent platelet level. The client's signs are suggestive of thrombocytopenia, thus the nurse should check the client's 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 client with Hodgkin's disease is hospitalized and experiencing respiratory distress. In which position should the nurse place the client?

High Fowler's The nurse should keep the neck in midline and place the client in high Fowler's position if respiratory distress develops. This position avoids unnecessary pressure on the trachea and provides for increased lung expansion and improved air exchange.

A nurse practitioner is assessing a client who has a fever, malaise, and a white blood cell count that is elevated. What principle should guide the nurse's management of the client's care?

Infection is the most likely cause of the client's 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 is helping to prepare a client with lymphedema for a procedure in which an intravenous dye and radiography will be used to detect lymph node involvement and reveal the degree and extent of blockage in the lymph system. What procedure will the client be undergoing?

Lymphangiography Lymphangiography is a special examination in which an intravenous (IV) dye and radiography are used to detect lymph node involvement, which reveals the degree and extent of blockage in the lymph system.

Which term refers to a form of white blood cell involved in immune response?

Lymphocyte Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.

Which of the following measures would the nurse recommend to the client with lymphedema to help manage the condition? Select all that apply.

Movement and exercise of the limb Elevation of the limb Compression garments The nurse encourages the client to move and exercise the affected arm or leg to enhance the flow of lymph from the congested area. The nurse instructs the client to elevate the edematous extremities when sitting and teaches how to apply and use elastic garments and mechanical devices.

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.

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 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.

A 16-year-old girl has been brought to her primary care provider by her mother due to the daughter's recent malaise and lethargy. Which of the following assessments should the clinician perform in an effort to confirm or rule out infectious mononucleosis?

Palpating the patient's lymph nodes In cases of infectious mononucleosis, the lymph nodes are typically enlarged throughout the body, particularly in the cervical, axillary, and groin areas. Palpation of these nodes is a priority assessment in cases of suspected mononucleosis. Bone pain, adventitious lungs sounds, and abnormal cranial nerve reflexes do not accompany mononucleosis.

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets?

Pancytopenia 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 is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?

Place the client in a modified Trendelenburg position. The first action by the nurse would be to place the client in a modified Trendelenburg position to facilitate blood flow to the brain. Administering a crystalloid solution and testing the client for blood in the stool may be later action but is not relevant in facilitating blood flow to the brain. Preparing the client for an endoscopy would be important after the physician obtains the informed consent but would not facilitate blood flow to the brain.

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 nurse is caring for a client who is being treated for leukemia in the hospital. The client 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 client with several small, soft-textured meals each day. For clients 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.

The nurse is reviewing the chart of a client with lymphoma. Which of the following findings would best indicate to the nurse that the client has Hodgkin's disease as opposed to non-Hodgkin's lymphoma?

Reed-Sternberg cells are found diagnostically. Although the exact cause of Hodgkin's disease is unknown, it appears that a virus, particularly the Epstein-Barr virus, causes mutations in some but not all lymphocytes, creating malignant cells known as Reed-Sternberg cells. Reed-Sternberg cells are present with Hodgkin's disease. The other findings, although also possible with Hodgkin's disease, could also be found in clients with non-Hodgkin's lymphoma.

Which of the following in a client's history would the nurse be likely to identify as risk factors for secondary lymphedema? Select all that apply.

Repeated phlebitis Burns Mastectomy Secondary lymphedema develops (1) as a complication of other disorders, such as repeated bouts of phlebitis and streptococcal infection, burns, or insect bites; or (2) as a consequence of treatment, such as the removal of multiple lymph nodes at the time of a mastectomy or radiation for cancer. Lymphedema affects more than one fourth of women who have received treatment for breast cancer. Worldwide, the most common cause of lymphedema is a parasitic worm; mosquitoes transmit the parasite, resulting in a condition known as elephantiasis.

A nurse is planning the care of client who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions?

Risk for Ineffective Tissue Perfusion Clients with ET are at risk for hypercoagulation and consequent ineffective tissue perfusion. Fluid volume, breathing, and thermoregulation are not normally affected.

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 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 has primary lymphedema. The nurse explains that primary lymphedema is:

usually congenitally acquired. Primary lymphedema usually is congenitally acquired, although manifestations usually do not appear until adolescence or early adulthood. Secondary lymphedema is a complication of other disorders. Secondary lymphedema is a consequence of treatment.

Laboratory and diagnostic test results have returned for a client with suspected lymphangitis. Which of the following would be most likely for the nurse to review in the results?

Streptococcus An infectious agent, commonly a streptococcal microorganism, usually causes both lymphangitis and lymphadenitis.

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.

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 having a discussion with a group of 14-year-old camp counselors about how infectious mononucleosis is transmitted. This disease is transmitted by:

contact with the saliva of an infected person. Infectious mononucleosis spreads by direct contact with saliva and pharyngeal secretions from an infected person. It is transmitted by kissing; oral spraying during coughing, talking, or sneezing; or sharing food, cigarettes, or other items containing oral secretions.

A client has a history of lymphedema. Impaired nutrition to the client's tissues could lead to:

ulcers and infection in the edematous area. In a client with lymphedema, tissue nutrition is impaired from the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area.