CH: 30 Malignant Hematologic Disorder

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

"Chronic leukemia develops slowly." Explanation: Chronic leukemia develops slowly, and the majority of leukocytes produced are mature. Acute leukemia develops quickly and the majority of leukocytes are undifferentiated cells.

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

A 72-year-old patient with a history of cancer Explanation: Primary MDS tends to be a disease of people older than 70 years. Because the initial findings are so subtle, the disease may not be diagnosed until later in the illness trajectory, if at all. Thus, the actual incidence of MDS is not known. MYELODYSPLASTIC SYNDROMES (MDSs), p. 962.

The clinic nurse is caring for a client diagnosed with leukopenia. What does the nurse know this client has?

A general reduction in all white blood cells Explanation: Leukopenia is a general reduction in all WBCs. Leukopenia does not have anything to do with erythrocytes. LEUKEMIA, Acute Myeloid Leukemia, p. 951.

The nurse is caring for a client with acute myeloid leukemia (AML) with high uric acid levels. What medication does the nurse anticipate administering that will prevent crystallization of uric acid and stone formation?

Allopurinol Explanation: Massive leukemic cell destruction from chemotherapy results in the release of intracellular electrolytes and fluids into the systemic circulation. Increases in uric acid levels, potassium, and phosphate are seen; this process is referred to as tumor lysis (cell destruction) syndrome. The increased uric acid and phosphorus levels make the client vulnerable to renal stone formation and renal colic, which can progress to acute renal failure. Patients require a high fluid intake, and prophylaxis with allopurinol or rasburicase to prevent crystallization of uric acid and subsequent stone formation LEUKEMIA, Acute Myeloid Leukemia, p. 954.

The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for?

Bone pain in the back of the ribs Explanation: Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma is bone pain, usually in the back or ribs. Unlike arthritic pain, the bone pain associated with myeloma increases with movement and decreases with rest; clients may report that they have less pain on awakening but the pain intensity increases during the day. MULTIPLE MYELOMA, p. 975.

A client is taking hydroxyurea as treatment for essential thrombocythemia. Which laboratory test will the nurse remind the client to have completed regularly?

Complete blood count Explanation: Clients taking hydroxyurea should have the CBC monitored regularly because the dosage is adjusted based on the platelet and WBC count. Uric acid, clotting factors, and serum potassium level do not need to be monitored when taking hydroxyurea. Essential Thrombocythemia, p. 968.

A client with multiple myeloma is complaining about pain. What instructions will the nurse give the client to help to reduce pain during activity?

Do not lift more than 10 pounds. Explanation: The client with multiple myeloma needs education about activity instructions, such as lifting no more than 10 pounds and using proper body mechanics. Braces may be needed. The client should be active and would not be instructed to stay in bed or limit activity, as he or she would become very stiff. Limiting fluids would be contraindicated; the client needs to remain well hydrated. Promoting Home, Community-Based, and Transitional Care, p. 980.

The nurse is interacting with a family that has been caring for a client with cancer for several months. What are the best interventions to assist in relieving caregiver stress in this family? Select all that apply.

Educate the family about medications and side effects. Allow family members to express feelings. Suggest support for household maintenance. Family members benefit from increased education on what to expect. Allowing family members to express their feelings has also been shown to relieve stress. Supporting the caregiver and family with help in household duties will also help the overburdened family. Antianxiety medications and church attendance have not been shown to reduce caregiver stress. Chronic Myeloid Leukemia, pp. 8955-956.

A client with multiple myeloma reports uncomfortable muscle cramping. Which nursing interventions will the nurse implement in response to the client's report of symptoms? Select all that apply.

Encourage hydration Encourage ambulation Explanation: Muscle cramping can be alleviated or reduced by encouraging hydration and ambulation. Warning the client to avoid abrupt position change best supports the client with postural hypotension. Paresthesias (tingling) can best be mediated with range of motion exercises. Clients experiencing hypoesthesia should be warned to avoid extremes in temperatures. MULTIPLE MYELOMA, p. 980.

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

Evaluate the client's platelet count. Explanation: Complications of AML include bleeding. The risk of bleeding correlates with the level and duration of platelet deficiency. Major hemorrhages may develop when the platelet count drops to less than 10,000/mm3. The bleeding is usually unrelated to falling. Keeping the client on bed rest will not prevent bleeding when the client has a low platelet count. Assessment for other areas of bleeding is also a priority intervention. Polycythemia Vera, p. 965.

A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host?

Graft-versus-host disease Explanation: Patients who undergo HSCT have a significant risk of infection, graft-versus host disease (in which the donor's lymphocytes [graft] recognize the patient's body as "foreign" and set up reactions to attack the foreign host), and other complications. Acute Myeloid Leukemia, p. 954.

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

Hypercalcemia Explanation: Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels. MULTIPLE MYELOMA, p. 976.

A patient with AML is having aggressive chemotherapy to attempt to achieve remission. The patient is aware that hospitalization will be necessary for several weeks. What type of therapy will the nurse explain that the patient will receive?

Induction therapy Explanation: Despite advances in understanding of the biology of AML, substantive advances in treatment response rates and survival rates have not occurred for decades, with the exception of advances made in treating APL (see later discussion). Even for patients with subtypes that have not benefited from advances in treatment, cure is still possible. The overall objective of treatment is to achieve complete remission, in which there is no evidence of residual leukemia in the bone marrow. Attempts are made to achieve remission by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks. Acute Myeloid Leukemia, p. 953.

The nurse is administering packed red blood cell (RBC) transfusions for a patient with myelodysplastic syndrome (MDS). The patient has had several transfusions and is likely to receive several more. What is a priority for the nurse to monitor related to the transfusions?

Iron levels Explanation: For most patients with MDS, transfusions of RBCs may be required to control the anemia and its symptoms. These patients can develop iron overload from the repeated transfusions; this risk can be diminished with prompt initiation of chelation therapy (see following Nursing Management section). MYELODYSPLASTIC SYNDROMES (MDSs), p. 964.

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. MYELOPROLIFERATIVE NEOPLASMS, Polycythemia Vera, p. 965.

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

Maintain nutrition. Explanation: Maintaining nutrition is the most important goal after induction therapy because the client experiences severe diarrhea and can easily become nutritionally deficient and develop fluid and electrolyte imbalance. The client is most likely not in pain at this point, and this is an intervention, not a goal. Chronic Lymphocytic Leukemia, pp. 957-960.

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. MULTIPLE MYELOMA, p. 975.

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. Acute Myeloid Leukemia, p. 951.

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

Neutrophil and platelet counts within normal limits Explanation: Recovery from induction therapy is indicated when the neutrophil and platelet counts have returned to normal and any infection has resolved. Stable vital signs, lack of edema, and absence of pain are not indicative of recovery from induction therapy. Acute Myeloid Leukemia, pp. 951-954.

The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures?

Osteoclasts break down bone cells so pathologic fractures occur. Explanation: The abnormal plasma cells proliferate in the bone marrow, where they release osteoclast-activating factor. This, in turn, causes osteoclasts to break down bone cells, resulting in increased blood calcium and pathologic fractures. The plasma cells also form single or multiple osteolytic (bone-destroying) tumors that produce a "punched-out" or "honeycombed" appearance in bones such as the spine, ribs, skull, pelvis, femurs, clavicles, and scapulae. Weakened vertebrae lead to compression of the spine accompanied by significant pain. The other options are distractors for this question.

Clients with multiple myeloma have abnormal plasma cells that proliferate in the bone marrow where they release osteoclast-activating factor, resulting in the formation of osteoclasts. What is the most common complication of the pathology resulting from this process?

Pathologic fractures Explanation: Osteoclasts are cells that break down and remove bone cells, which results in increased blood calcium and pathologic fractures. MULTIPLE MYELOMA, p. 975.

The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take?

Perform a neurologic assessment with vital signs. Explanation: With platelets less than 10,000/mm³ there is a risk for spontaneous bleeding, including within the cranial vault. The nurse performs a neurologic examination to assess for this possibility. Though the client is receiving immunosuppressants, it is not necessary to use contact precautions with this client. Contact precautions are used with clients who have known or suspected transmittable illnesses. Diphenoxylate and atropine can cause constipation and inhibit accurate assessment of the client's gastrointestinal bleeding. If the client strains when having a bowel movement, the client could bleed even more. The client is not to floss vigorously; doing so can cause bleeding. LEUKEMIA, Acute Myeloid Leukemia, p. 954.

The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple areas of ecchymosis and petechiae. What laboratory study should the nurse be concerned about?

Platelet count of 9,000/mm3 Explanation: Complications of AML include bleeding and infection, which are the major causes of death. The risk of bleeding correlates with the level and duration of platelet deficiency (thrombocytopenia). The low platelet count can cause ecchymoses (bruises) and petechiae. Major hemorrhages also may develop when the platelet count drops to less than 10,000/mm3. LEUKEMIA, Acute Myeloid Leukemia, p. 954.

The nurse recognizes the clinical assessment of a patient with acute myeloid leukemia (AML) includes observing for signs of infection early. What nursing action will most likely help prevent infection?

Practice vigilant handwashing. Explanation: Infection prevention is best handled by vigilant handwashing. Monitoring the client's temperature once a shift is not often enough. The client will take precautions, but precautions are enough to prevent infections. Encouraging increased fluid consumption will not prevent infection. NURSING PROCESS The Patient with Acute Leukemia, p. 961.

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

Reed-Sternberg cells Explanation: The malignant cell of Hodgkin lymphoma is the Reed-Sternberg cell, a gigantic tumor cell that is morphologically unique and thought to be of immature lymphoid origin. These cells arise from the B lymphocyte. They may have more than one nucleus and often have an owl-like appearance. The presence of Reed-Sternberg cells is the pathologic hallmark and essential diagnostic criterion. Basophils, platelets, or red blood cells are not used to diagnose Hodgkin lymphoma. Hodgkin Lymphoma, p. 970.

The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma?

The client with enlarged lymph nodes in the neck. Explanation: Lymph node enlargement in Hodgkin lymphoma is not painful. The client with enlarged lymph nodes in the neck is most likely to have Hodgkin lymphoma if the enlarged nodes are painless. Sore throat is not a sign for this disorder. Hodgkin Lymphoma, p. 970.

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. Complete the following sentence by choosing from the lists of options. The nurse anticipates that the client has developed _____ and that the laboratory results will reveal _____

hemorrhage and thrombocytopenia Explanation: This client has manifestations of hemorrhage, including petechiae (pinpoint bleeding in the skin), epistaxis (nosebleeds), and ecchymosis (bruises) due to a low platelet count (thrombocytopenia) secondary to chemotherapy. Chemotherapy with fludarabine may cause bone marrow suppression with neutropenia (low neutrophil count) and thrombocytopenia (low platelet count). When the platelet count is low, the client is at risk for hemorrhage as evidenced by petechiae, epistaxis, and ecchymosis. Chemotherapy with fludarabine may cause bone marrow suppression, leading to thrombocytopenia (low platelet count) and hemorrhage. Although the client is at risk for infection, the assessment findings of petechiae, epistaxis, and ecchymoses are indicators of a low platelet count. The assessment findings do not support a diagnosis of deep vein thrombosis (DVT). Manifestations of DVT include calf pain, leg swelling, and warmth, and pain over the thrombosis. Hyperkalemia does not cause signs and symptoms of hemorrhage. Leukocytosis (a low white count) may occur following treatment with fludarabine, but it does not cause petechiae, epistaxis, and ecchymosis. Electrolyte imbalances and abnormal renal function also do not cause petechiae, epistaxis, and ecchymosis. Acute Myeloid Leukemia, pp. 951-954.

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.