Msp30

Which statement best describes the function of stem cells in the bone marrow? They are active against hypersensitivity reactions. They produce antibodies against foreign antigens. They produce all blood cells. They defend against bacterial infection.

They produce all blood cells. Rationale: 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.

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

Pancytopenia Rationale: 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 teaching a client about the development of leukemia. What statement should be included in the teaching plan? "Acute leukemia develops slowly." "In chronic leukemia, the minority of leukocytes are mature." "In acute leukemia there are not many undifferentiated cells." "Chronic leukemia develops slowly."

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

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 of the lungs is an expected effect of induction therapy." "Consolidation is the term used when a client does not tolerate chemotherapy." "Consolidation occurs as a side effect of chemotherapy."

"Consolidation therapy is administered to reduce the chance of leukemia recurrence." Rationale: 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.

Which statement indicates the client understands teaching about induction therapy for leukemia? "I will be in the hospital for several weeks." "I will start slowly with medication treatment." "I know I can never be cured." "I will need to come every week for treatment."

"I will be in the hospital for several weeks." Rationale: 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.

A client who is undergoing chemotherapy for AML reports pain in the low back. What is the nurse's first action? Assess renal function. Place heating pads on the client's back. Administer pain medication, as ordered. Refer the client to a chiropractor.

Assess renal function. Rationale: 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.

A client with AML has pale mucous membranes and bruises on the legs. What is the primary nursing intervention? Check the client's history. Assess the client's pulse and blood pressure. Assess the client's hemoglobin and platelets. Assess the client's skin.

Assess the client's hemoglobin and platelets. Rationale: 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.

Which assessment findings support the client's diagnosis of acute myeloid leukemia? Select all that apply. Enlarged lymph nodes Bone pain Enlarged heart Petechiae Weakness and fatigue

Enlarged lymph nodes, Bone pain, Petechiae, Weakness and fatigue Rationale: Clients with AML may present with petechiae, enlarged lymph nodes, weakness, fatigue, and bone pain. An enlarged heart is not a typical finding with this disorder.

A client with leukemia has developed a cough and increased fatigue. What is the primary nursing intervention? Evaluate the client for potential infection. Place a cooling blanket on the client. Medicate the client to relieve pain. Administer an antitussive.

Evaluate the client for potential infection. Rationale: The client with leukemia has a lack of mature and normal granulocytes to fight infection. For this reason, the client is susceptible to infection. The primary nursing intervention is to evaluate for potential infection if the client has a cough and increased fatigue. Administering an antitussive would not be appropriate before determining the cause of the cough. A cooling blanket would not be needed if the client does not have a fever. Medicating the client to relieve pain would come after the assessment phase.

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 INR. Evaluate the client's platelet count. Ask the client whether they have recently fallen. Keep the client on bed rest.

Evaluate the client's platelet count. Rationale: 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.

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 Age and gender Menstrual history Lifestyle assessments, such as exercise routines

Health history, such as bleeding, fatigue, or fainting Rationale: When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Age, gender, menstrual history, or lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.

Which term refers to a form of white blood cell involved in immune response? Thrombocyte Lymphocyte Spherocyte Granulocyte

Lymphocyte Rationale: 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.

A client has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal? Maintain nutrition. Place the client in reverse isolation. Address issues of negative body image. Administer pain medication.

Maintain nutrition. Rationale: 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.

A client with suspected multiple myeloma is reporting back pain. What is the priority nursing action? Have the client rest. Encourage ambulation. Have the client lie on a hard surface. Send the client for a spinal x-ray study.

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

The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma? The client with painful lymph nodes under the arm. The client with enlarged lymph nodes in the neck. The client with painful lymph nodes in the groin. The client with a painful sore throat.

The client with enlarged lymph nodes in the neck. Rationale: 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.

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 detect compromised ventilation. reduce deficits in the blood oxygen concentration. increase lung expansion. anticipate the need for airway management.

increase lung expansion. Rationale: 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.

What assessment finding best indicates that the client has recovered from induction therapy? Neutrophil and platelet counts within normal limits Absence of bone pain No evidence of edema Vital signs within normal ranges

Neutrophil and platelet counts within normal limits Rationale: 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 teaching a client with acute lymphocytic leukemia (ALL) about therapy. What statement should be included in the plan of care? "The goal of therapy is palliation." "Side effects are rare with therapy." "Treatment is simple and consists of single-drug therapy." "Intrathecal chemotherapy is used primarily as preventive therapy."

"Intrathecal chemotherapy is used primarily as preventive therapy." Rationale: 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.

After chemotherapy for AML, what interventions will best help to prevent renal complications? Select all that apply. Administer rasburicase. Increase hydration. Administer potassium therapy. Encourage exercise. Administer allopurinol.

Administer rasburicase., Increase hydration., Administer allopurinol. Rationale: Increased uric acid and phosphorus concentrations after chemotherapy for AML can lead to renal calculi formation. Increasing hydration and administering allopurinol (a uricosuric) will help to eliminate the uric acid. Rasburicase is an enzyme that can also decrease uric acid. Administration of potassium is not indicated, as concentrations are elevated after chemotherapy. Exercise is not initially encouraged because the client could have weakness and cramping during this time.

A client with multiple myeloma is complaining about pain. What instructions will the nurse give the client to help to reduce pain during activity? Stay in bed as much as possible. Limit fluids to prevent going to the bathroom. Limit activity to once a day. Do not lift more than 10 pounds.

Do not lift more than 10 pounds. Rationale: 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.

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. Suggest the prescription of antianxiety medications. Suggest the family go to church more often. Allow family members to express feelings. Educate the family about medications and side effects. Suggest support for household maintenance.

Allow family members to express feelings., Educate the family about medications and side effects., Suggest support for household maintenance. Rationale: 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.

A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention? Assess for signs of injury. Encourage ambulation. Elevate the client's legs. Keep the feet cool.

Assess for signs of injury. Rationale: A client with hypoesthesia of the feet will have decreased sensation and numbness. The nurse should assess for signs of injury. If the client is injured, he or she will not be able to feel it; this could lead to the development of infection. Ambulation will not help the client, and elevating the legs may make the problem worse, as blood flow to the feet would be decreased. Keeping the feet cold will also decrease blood flow.