Med Surg: Chapter 34

A nurse cares for an adult client with chronic lymphocytic leukemia (CLL). Which statements regarding the disease will the nurse include in the teaching?

"This type of leukemia primarily impacts older adults." "This type of leukemia is rarely seen in certain ethnicities." Chronic lymphocytic leukemia (CLL) is a common malignancy of older adults and primarily impacts older adults and has a strong familial predisposition. This type of leukemia rarely impacts Native Americans and infrequently individuals of Asian descent. While many clients will have a normal life expectancy, others will have a very short life expectancy due to the aggressive nature of the disease.

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 receiving chemotherapy for acute myeloid leukemia and has poor nutritional intake. The first action of the nurse is to

Ask, "Are you experiencing nausea?" All these options are things the nurse can do to assist the client to obtain better nutrition. The nurse first needs to assess the reason for poor nutritional intake. It could be because of nausea, in which case the nurse would implement interventions to address the client's nausea.

A client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include:

Bence Jones protein in the urine Presence of Bence Jones protein in the urine almost always confirms multiple myeloma; however, absence of the protein doesn't rule out the disease. Serum creatinine level may be increased (above 1.2 mg/dl in men and 0.9 mg/dl in women). Serum calcium levels are above 10.2 mg/dl in multiple myeloma because calcium is lost from the bone and reabsorbed in the serum. The serum protein level is increased in multiple myeloma, not decreased.

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 multiple myeloma. Which of the following laboratory values should the nurse expect to find in a client with multiple myeloma?

Increased urinary protein A characteristic finding in multiple myeloma is protein in the urine. Other laboratory findings include increased serum protein, hypercalcemia, anemia, and hyperuricemia. Polycythemia vera is not found in multiple myeloma.

The nurse is aware that chronic lymphocytic leukemia (CLL), a common malignancy in those older than 60, has an early stage and a late stage. The nurse assesses a patient for late stage CLL by looking for:

Thrombocytopenia. Anemia and thrombocytopenia are late-stage indicators of CLL. The others are early-stage signs.

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 acute myeloid leukemia (AML) receiving chemotherapy is treated for an acute renal injury. What is the nurse's best understanding of the pathophysiological reason behind the client's injury?

Chemotherapy causes an increase in kidney stone formation. Massive leukemic cell destruction from chemotherapy results in the release of intracellular electrolytes and fluids into the systemic circulation. This causes an increase in uric acid levels, potassium, and phosphate (also known as tumor lysis). The increase in uric acid predisposes the client to the development of kidney stones and increases the risk for renal injury.

A patient is scheduled for a test to help confirm the diagnosis of acute myeloid leukemia (AML). Which of the following is the result that the nurse knows is consistent with the diagnosis?

Excess of immature blast cells

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.

Which nursing intervention is most appropriate for a client with multiple myeloma?

Preventing bone injury When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict his fluid intake.

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.

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. There is a rapid proliferation of red blood cells from the marrow in polycythemia vera. However, these red blood cells die sooner than normal and the dead red blood cells release potassium and uric acid. This build up of uric acid in the blood leads to gouty arthritis symptoms.

The nurse practitioner suspects that a patient has multiple myeloma based on his major presenting symptom and the analysis of his laboratory results. Select the classic symptom for this disease.

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; patients may report that they have less pain on awakening but the pain intensity increases during the day.

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. 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 clent 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 Oncology Advanced Practice Nurse (APN) is assessing a client with leukemia. How would the Oncology APN assess for enlargement and tenderness over the liver and spleen?

By palpating the abdomen In a client with leukemia, the nurse palpates the abdomen to detect enlargement and tenderness over the liver and spleen. The nurse reviews laboratory test results to note the number and types of blood cells. The nurse may calculate the absolute neutrophil count to determine the client's potential for infection.

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 nurse cares for a client with myelodysplastic syndrome (MDS). Which assessment finding does the nurse recognize is the most common finding with this condition?

Macrocytic anemia Macrocytic anemia is the most common symptom of MDS.

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

Maintain nutrition. 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.

The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list 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. Options B, C, and D do not have the characteristics of erythrocytosis.

A home care nurse is caring for a client with multiple myeloma. Which nursing interventions are appropriate for this client?

Delay position changes and bathing if the client is experiencing pain. Instruct the client to avoid activities that may cause injury. Monitor renal function Pain can become quite severe. Delay position changes and bathing until analgesic has reached peak concentration level and the client is experiencing maximum pain relief. Safety is paramount because any injury, no matter how slight, can result in a fracture. The nurse assists the client with ambulation because immobility can worsen loss of calcium from the bone. The nurse provides up to 4000 mL of fluid to prevent renal damage from hypercalcemia and precipitation of protein in the renal tubules.

The nurse is caring for a patient 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 (Zyloprim) 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 patient 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 (Zyloprim) to prevent crystallization of uric acid and subsequent stone formation.

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.

Which of the following is the only curative treatment for chronic myeloid leukemia (CML)?

Allogeneic stem cell transplant Allogeneic stem cell transplantation remains the only curative treatment for CML. The efficacy of Imatinib as first-line treatment and the treatment-related mortality of stem cell transplant limits use of transplant to patients with high risk or relapsed disease, or in those patients who did not respond to therapy with TKI. Cytarabine and idarubicin are part of induction therapy for acute myeloid leukemia (AML).

What assessment findingbest 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 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.

Following bone marrow aspiration of a 19-year-old client, analysis reveals more than 20% immature blast cells. Platelet counts are 9000/mm³. What nursing interventions should the nurse employ for the care of this client?

Assess for mental state changes. Administer prescribed docusate (Colace) daily. The client has leukemia with immature blast cells and an extremely low platelet count. The client is at increased risk for bleeding. Interventions that would address bleeding include assessing for mental status changes (because bleeding could occur in the brain) and administering stool softeners to prevent constipation (which would increase the risk of bleeding from the rectum). Oral contraceptives would be administered to induce amenorrhea. Ibuprofen would be avoided because this medication inhibits platelet function. The nurse is to apply pressure to venipuncture sites for 5 minutes.

A nurse is caring for an asymptomatic client with acute myelogenous leukemia. The client has a total white blood cell (WBC) count of 0 ?l, a platelet count of 3,000 mm2, and a hemoglobin level of 9 mg/dl. He has a single lumen central venous catheter in place and the physician has ordered the nurse to administer imipenem cilastatin (Primaxin) 500 mg every 8 hours, transfuse 1 unit packed red blood cells (RBCs), give amphotericin B (Fungizone) 40 mg I.V. over 4 hours, and transfuse 2 pheresis units of platelets. In what order should the nurse infuse these medications and blood products?

Platelets, imipenem cilastatin, amphotericin B, packed RBCs Although the client is currently asymptomatic, a platelet count of 3,000 mm2 puts him at risk for spontaneous hemorrhage, the most immediate and serious risk he faces. A WBC count of 0 clearly indicates neutropenia; the client needs an antibiotic and antifungal therapy to prevent infection. Although the client is anemic, he's currently asymptomatic. The absence of clinical manifestations makes his need for a transfusion less urgent.