PrepU Management of Patients with Hematologic Neoplasms

Fill in the Blank: 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. The nurse anticipates that the client has developed ___ and that the laboratory results will reveal ___.

First blank: hemorrhage Second blank: thrombocytopenia

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? a. Pathologic fractures b. Osteoporosis c. Calcified bones d. Increased mobility

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

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? a. Polycythemia vera b. Sickle cell disease c. Aplastic anemia d. Pernicious anemia

a; 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. The other options do not have the characteristics of erythrocytosis.

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? a. Acute pain b. Risk for falls c. Impaired tissue integrity d. Sensory-perception disturbance

b; 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.

The nurse is teaching a client about the development of leukemia. What statement should be included in the teaching plan? a. "Acute leukemia develops slowly." b. "Chronic leukemia develops slowly." c. "In chronic leukemia, the minority of leukocytes are mature." d. "In acute leukemia there are not many undifferentiated cells."

b; Chronic leukemia develops slowly, and the majority of leukocytes produced are mature. Acute leukemia develops quickly and the majority of leukocytes are undifferentiated cells.

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). a. Hypercalcemia b. Renal insufficiency c. Anemia d. Bone lesions e. Acidosis

a, b, c, d; The acronym CRAB is used to describe the combined pathologic effects of multiple myeloma and include: calcium levels elevated (hypercalcemia), renal insufficiency, anemia, bone lesions. Acidosis is not part of the acronym used to describe the pathologic effects of the disease.

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? a. Increase mobility. b. Provide adequate hydration. c. Promote safety. d. Encourage adequate nutrition.

c; 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.

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? a. Monitor the client's temperature every shift. b. Maintain contact precautions. c. Encourage increased fluid consumption. d. Practice vigilant handwashing.

d; 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.

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? a. Chronic myeloid leukemia b. Multiple myeloma c. Hodgkin lymphoma d. Non-Hodgkin lymphoma

b; 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.

Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)? a. A 24-year-old female taking oral contraceptives b. A 40-year-old patient with a history of hypertension c. A 52-year-old patient with acute kidney injury d. A 72-year-old patient with a history of cancer

d; 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 patient with polycythemia vera has a high red blood cell (RBC) count and is at risk for the development of thrombosis. What treatment is important to reduce blood viscosity and to deplete the patient's iron stores? a. Blood transfusions b. Radiation c. Chelation therapy d. Phlebotomy

d; The objective of management is to reduce the high BC count and reduce the risk of thrombosis. Phlebotomy is an important part of therapy (Fig. 34-5). It involves removing enough blood (initially 500 mL once or twice weekly) to reduce blood viscosity and to deplete the patient's iron stores, thereby rendering the patient iron deficient and consequently unable to continue to manufacture hemoglobin excessively.

A client is newly diagnosed with Hodgkin lymphoma. The nurse understands that the client's treatment will be based on what concept? a. Histology of tissue b. Staging of disease c. Involvement of lymph nodes d. Total blood cell count

b; 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.

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? a. Increased basophils b. Reed-Sternberg cells c. Elevated platelet count d. Misshaped red blood cells

b; 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 with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever? a. Pancytopenia b. Thrombocytopenia c. Anemia d. Neutropenia

d; 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 petechia and bruising in AML.

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

d; 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 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? a. polycythemia vera b. sickle cell disease c. aplastic anemia d. pernicious anemia

a; 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.

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

a; 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.

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? a. Axillary b. Cervical c. Inguinal d. Popliteal

b; Non painful swelling of the cervical lymph nodes is the earliest symptom of Hodgkin lymphoma.

The nurse is caring for a client at high risk for thrombocythemia. Which treatments will the nurse anticipate being prescribed for this client? (Select all that apply). a. Aspirin b. Anagrelide c. Hydroxyurea d. Diphenhydramine e. Interferon-alfa

a, b, c, e; Treatment for essential thrombocythemia is based upon a client's risk stratification. A patient is deemed high risk when there is a history of thrombosis at any age, or is age 60 or older, or has the JAK2 mutation. Besides the use of aspirin, treatment may also include anagrelide, hydroxyurea, or interferon alfa, all of which are effective in decreasing platelet counts to a level below 400,000/mm3 (400,000 ×10°/L) and reduce the risk of developing arterial thrombosis and hemorrhage. Antihistamines (diphenhydramine) are not used for active thrombosis and ineffective for treating pruritis.

A client receiving treatment for leukemia is experiencing stomatitis. Which interventions will the nurse implement to improve the client's nutritional status? (Select all that apply). a. Encourage small frequent meals. b. Suggest foods that are soft in texture. c. Provide foods that are hot in temperature. d. Administer pain medication before meals. e. Provide mouth care before and after meals.

a, b, d, e; In leukemia, nutritional intake is often reduced because of pain and discomfort from stomatitis. Actions to improve the client's nutritional intake include small, frequent meals that are soft in texture and moderate in temperature. Hot foods can be irritating to the stomach. Pain medication should be provided before meals to reduce discomfort. Mouth care should be provided before and after meals to help improve oral intake.

The nurse is teaching the client about consolidation. What statement should be included in the teaching plan? a. "Consolidation therapy is administered to reduce the chance of leukemia recurrence." b. "Consolidation occurs as a side effect of chemotherapy." c. "Consolidation of the lungs is an expected effect of induction therapy." d. "Consolidation is the term used when a client does not tolerate chemotherapy."

a; 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.

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? a. Creatinine and blood urea nitrogen (BUN) levels b. Iron levels c. Magnesium levels d. Potassium levels

b; 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 diagnosed with multiple myeloma (MM) is prescribed long-term corticosteroid therapy. Which assessments will the nurse prioritize to monitor for possible complications? (Select all that apply). a. Glucose levels b. Sleeping patterns c. Vision problems d. Hair growth disorders e. Skin disorders

a, b, c; Many clients with MM are treated with high doses of corticosteroids for protracted periods of time. Clients must be monitored for potential short- and long-term effects of steroids, including hyperglycemia and insomnia (short term), and osteopenia, osteoporosis, cataracts, and diabetes (long term). Neither skin disorders nor hair-growth-pattern disorders are generally associated with corticosteroid therapy.

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? a. Have the client maintain complete bedrest. b. Assist the client to sit in a chair for meals. c. Talk to the family about not visiting so the client can obtain rest. d. Provide sedentary activities only, such as watching television.

b; Fatigue is a common symptom with clients who have leukemia. Despite the fatigue, clients still need to maintain some physical activity. An example of physical activity is having the client sit in a chair for meals. The nurse does not want to encourage complete bedrest or sedentary activities, such as watching television, due to possible deconditioning. The nurse has not discussed with the client about limiting family visits. The client may want some family to visit.

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

c; 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.

The nurse is caring for a patient with Hodgkin lymphoma in the hospital and preparing discharge planning education. Knowing that this patient is at risk for the development of a second malignancy, what education would be beneficial to reduce the risk factors? (Select all that apply). a. Reduce exposure to excessive sunlight b. Smoking cessation c. Decrease alcohol intake d. Decrease intake of antipyretic medications such as acetaminophen e. Decrease fat intake

a, b, c; The potential development of a second malignancy should be addressed with the patient when initial treatment decisions are made. However, patients should also be told that Hodgkin lymphoma is often curable. The nurse should encourage patients to reduce other factors that increase the risk of developing second cancers, such as use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight.

A client with myelofibrosis is experiencing extreme fatigue. Which suggestions will the nurse recommend to this client? (Select all that apply). a. Use adaptive equipment as needed b. Take a walk c. Set activity priorities d. Increase bedrest e. Postpone nonessential activities

a, b, d, e; Fatigue is a major symptom in clients with myelofibrosis. Actions to reduce the fatigue focus on energy conservation activities to include exercise, taking a walk, setting activity priorities, and postponing non-essential activities. Increased bedrest is not a strategy to reduce the fatigue caused by this condition.

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? a. Hypercalcemia b. Hyperkalemia c. Hypernatremia d. Hypermagnesemia

a; Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

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? a. Induction therapy b. Supportive therapy c. Antimicrobial therapy d. Standard therapy

a; 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.

The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm. The client is receiving prednisone and azathioprine. What action will the nurse take? a. Use contact precautions with this client. b. Perform a neurologic assessment with vital signs. c. Request a prescription of diphenoxylate and atropine for loose stools. d. Teach the client to vigorously floss the teeth to prevent infections.

b; With platelets less than 10,000/mm™ 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.

A nurse is assessing a client with multiple myeloma. Due to this condition, what will this client be at risk for? a. Chronic liver failure. b. Acute heart failure. c. Pathologic bone fractures. d. Hypoxemia.

c; Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Also, clients are at risk for renal failure secondary to myeloma proteins by causing renal tubular obstruction. Liver failure and heart failure aren't usually sequelae of multiple myeloma. Hypoxemia isn't usually related to multiple myeloma.

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? a. WBC count of 4,200 cells/uL b. Hematocrit of 38% c. Platelet count of 9,000/mm3 d. Creatinine level of 1.0 mg/dL

c; 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.

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

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

b; 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 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? a. Allopurinol b. Filgrastim c. Hydroxyurea d. Asparaginase

a; 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.

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

a; 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.

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? a. The dead red blood cells release excess uric acid. b. The dead red blood cells occlude the small vessels in the joints. c. Excess red blood cells produce extracellular toxins that build up. d. Excess red blood cells cause vascular injury in the joints.

a; 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 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? a. Debilitating fatigue b. Bone pain in the back or the ribs c. Gradual muscle paralysis d. Severe thrombocytopenia

b; 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 client who is being treated for AML has bruises on both legs. What is the nurse's most appropriate action? a. Ask the client whether they have recently fallen. b. Evaluate the client's INR. c. Keep the client on bed rest. d. Evaluate the client's platelet count.

b; 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/mm?. 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.

The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? a. Osteopathic tumors destroy bone causing fractures. b. Osteoclasts break down bone cells so pathologic fractures occur. c. Osteolytic activating factor weakens bones producing fractures. d. Osteosarcomas form producing pathologic fractures.

b; 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.

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

c; 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.

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

a, b, c; 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.