Unit 6 Study

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. Which of the following is the most common complication of the pathology resulting from this process? a) Osteoporosis b) Calcified bones c) Pathologic fractures d) All of the options are correct.

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

What happens when you have increased blood calcium levels

Pathological bone fractures

What happens to a pt if they are not treated for vitamin B12 deficiency?

Pernicious anemia can result, which is a type of megaloblastic anemia

How does nitric oxide reduce sickling

Reduces sickling by promoting the binding of oxygen to hemoglobin

What kind of clients need Epogen?

Renal patients

A patient with suspected multiple myeloma is complaining of pain in the back. What is the priority nursing action? a) Send the patient for x-ray study of the spine. b) Have the patient lie on a hard surface. c) Have the patient rest. d) Encourage ambulation.

Send the patient for x-ray study of the spine. Explanation: The patient 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 patient does not have a fracture of the spine, as the bone destruction in this disease is sufficiently severe to cause vertebral collapse.

A client with multiple myeloma presents to the emergency department complaining of excessive thirst and constipation. His family members report that he has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms? a) Serum calcium level 13.8 mg/dl b) Serum sodium level of 133 mEq/L c) Hemoglobin of 9.8 g/dl d) Platelet count 300,000/mm3

Serum calcium level 13.8 mg/d Explanation: Excessive thirst, constipation, dehydration, confusion, and altered mental state are possible signs of hypercalcemia. Hypercalcemia is common in multiple myeloma because of the increased bone destruction. A platelet count of 300,000/mm3 is normal and wouldn't cause the client's symptoms. A sodium level of 133 mEq/L is slightly decreased but wouldn't cause confusion and excessive thirst. A hemoglobin of 9.8 g/dl level is slightly low but isn't likely responsible for the client's symptoms.

Extreme microcytosis

Smaller-than-normal erythrocytes

Complications that may occur to a patient with low platelet count

Spontaneous hemorrhaging can occur, neutropenia (low WBC)

What is important to give to pt with ITP to avoid straining?

Stool softeners

Nitric oxide classification

Vasodilator

A 50-year-old client is reporting that the client's oral B12 is not working. The nurse knows that the vitamin may have a decreased absorption rate when taken with other substances. The nurse would begin the history by asking which questions? (Select all that apply.)

"Do you use neomycin?" "Do you drink alcohol?" "Do you take colchicine?" Rationale: Alcohol, neomycin, and colchicine may decrease the absorption level of oral vitamin B12. Constipation would not affect the absorption level of oral vitamin B12.

A female client with the beta-thalassemia trait plans to marry a man of Italian ancestry who also has the trait. Which client statement indicates that she understands the teaching provided by the nurse? a) "If my fiancé was of Middle Eastern descent, I wouldn't be worried about having children." b) "I need to learn how to give myself vitamin B12 injections." c) "Thalassemia is treated with iron supplements." d) "I'll see a genetic counselor before starting a family."

"I'll see a genetic counselor before starting a family." Explanation: Two people with the beta-thalassemia trait have a 25% chance of having a child with thalassemia major, a potentially life-threatening disease. Iron supplements aren't used to treat thalassemia; in fact, they could contribute to iron overload. Vitamin B12 injections are used to treat pernicious anemia, not thalassemia. Thalassemia occurs primarily in people of Italian, Greek, African, Asian, Middle Eastern, East Indian, and Caribbean descent.

Defect in the lymphoid stem cells can cause problems with

- T or B lymphocytes - plasma cells (a more differentiated form of B lymphocyte) - or natural killer (NK) cells

Hepatitis A incubation period

15-50 days with average 28 days

A patient has been diagnosed with a lymphoid stem cell defect. This patient has the potential for a problem involving which of the following? A) Plasma cells B) Neutrophils C) Red blood cells D) Platelets

A (Feedback: A defect in a myeloid stem cell can cause problems with erythrocyte, leukocyte, and platelet production. In contrast, a defect in the lymphoid stem cell can cause problems with T or B lymphocytes, plasma cells (a more differentiated form of B lymphocyte), or natural killer (NK) cells.)

Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply. A) Leukocytes B) Natural killer cells C) Cytokines D) Platelets E) Erythrocytes

A, D, E (Feedback: Myeloid stem cells differentiate into three broad cell types: erythrocytes, leukocytes, and platelets. Natural killer cells and cytokines do not originate as myeloid stem cells.)

Hypochromia

Abnormal decrease in the hemoglobin content of erythrocytes

Megaloblasts

Abnormally large, immature, and dysfunctional RBCs

Important teachings to be given to a pt with idiopathic thrombocytopenia purpura (ITP)?

Avoid Valsalva maneuver

Education for pt with CABG procedure

Avoid Valsalva maneuver, hold pillow on chest so they don't strain when they cough and deep breathe

CH. 33 A patient is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications? A) Folic acid B) Vitamin B12 C) Lactulose D) Magnesium sulfate

B Feedback: Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic acid do not address the pathology of this type of anemia.

One most common cause of iron-deficiency anemia

Bleeding

What happens to calcium in multiple myeloma

Calcium is lost from the bone and reabsorbed in the serum

Osteoclasts

Cells that break down bone

Vitamin B12 and folate deficiencies are characterized by what (with the erythrocytes)

Characterized by the production of abnormally large erythrocytes

The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient? A) It is part of the required assessment information. B) It is important for the nurse to determine what type of foods the patient will eat. C) It may indicate deficiencies in essential nutrients. D) It will determine what type of anemia the patient has.

Correct response: C) It may indicate deficiencies in essential nutrients. Explanation: A nutritional assessment is important, because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folate.

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the physician. What type of anemia is the nurse concerned the co-worker may have? Iron deficiency anemia Megaloblastic anemia Sickle cell anemia Aplastic anemia

Correct response: Iron deficiency anemia Explanation: People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica.

The most common cause of iron-deficiency anemia in premenopausal women includes which of the following? Menorrhagia Inadequate iron supplementation Iron malabsorption Lack of vitamin B12

Correct response: Menorrhagia Explanation: The most common cause of iron deficiency anemia in premenopausal women is menorrhagia. In pregnancy, it may be caused by inadequate intake of iron. Iron malabsorption may occur following a gastrectomy or with celiac disease. Lack of vitamin B12 is also a potential cause of anemia.

Goal in treatment of Hodgkin lymphoma

Cure

In iron-deficiency anemia, MCV is increased or decreased?

Decreased

In patients w iron-deficiency anemia, is ferritin level increased or decreased

Decreased; low ferritin level

Pernicious anemia that has not been treated for more than 3 months can result in

Degenerative lesions of the spinal cord, can cause damage to nerves and can affect memory and thinking, can lead to pernicious anemia

What causes megaloblastic anemia

Due to impairment of DNA synthesis caused by folic acid deficiency and vitamin B12 deficiency

Hepatitis A transmission

Fecal-oral

Explain the changes of ferritin, MCV, RBC, and hematocrit levels in a pt with iron-deficiency anemia

Ferritin level: decreased MCV: decreased RBC: decreased Hematocrit: decreased

Source of vitamin B12

Found only in foods of animal origin

What are thalassemias

Group of hereditary anemias characterized by hypochromia, extreme microcytosis, hemolysis, and variable degrees of anemia

What labs to look at when giving Epogen

H&H

The nurse should check the hemoglobin prior to administration of erythropoietin, because too high a hemoglobin level can put the client at risk for

HF, MI, and CVA

Labs that would support that the client has iron-deficiency anemia

Hemoglobin and hematocrit, ferritin level

Idiopathic thrombocytopenia purpura (ITP)

Hemorrhagic disorder (autoimmune) characterized by excessive destruction of normal platelets

Thrombocytopenia

Low platelet count

Which one is a vasodilator used as an inhalant to reduce sickling: nitric oxide or nitrous oxide?

NITRIC oxide

Drugs that may decrease absorption of oral vitamin B12

Neomycin, alcohol, colchicine

Hodgkin's lymphoma is considered what

One of the most treatable cancers

A nurse is teaching a client with a vitamin B12 deficiency about appropriate food choices to increase the amount of B12 ingested with each meal. The nurse knows the teaching is effective based on which statement by the client?

"I will eat a meat source such as chicken or pork with each meal." Explanation: Vitamin B12 is found only in foods of animal origin.

Defect in the myeloid stem cells can cause problems with

- erythrocyte - leukocyte - and platelet production

A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below: a)75,000/?l. b)10,000/?l. c)20,000/?l. d)135,000/?l.

10,000/?l.

Normal platelet count

150,000-400,000 cells/mm3

Normal albumin level

3.5-5 g/dL

A patient with sickle cell anemia is to begin treatment for the disease with hydroxyurea. What does the nurse inform the patient will be the benefits of treatment with this medication? Select all that apply. A) Fewer painful episodes of sickle cell crisis B) Lower incidence of acute chest syndrome C) Decreased need for blood transfusions D) Decreased need for other analgesic medications E) Ability to reverse the damage done from sickling of cells

A) Fewer painful episodes of sickle cell crisis B) Lower incidence of acute chest syndrome D) Decreased need for blood transfusions Explanation: Hydroxyurea is a chemotherapy agent that is effective in increasing fetal hemoglobin (i.e., hemoglobin F) levels in patients with sickle cell anemia, thereby decreasing the formation of sickled cells. Patients who receive hydroxyurea appear to have fewer painful episodes of sickle cell crisis, a lower incidence of acute chest syndrome, and less need for transfusions. However, whether hydroxyurea can prevent or reverse actual organ damage remains unknown.

For a client diagnosed with idiopathic thrombocytopenia purpura (ITP), which nursing intervention is appropriate? a)Giving aspirin, as ordered, to control body temperature b)Teaching coughing and deep-breathing techniques to help prevent infection c)Administering platelets, as ordered, to maintain an adequate platelet count d)Administering stool softeners, as ordered, to prevent straining during defecation

Administering stool softeners, as ordered, to prevent straining during defecation

GI effects of taking hydroxyurea

Anorexia, N/V/D/C

The patient receiving epoetin alfa (Procrit) asks the nurse why it has to be administered IV because he read that it could be self-administered subcutaneously. What is the nurse's best response? a. giving the drug IV reduces the risk of a potentially serious response to the drug b. giving the drug by the IV route makes it begin working sooner c. only patients with renal disease can receive the drug subcutaneously d. it is all determined by physician preference and this doctor prefers the IV route

Ans: A It is now recommended that patients receive Procrit and other drugs in this classification intravenously rather than subcutaneously because this reduces the risk of antibody production that can result from severe anemia. This decision is not based on speed of onset, diagnosis, or physician preference.

The nurse is instructing the client with sickle cell disease about the use of an inhaled vasodilator that may reduce sickling. What medication is the nurse instructing the client about? A) Nitrous oxide B) Nitric oxide C) Betamethasone D) Terbutaline (Brethine)

Ans: B Feedback: Inhaled nitric oxide—not nitrous oxide (laughing gas), a vasodilating agent—is believed to reduce sickling by promoting the binding of oxygen to hemoglobin. It is being used in the form of handheld inhalers to abort or relieve pain experienced during sickle cell crises. Betamethasone is a corticosteroid, and terbutaline is not used as an inhaler.

During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding? Elevated hematocrit concentration Enlarged mean corpuscular volume (MCV) Low ferritin level concentration Elevated red blood cell (RBC) count

Ans: Low ferritin level The most consistent indicator of iron deficiency anemia is a low ferritin level, which reflects low iron stores. As the anemia progresses, the MCV, which measures the size of the erythrocytes, also decreases. Hematocrit and RBC levels are also low in relation to the hemoglobin concentration.

A client in end-stage renal disease is prescribed epoetin alfa (Epogen) and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, the nurse

Assesses the hemoglobin level Explanation: Erythropoietin with oral iron supplements can raise hematocrit levels in the client with end-stage renal disease. The nurse should check the hemoglobin prior to administration of erythropoietin, because too high a hemoglobin level can put the client at risk for heart failure, myocardial infarction, and cerebrovascular accident. Erythropoietin may be administered during dialysis treatments. The BUN will be elevated in the client with end-stage renal disease.

Common causes of iron-deficiency anemia

Bleeding ulcers in men, gastritis, IBD, GI tumors

Definitive method of diagnosis for iron deficiency anemia

Bone marrow aspiration and serum ferritin level

A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. A) Antihypertensives B) Penicillins C) Sulfa-containing medications D) Aspirin-based drugs E) NSAIDs

C, D, E Feedback: The nurse must be alert for sulfa-containing medications and others that alter platelet function (e.g., aspirin-based or other NSAIDs). Antihypertensive drugs and the penicillins do not alter platelet function.

Megaloblastic anemia

Condition in which bone marrow produces unusually large, structurally abnormal, immature red blood cells (megaloblasts)

The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client? A) Fresh frozen plasma B) Vitamin B12 C) Folate D) Iron

D) Iron Explanation: With iron deficiency, the erythrocytes produced by the marrow are small and low in hemoglobin. Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes. Fresh frozen plasma are infused due to a low platelet level, not light-colored hemoglobin.

Adverse effects of hydroxyurea

Death of cells (esp cells that are rapidly turning over, GI cells)

Pt teaching for a pt taking hydroxyurea

Hydroxyurea is a cytotoxic drug

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

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

Osteoclasts' action can result in

Hypercalcemia and pathological bone fractures

What lab values might support that the client has multiple myeloma

Hypercalcemia, increased serum creatinine, increased serum protein

A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage?

Iron chelation therapy Explanation: Iron overload is a complication unique to people who have had long-term PRBC transfusions. One unit of PRBCs contains 250 mg of iron. Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. Over time, the excess iron deposits in body tissues and can cause organ damage, particularly in the liver, heart, testes, and pancreas. Promptly initiating a program of iron chelation therapy can prevent end-organ damage from iron toxicity.

Nonhodgkins lymphoma

Is the more common type -- a malignancy in the lymphocytes and not so much of a good outcome

What does hydroxyurea do for in pts with sickle cell anemia?

It is a chemotherapy agent that is effective in increasing fetal hemoglobin (i.e., hemoglobin F) levels in patients with sickle cell anemia, thereby decreasing the formation of sickled cells.

Normal hemoglobin levels

Male: 13-18 g/100mL Female: 12-16 g/100mL

Normal hematocrit levels

Male: 42-52% Female: 37-47%

Priority for pt taking hydroxyurea

Managing GI side effects

MCV (mean corpuscular volume) measures what

Measures the size of RCBs

A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms? a) Hemolytic anemia b) Leukemia c) Multiple myeloma d) Polycythemia vera

Multiple myeloma Explanation: The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease progresses, the pain becomes more severe and localized. The pain intensifies with activity and is relieved by rest. When tumors replace bone marrow, pathologic fractures develop. Hemolytic anemia does not result in pathologic fractures nor does polycythemia vera or leukemia.

You are 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) Osteosarcomas form producing pathologic fractures. d) Osteolytic activating factor weakens bones producing 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. Options A, C, and D are distractors for this question.

Which nursing intervention is most appropriate for a client with multiple myeloma? a) Monitoring respiratory status b) Restricting fluid intake c) Balancing rest and activity d) Preventing bone injury

Preventing bone injury Explanation: 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.

Why would a pt receiving hemodialysis receive Epogen and other drugs in this classification intravenously rather than subcutaneously?

This reduces the risk of antibody production that can result from severe anemia

You are caring for a client with thalassemia who is being transfused. What your role during a transfusion? To closely monitor the rate of administration To administer vitamin B12 injections To instruct the client to rest immediately if chest pain develops To assess for enlargement and tenderness over the liver and spleen

To closely monitor the rate of administration Explanation: In a client with thalassemia, when transfusions are necessary, the nurse closely monitors the rate of administration. Assessing for enlargement and tenderness over the liver and spleen, advising rest, or administering vitamin B12 injections are not indicated for thalassemia.

What can Valsalva maneuver cause

Too much pressure can cause intracranial bleeding

T/F: thalassemias are hereditary

True

Recovery time of hepatitis A

Usually spontaneous recovery

Pernicious anemia is a type of?

Vitamin B12 deficiency / megaloblastic anemia

When can spontaneous hemorrhaging occur

When platelet count is < 10,000

A patient with chronic kidney disease is being examined by the nurse practitioner for anemia. The nurse has reviewed the laboratory data for hemoglobin and RBC count. What other test results would the nurse anticipate observing? a) Decreased total iron-binding capacity b) Decreased level of erythropoietin c) Increased reticulocyte count d) Increased mean corpuscular volume

b) Decreased level of erythropoietin Explanation: Differentiation of the primitive myeloid stem cell into an erythroblast is stimulated by erythropoietin, a hormone produced primarily by the kidney. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), or with people living at high altitudes with lower atmospheric oxygen concentrations, erythropoietin levels increase. The increased erythropoietin then stimulates the marrow to increase production of erythrocytes. The entire process of erythropoiesis typically takes 5 days (Cook, Ineck, & Lyons, 2011). For normal erythrocyte production, the bone marrow also requires iron, vitamin B12, folate, pyridoxine (vitamin B6), protein, and other factors. A deficiency of these factors during erythropoiesis can result in decreased red cell production and anemia.

A client comes into the emergency department reporting an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the client states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which problem? a) Folic acid deficiency b) Vitamin B12 deficiency c) Vitamin A deficiency d) Vitamin C deficiency

b) Vitamin B12 deficiency Explanation: Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12-intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished. The effects of either decreased absorption or decreased intake of vitamin B12 are not apparent for 2-4 years. This results in megaloblastic anemia. Some symptoms are a smooth, beefy red, enlarged tongue and cranial nerve deficiencies.

Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called A) megaloblasts. B) blast cells. C) mast cells. D) monocytes.

megaloblasts. Explanation: Megaloblasts are abnormally large erythrocytes. Blast cells are primitive WBCs. Mast cells are cells found in connective tissue involved in defense of the body and coagulation. Monocytes are large WBCs that become macrophages when they leave the circulation and move into body tissues.

A nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for: a) acute heart failure. b) hypoxemia. c) chronic liver failure. d) pathologic bone fractures.

pathologic bone fractures. Explanation: 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.