Ch 34: Management of Patients with Hematologic Neoplasms

B (Graft-versus-host disease 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.)

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? A) Acute respiratory distress syndrome B) Graft-versus-host disease C) Remission D) Bone marrow depression

C, D, E (- Alcohol consumption - Exposure to water of any temperature - Temperature change Pruritus is very common, occurring in up to 70% of patients with polycythemia vera (Saini, Patnaik & Tefferi, 2010) and is one of the most distressing symptoms of this disease. It is triggered by contact with temperature change, alcohol consumption, or, more typically, exposure to water of any temperature but seems to be worse with exposure to hot water.)

A patient with polycythemia vera is complaining of severe itching. What triggers does the nurse know can cause this distressing symptom? (Select all that apply.) A) Aspirin B) Allergic reaction to the red blood cell increase C) Alcohol consumption D) Exposure to water of any temperature E) Temperature change

A (Hypercalcemia Hypercalcemia may occur when bone destruction occurs due to the disease process. Elevated serum viscosity occurs because plasma cells excrete excess immunoglobulin. RBC count will be decreased. Hyperproteinemia would not be present.)

The nurse is currently planning the care of a patient with multiple myeloma who is experiencing bone destruction. When reviewing the patient's most recent blood work, what value would the nurse pay particular attention to? A) Hypercalcemia B) Elevated red blood cell (RBC) count C) Hyperproteinemia D) Elevated serum viscosity

B (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.)

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. A) Severe thrombocytopenia B) Bone pain in the back of the ribs C) Gradual muscle paralysis D) Debilitating fatigue

D (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.)

What assessment findingbest indicates that the client has recovered from induction therapy? A) Absence of bone pain B) No evidence of edema C) Vital signs within normal ranges D) Neutrophil and platelet counts within normal limits

C (Pancytopenia 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.)

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

D (Stem cell Stem cells may differentiate into myeloid or lymphoid stem cells. A band cell is a slightly immature neutrophil. A spherocyte is a red blood cell without central pallor. A reticulocyte is a slightly immature red blood cell.)

Which term is used to refer to a primitive cell that is capable of self-replication and differentiation? A) Reticulocyte B) Spherocyte C) Band cell D) Stem cell

B (Splenomegaly. Acute myeloid leukemia starts inside the bone marrow and prevents the formation of white blood cells. A bone marrow analysis that shows greater than 30% of immature blast cells is indicative of an AML diagnosis.)

Clinical assessment of a patient with AML includes observing for signs of infection, the major cause of death for AML. The nurse should assess for indicators of: A) Thrombocytopenia. B) Splenomegaly. C) Bone marrow expansion. D) Neutropenia.

B (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.)

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 enlarged lymph nodes in the neck. C) The client with painful lymph nodes in the groin. D) The client with a painful sore throat.

A (Safety)

The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing diagnosis to help prevent fractures in this client? A) Safety B) Adequate nutrition C) Adequate hydration D) Increased mobility

A, D (Administer prescribed docusate (Colace) daily. Assess for mental state changes. 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.)

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? Select all answers that apply. A) Administer prescribed docusate (Colace) daily. B) Recommend taking ibuprofen for mild aches and pains. C) Apply pressure to venipuncture sites for 1 to 2 minutes. D) Assess for mental state changes. E) Discuss the withholding of oral contraceptives.

A (Reduced urine output Acute hypovolemic anemia from severe blood loss is evidenced by the signs and symptoms of hypovolemic shock, which include reduced urine output. The symptoms of chronic hypovolemic anemia include fatigue and postural hypotension. Clients with malabsorption disorders are at great risk of iron deficiency anemia.)

The client was admitted to the Emergency Department after an accident with a chain saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would the nurse assess for? A) Reduced urine output B) Malabsorption disorders C) Fatigue D) Postural hypotension

A (Applying standard precautions conscientiously to reduce the patient's risk of infection Treatment for NHL creates a significant risk of infection, a threat that must be minimized when planning and implementing nursing care. This is a priority over ADLs in the short term. The patient does not have a significantly increased risk of skin breakdown or constipation, although the nurse would assess for each problem.)

A 50-year-old woman was recently diagnosed with non-Hodgkin's lymphoma (NHL) and has begun a treatment regimen that includes simultaneous radiation therapy and chemotherapy. The combination of severe symptoms and aggressive therapy has necessitated admission to the hospital. When providing care for this patient, which of the following actions should the nurse implement? A) Applying standard precautions conscientiously to reduce the patient's risk of infection B) Monitoring the patient's bowel pattern and facilitating a high-fiber diet C) Encouraging frequent mobilization and independence in activities of daily living D) Providing meticulous skin care and turning the patient at least once every 2 hours

B (Lifestyle modifications and techniques for preventing thromboembolism The increased blood volume and viscosity that are the hallmarks of PV create a significant risk of thromboembolism. A vascular access device is not necessary for the treatment of PV, and a low-iron diet does not resolve the disease. Patients may experience fatigue, but this risk is superseded by that of thromboembolism.)

A 63-year-old woman has been diagnosed with polycythemia vera (PV) after undergoing a series of diagnostic tests. When the woman's nurse is providing health education, what subject should the nurse prioritize? A) Maintenance of long-term vascular access device B) Lifestyle modifications and techniques for preventing thromboembolism C) Strategies for managing activity D) Nutritional modifications necessary for maintaining a low-iron diet

D ("Do you ever take aspirin to treat the pain of your arthritis?" An important functional platelet disorder is that induced by aspirin. Even small amounts of aspirin reduce normal platelet aggregation, and the prolonged bleeding time lasts for several days after aspirin ingestion. Diuretics, hypertension, and family history are not central parameters in the assessment of a bleeding disorder.)

A 71-year-old woman with a history of rheumatoid arthritis and chronic heart failure has been admitted to the hospital for the treatment of a suspected upper gastrointestinal bleed. When performing an assessment of this patient, which of the following questions most directly addresses a likely cause of the woman's bleeding disorder? A) "Did either of your parents or siblings have problems with bleeding?" B) "How closely do you tend to monitor your blood pressure when you're at home?" C) "Has your doctor prescribed a water pill for your heart failure?" D) "Do you ever take aspirin to treat the pain of your arthritis?"

C (Bence Jones protein in the urine Presence of Bence Jones protein in the urine almost always confirms multiple myeloma; however, the 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 client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include: A) Serum calcium level of 7.5 mg/dl B) Serum creatinine level 0.5 mg/dl C) Bence Jones protein in the urine D) Serum protein level 5.8 g/dl

Assess for signs of injury. A client with hypothesia 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.

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

A (Multiple myeloma 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.)

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) Multiple myeloma B) Leukemia C) Hemolytic anemia D) Polycythemia vera

D (Evaluate the client's platelet count. 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.)

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) Keep the client on bed rest. C) Evaluate the client's INR. D) Evaluate the client's platelet count.

A (Assess the client's hemoglobin and platelets. 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.)

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

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

A ("I do not understand why this happened to me." The statement "I do not understand why this happened to me" indicates that the client is not accepting of the consequences of his health problems and impending death. The other statements indicate the client has plans that would result in spiritual well-being or harmony.)

A client with leukemia is being discharged from the hospital to hospice care. Which statement by the client indicates the client has not achieved the goal for the nursing diagnosis Spiritual Distress? A) "I do not understand why this happened to me." B) "I know I am going to die. I want to say good-bye to my family." C) "I am going to call my clergy to pray with me." D) "I have resources within myself that I can depend on."

C, E, F (- Increased blood urea nitrogen (BUN) and creatinine - Dyspnea and hypoxia - Cyanosis in the extremities Urine output would be decreased in DIC, and capillary fill time would be more than 3 seconds; breath sounds would be decreased. Refer to Table 20-4 in the text.)

A nurse assesses a patient who has been diagnosed with DIC. Which of the following indicators are consistent with this diagnosis? Select all that apply. A) Capillary fill time <3 seconds B) Increased breath sounds C) Cyanosis in the extremities D) Polyuria E) Increased blood urea nitrogen (BUN) and creatinine F) Dyspnea and hypoxia

D ("I will be in the hospital for several weeks." 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.)

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 know I can never be cured." D) "I will be in the hospital for several weeks."

C (Lymphocyte 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.)

Which term refers to a form of white blood cell involved in immune response? A) Spherocyte B) Thrombocyte C) Lymphocyte D) Granulocyte

A (Platelet count of 9,000/mm3 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.)

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) Platelet count of 9,000/mm3 B) WBC count of 4,200 cells/mcL C) Hematocrit of 38% D) Creatinine level of 1.0 mg/dL

B (Coagulopathies are bleeding disorders that involve platelets or clotting factors. Coagulopathies are bleeding disorders that involve platelets or clotting factors. Coagulopathies do not involve the numbers and types of red blood cells. They are not characterized by a deficiency of globulins in the plasma and they do not involve the destruction of stem cells in the bone marrow.)

The nursing instructor is talking with their clinical group about coagulopathies. How should the instructor define coagulopathies? A) Coagulopathies are bleeding disorders that are characterized by a deficiency of globulins in the plasma. B) Coagulopathies are bleeding disorders that involve platelets or clotting factors. C) Coagulopathies are bleeding disorders that are characterized by abnormalities in the numbers and types of red blood cells in the body. D) Coagulopathies are bleeding disorders that involve the destruction of stem cells in the bone marrow.

B (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.)

Which nursing intervention is most appropriate for a client with multiple myeloma? A) Restricting fluid intake B) Preventing bone injury C) Monitoring respiratory status D) Balancing rest and activity

A (Apply prolonged pressure to needle sites or other sources of external bleeding. For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.)

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia? A) Apply prolonged pressure to needle sites or other sources of external bleeding. B) Monitor temperature at least once per shift. C) Eliminate direct contact with others who are infectious. D) Implement neutropenic precautions.

C (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).)

Which of the following is the only curative treatment for chronic myeloid leukemia (CML)? A) Idarubicin B) Cytarabine C) Allogeneic stem cell transplant D) Imatinib

D (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.)

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) Administer pain medication. C) Place the client in reverse isolation. D) Maintain nutrition.

A, C, E (- Assess skin and mucus membranes every shift. - Encourage the client to take deep breaths every 4 hours while awake. - Auscultate lung sounds every shift and prn.)

A nurse has established for a client the nursing diagnosis of risk for infection. Which of the following interventions would the nurse include in the plan of care for this client? Select all answers that apply. A) Assess skin and mucus membranes every shift. B) Provide oral hygiene once daily. C) Encourage the client to take deep breaths every 4 hours while awake. D) Place fresh flowers on a shelf on the opposite wall from the client. E) Auscultate lung sounds every shift and prn.

B (Pathologic bone fractures. 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.)

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) Hypoxemia. B) Pathologic bone fractures. C) Chronic liver failure. D) Acute heart failure.

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

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

D (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.)

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) Standard therapy B) Supportive therapy C) Antimicrobial therapy D) Induction therapy

A (Platelet destruction and impaired platelet production resulting from an autoimmune process Although the precise cause of ITP remains unknown, the platelet count is decreased by a combination of autoantibody-mediated platelet destruction and impaired platelet production secondary to autoantibody effects on the megakaryocyte. Viruses, impaired liver function, and inappropriate platelet aggregation are not dimensions of the etiology of ITP.)

A patient with a diagnosis of immune thrombocytopenic purpura (ITP) is currently receiving IVIG for the treatment of her health condition. The nurse who is providing this patient's care is aware that ITP is a consequence of: A) Platelet destruction and impaired platelet production resulting from an autoimmune process B) Impaired liver function and the sequestering of platelets by hepatocytes C) Hemolysis of platelets in individuals who lack immunity to the Epstein-Barr virus D) Inappropriate platelet aggregation on the walls of the great vessels

B (Trauma and microabrasions may contribute to anemia. In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.)

The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. Why? A) The client is at risk for spontaneous and uncontrolled bleeding. B) Trauma and microabrasions may contribute to anemia. C) Fragile tissues and altered clotting mechanisms may result in hemorrhage. D) The client is at risk for infection from microorganisms.

B, D, E (- Suggest support for household maintenance. - Educate the family about medications and side effects. - Allow family members to express feelings.)

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

C (Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing. Neutropenia occurs when the absolute neutrophil count falls below 1,000/mm3, reflecting a severe risk of infection. The nurse should provide a low-bacterial diet, which means eliminating fresh fruits and vegetables, avoiding invasive procedures such as enemas, and practicing frequent hand washing. Using a soft toothbrush, avoiding straight-edged razors and enemas, and monitoring for bleeding are precautions for clients with thrombocytopenia. Putting on a mask, gown, and gloves when entering the client's room are reverse isolation measures. A neutropenic client doesn't need a clear liquid diet or sodium restrictions.)

Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia? A) Provide a clear liquid, low-sodium diet. B) Put on a mask, gown, and gloves when entering the client's room. C) Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing. D) Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for signs of bleeding.

D (Absorption of iron will decrease. When a client takes the drug with coffee, tea, eggs, or milk, absorption of oral iron decreases. The use of meperidine or Demerol when treating pain in clients with sickle cell crisis may result in grand mal seizures. Antacids, tetracyclines, and vitamin C interact with oral iron.)

Your client has just been prescribed oral iron. Why would you advise this client to avoid taking their medication with coffee, tea, eggs, or milk? A) Untoward reactions may occur. B) Coffee, tea, eggs, and milk interact with oral iron. C) Grand mal seizures may result. D) Absorption of iron will decrease.