Chapter 34: Management of Patients With Hematologic Neoplasms

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

Neutropenia

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

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.

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? Hemolytic anemia Polycythemia vera Leukemia Multiple myeloma

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

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 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? Acute respiratory distress syndrome Graft-versus-host disease Remission Bone marrow depression

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.

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

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

Practice vigilant handwashing. 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 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? polycythemia vera sickle cell disease aplastic anemia pernicious anemia

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. Sickle cell disease and the anemias do not have the characteristics of erythrocytosis.

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? Debilitating fatigue Bone pain in the back of the ribs Gradual muscle paralysis Severe thrombocytopenia

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

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

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

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? Pathologic fractures Osteoporosis Calcified bones Increased mobility

Pathologic fractures

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? Allopurinol Filgrastim Hydroxyurea Asparaginase

Allopurinol 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. Clients require a high fluid intake, and prophylaxis with allopurinol (Zyloprim) to prevent crystallization of uric acid and subsequent stone formation.

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

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

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

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.

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

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.

Following bone marrow aspiration of a 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 that apply. Assess for mental state changes. Administer prescribed docusate daily. Discuss the withholding of oral contraceptives. Recommend taking ibuprofen for mild aches and pains. Apply pressure to venipuncture sites for 1 to 2 minutes.

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

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

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? Chronic myeloid leukemia Multiple myeloma Hodgkin lymphoma Non-Hodgkin lymphoma

Multiple myeloma 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.

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

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.

When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? Health history, such as bleeding, fatigue, or fainting Menstrual history Age and gender Lifestyle assessments, such as exercise routines

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

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 Supportive therapy Antimicrobial therapy Standard therapy

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

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.

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

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? Pathologic fractures Osteoporosis Calcified bones Increased mobility

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

The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take? Use contact precautions with this client. Perform a neurologic assessment with vital signs. Request a prescription of diphenoxylate and atropine for loose stools. Teach the client to vigorously floss the teeth to prevent infections.

Perform a neurologic assessment with vital signs. With platelets less than 10,000/mm³ 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.

The nurse is caring for a patient who will begin taking long-term biphosphate therapy. Why is it important for the nurse to encourage the patient to receive a thorough evaluation of dentition, including panoramic dental x-rays? The patient is at risk for tooth decay. The patient will develop gingival hyperplasia. The patient can develop osteonecrosis of the jaw. The patient can develop loosening of the teeth.

The patient can develop osteonecrosis of the jaw. Osteonecrosis of the jaw is an infrequent but serious complication that can arise in patients treated long-term with bisphosphonates; the mandible or maxilla are affected. Careful assessment for this complication should be conducted and a thorough evaluation of the patient's dentition should be performed prior to initiating bisphosphonate therapy, including panoramic dental x-rays.

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

Neutropenia 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 petechiae and bruising in AML.

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

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 48-year-old female recently diagnosed with leukemia presents with increased immature lymphocytes, decreased granulocytes, and normal erythrocytes. The client most likely has which type of leukemia? Chronic lymphocytic leukemia Acute lymphocytic leukemia Acute myelogenous leukemia Chronic myelogenous leukemia

Chronic lymphocytic leukemia

A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client? Monitoring respiratory status Balancing rest and activity Restricting fluid intake Preventing bone injury

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 fluid intake.