Hematological: Lymphoma

The 33-year-old client diagnosed with Stage IV Hodgkin's lymphoma is at the five (5)-year remission mark. Which information should the nurse teach the client? 1. Instruct the client to continue scheduled screenings for cancer. 2. Discuss the need for follow-up appointments every five (5) years. 3. Teach the client that the cancer risk is the same as for the general population. 4. Have the client talk with the family about funeral arrangements.

1. Instruct the client to continue scheduled screenings for cancer. Rationale: The five (5)-year mark is a time for celebration for clients diagnosed with cancer, but the therapies can cause secondary malignancies and there may be a genetic predisposition for the client to develop cancer. The client should continue to be tested regularly. Why it's not the rest: Follow-up appointments should be at least yearly. The client's risk for developing cancer has increased as a result of the therapies undergone for the lymphoma. This client is in remission, and death is not imminent.

The nurse is admitting a client with a diagnosis of rule-out Hodgkin's lymphoma. Which assessment data support this diagnosis? 1. Night sweats and fever without "chills." 2. Edematous lymph nodes in the groin. 3. Malaise and complaints of an upset stomach. 4. Pain in the neck area after a fatty tumor.

1. Night sweats and fever without "chills." Rationale: Client's with Hodgkin's disease experience drenching diaphoresis, especially at night; fever without chills; and unintentional weight loss. Early stage disease is indicated by a painless enlargement of a lymph node on one side of the neck (cervical area). Pruritis is also a common symptom. Why it's not the rest: Lymph node enlargement with Hodgkin's disease is in the neck area, not the groin. Malaise and stomach complaints are not symptoms of Hodgkin's. Pain in the neck area at the site of the cancer occurs in some clients after the ingestion of alcohol, but the cause for this is unknown.

The female client recently diagnosed with Hodgkin's lymphoma asks the nurse about her prognosis. Which is the nurse's best response? 1. Survival for Hodgkin's disease is relatively good with standard therapy. 2. Survival depends on becoming involved in an investigational therapy program. 3. Survival is poor, with more than 50% of clients dying within six (6) months. 4. Survival is fine for primary Hodgkin's, but secondary cancers occur within a year.

1. Survival for Hodgkin's disease is relatively good with standard therapy. Rationale: Up to 90% of clients respond well to standard treatment with chemotherapy and radiation therapy, and those who relapse usually respond to a change of chemotherapy medications. Survival depends on the individual client and the stage of disease at diagnosis. Why it's not the rest: Investigational therapy regimens would not be recommended for clients initially diagnosed with Hodgkin's disease because of the expected prognosis with standard therapy. Clients usually achieve a significantly longer survival rate than six (6) months; many clients survive to develop long-term secondary complications. Secondary cancers can occur as long as 20 years after a remission of the Hodgkin's disease has occurred.

The nurse and the UAP are caring for clients in a bone marrow transplantation unit. Which nursing task should the nurse delegate? 1. Take the hourly vital signs on a client. 2. Monitor the infusion of antineoplastic medications. 3. Transcribe the HCP's orders onto the MAR. 4. Determine the client's response to the therapy.

1. Take the hourly vital signs on a client. Rationale: After the first 15 minutes during which the client tolerates the blood transfusion, it is appropriate to ask the UAP to take the vital signs as long as the UAP has been given specific parameters for the vital signs. Any vital sign outside the normal parameters must have an intervention by the nurse. Why it's not the rest: Antineoplastic medication infusions must be monitored by a chemotherapy-certified, competent nurse. Transcribing is the responsibility of the ward secretary or the nurse, not the UAP. Determining the client's response represents the evaluation portion of the nursing process and cannot be delegated.

The client diagnosed with non-Hodgkin's lymphoma is scheduled for a lymphangiogram. Which information should the nurse teach? 1. The scan will identify any malignancy in the vascular system. 2. Radioopaque dye will be injected between the toes. 3. The test will be done similar to a cardiac angiogram. 4. The test will be completed in about five (5) minutes.

2. Radioopaque dye will be injected between the toes. Rationale: Dye is injected between the toes of both feet and then scans are performed in a few hours, at 24 hours, and then possibly once a day for several days. Why it's not the rest: The scan detects abnormalities in the lymphatic system, not the vascular system. Cardiac angiograms are performed through the femoral or brachial arteries and are completed in one session. The test takes 30 minutes to one (1) hour and then is repeated in intervals.

Which information about reproduction should be taught to the 27-year-old female diagnosed with Hodgkin's disease? 1. The client's reproductive ability will be the same after treatment is completed. 2. The client should practice birth control for at least two (2) years following therapy. 3. All clients become sterile from the therapy and should plan to adopt. 4. The therapy will temporarily interfere with the client's menstrual cycle.

2. The client should practice birth control for at least two (2) years following therapy. Rationale: The client should be taught to practice birth control during treatment and for at least two (2) years after treatment has ceased. The therapies used to treat the cancer can cause cancer. Antineoplastic medications are carcinogenic, and radiation therapy has proved to be a precursor to leukemia. A developing fetus would be subjected to the internal conditions of the mother. Why it's not the rest: Option 1 is a false promise; many clients undergo premature menopause as a result of the cancer therapy. Some clients-but not all-do become sterile; the client must understand the risks of therapy, but the nurse should give a realistic picture of what the client can expect; it is correct procedure to tell the client the nurse does not know the absolute outcome of therapy; this is the ethical principle of veracity. The therapy may interfere with the client's menses, but it may be temporary.

Which clinical manifestation of Stage I non-Hodgkin's lymphoma would the nurse expect to find when assessing the client? 1. Enlarged lymph tissue anywhere in the body. 2. Tender left upper quadrant. 3. No symptom at this stage. 4. Elevated B-cell lymphocytes on the CBC.

3. No symptom at this stage. Rationale: Stage I lymphoma presents with no symptoms; for this reason, clients are usually not diagnosed until the later stages of lymphoma. Why it's not the rest: Enlarged lymph tissue would occur in Stage III or IV Hodgkin's lymphoma. A tender left upper quadrant would indicate spleen infiltration and occurs at a later stage. B-cell lymphocytes are the usual lymphocytes involved in the development of lymphoma, but a serum blood test must be done specifically to detect B cells; they are not tested on a CBC.

Which client is at the highest risk for developing a lymphoma? 1. The client diagnosed with chronic lung disease who is taking a steroid. 2. The client diagnosed with breast cancer who has extensive lymph involvement. 3. The client who received a kidney transplant several years ago. 4. The client who has had ureteral stent placements for a neurogenic bladder.

3. The client who received a kidney transplant several years ago. Rationale: Clients who have received a transplant must take immunosuppressive medications to prevent rejection of the organ. This immunosuppression blocks the immune system from protecting the body against cancers and other diseases. There is a high incidence of lymphoma among transplant recipients. Why it's not the rest: Long-term steroid use suppresses the immune system and has many side effects, but is not the highest risk. The client with breast cancer would be considered late-stage; cancers are described by the original cancerous tissue, and this cancer has metastasized to the lymph system. A neurogenic bladder is a benign disease; stent placement would not put the client at risk for cancer.

Which test is considered diagnostic for Hodgkin's lymphoma? 1. A magnetic resonance image (MRI) of the chest. 2. A computed tomography (CT) scan of the cervical area. 3. An erythrocyte sedimentation rate (ESR). 4. A biopsy of the cervical lymph nodes.

4. A biopsy of the cervical lymph nodes. Rationale: Cancers of are definitively diagnosed through biopsy procedures. The pathologist must identify Reed-Sternberg cells for a diagnosis of Hodgkin's disease. Why it's not the rest: An MRI of the chest area will determine numerous disease entities, but it cannot determine the specific morphology of Reed-Sternberg cells. A CT scan will show tumor masses in the area, but are not capable of a pathological diagnosis. ESR laboratory tests are sometimes used to monitor the progress of the treatment of Hodgkin's, but ESR levels can be elevated in several disease processes.

The nurse writes the problem "grieving" for a client diagnosed with non-Hodgkin's lymphoma. Which collaborative intervention should be included in the plan of care? 1. Encourage the client to talk about their feelings of loss. 2. Arrange for the family to plan a memorable outing. 3. Refer the client to the American Cancer Society's Dialogue Group. 4. Have the chaplain visit with the client.

4. Have the chaplain visit with the client. Rationale: Collaborative interventions involve other departments of the health-care facility. A chaplain is a referral that can be made, and the two disciplines should work together to provide the needed interventions. Why it's not the rest: Encouraging the client to talk about his or her feelings is an independent nursing intervention. Discussing activities that will make pleasant memories and planning a family outing improve the client's quality of life and assist the family in the grieving process after the client dies, but is an independent nursing intervention. Nurses can and do refer clients diagnosed with cancer to the American Cancer Society-sponsored groups independently; dialogue is a group support meeting that focuses on dealing with feelings associated with a cancer diagnosis.

The client asks the nurse, "They say I have cancer. How can they tell if I have Hodgkin's disease from a biopsy?" The nurse's answer is based on which scientific rationale? 1. Biopsies are nuclear medicine scans that can detect cancer. 2. A biopsy is a laboratory test that detects cancer cells. 3. It determines which kind of cancer the client has. 4. The HCP takes a small piece out of the tumor and looks at the cells.

4. The HCP takes a small piece out of the tumor and looks at the cells. Rationale: A biopsy is the removal of cells from a mass and examination of the tissue under a microscope to determine if the cells are cancerous. Reed-Sternberg cells are diagnostic for Hodgkin's disease. If these cells are not found in the biopsy, the HCP can rebiopsy to make sure the specimen provided the needed sample or, depending on involvement of the tissue, diagnose a non-Hodgkin's lymphoma. Why it's not the rest: Biopsies are surgical procedures requiring needle aspiration or excision of the area; they are not nuclear medicine scans. The biopsy specimen is sent to the pathology lab for the pathologist to determine the type of cell; "laboratory test" refers to tests of body fluids performed by a laboratory technician. A biopsy is used to determine if the client has cancer, and if so, what kind, but does not answer the client's question.

Which client should be assigned to the experienced medical-surgical nurse who is in the first week of orientation to the oncology floor? 1. The client diagnosed with non-Hodgkin's lymphoma who is having daily radiation treatments. 2. The client diagnosed with Hodgkin's disease who is receiving combination chemotherapy. 3. The client diagnosed with leukemia who has petechiae covering both anterior and posterior body surfaces. 4. The client diagnosed with diffuse histolytic lymphoma who is to receive two (2) units packed red blood cells.

4. The client diagnosed with diffuse histolytic lymphoma who is to receive two (2) units packed red blood cells. Rationale: This client is receiving blood. The nurse with experience on a medical-surgical floor should be able to administer blood and blood products. Why it's not the rest: Client 1 is receiving treatments that can have life-threatening side effects; the med/surg nurse is not experienced with this type of client. Chemotherapy is administered only by nurses who have received training in chemotherapy medications and their effects on the body and are aware of necessary safety precautions. Client 3 has expected symptoms of leukemia, which indicates a severely low platelet count; this is requires more experience.