chapter 34 combined but only the stuff that matters

1. An oncology nurse is providing health education for a patient who has recently been diagnosed with

leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia?

A) The different leukemias all involve unregulated proliferation of white blood cells.

B) The different leukemias all have unregulated proliferation of red blood cells and decreased bone

marrow function.

C) The different leukemias all result in a decrease in the production of white blood cells.

D) The different leukemias all involve the development of cancer in the lymphatic system.

Ans: A

Feedback:

Leukemia commonly involves unregulated proliferation of white blood cells. Decreased production of red blood cells is associated with anemias. Decreased production of white blood cells is associated with leukopenia. The leukemias are not characterized by their involvement with the lymphatic system.

2. A nurse is caring for a patient who has a diagnosis of acute leukemia. What assessment most directly

addresses the most common cause of death among patients with leukemia?

A) Monitoring for infection

B) Monitoring nutritional status

C) Monitor electrolyte levels

D) Monitoring liver function

Ans: A

Feedback:

In patients with acute leukemia, death typically occurs from infection or bleeding. Compromised nutrition, electrolyte imbalances, and impaired liver function are all plausible, but none is among the most common causes of death in this patient population.

4. A nurse is planning the care of a patient who has been admitted to the medical unit with a diagnosis of

multiple myeloma. In the patients care plan, the nurse has identified a diagnosis of Risk for Injury. What pathophysiologic effect of multiple myeloma most contributes to this risk?

A) Labyrinthitis

B) Left ventricular hypertrophy

C) Decreased bone density

D) Hypercoagulation

Ans: C

Feedback:

Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Labyrinthitis is uncharacteristic, and patients do not normally experience hypercoagulation or cardiac hypertrophy.

6. A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnoses?

A) Activity Intolerance

B) Risk for Infection

C) Acute Confusion

D) Risk for Spiritual Distress

Ans: B

Feedback:

Induction therapy places the patient at risk for infection, thus this is the priority nursing diagnosis. During the time of induction therapy, the patient is very ill, with bacterial, fungal, and occasional viral infections; bleeding and severe mucositis, which causes diarrhea; and marked decline in the ability to maintain adequate nutrition. Supportive care consists of administering blood products and promptly treating infections. Immobility, confusion, and spiritual distress are possible, but infection is the patients most acute physiologic threat.

8. A 35-year-old male is admitted to the hospital complaining of severe headaches, vomiting, and testicular pain. His blood work shows reduced numbers of platelets, leukocytes, and erythrocytes, with a high proportion of immature cells. The nurse caring for this patient suspects a diagnosis of what?

A) AML

B) CML

C) MDS

D) ALL

Ans: D

Feedback:

In acute lymphocytic leukemia (ALL), manifestations of leukemic cell infiltration into other organs are more common than with other forms of leukemia, and include pain from an enlarged liver or spleen, as well as bone pain. The central nervous system is frequently a site for leukemic cells; thus, patients may exhibit headache and vomiting because of meningeal involvement. Other extranodal sites include the testes and breasts. This particular presentation is not closely associated with acute myeloid leukemia (AML), chronic myeloid leukemia (CML), or myelodysplastic syndromes (MDS).

10. A patient diagnosed with acute myelogenous leukemia has just been admitted to the oncology unit.

When writing this patients care plan, what potential complication should the nurse address?

A) Pancreatitis

B) Hemorrhage

C) Arteritis

D) Liver dysfunction

Ans: B

Feedback:

Pancreatitis, arteritis, and liver dysfunction are generally not complications of leukemia. However, the patient faces a high risk of hemorrhage.

11. An emergency department nurse is triaging a 77-year-old man who presents with uncharacteristic fatigue

as well as back and rib pain. The patient denies any recent injuries. The nurse should recognize the need for this patient to be assessed for what health problem?

A) Hodgkin disease

B) Non-Hodgkin lymphoma

C) Multiple myeloma

D) Acute thrombocythemia

Ans: C

Feedback:

Back pain, which is often a presenting symptom in multiple myeloma, should be closely investigated in older patients. The lymphomas and bleeding disorders do not typically present with the primary symptom of back pain or rib pain.

13. A nurse is caring for a patient with Hodgkin lymphoma at the oncology clinic. The nurse should be

aware of what main goal of care?

A) Cure of the disease

B) Enhancing quality of life

C) Controlling symptoms

D) Palliation

Ans: A

Feedback:

The goal in the treatment of Hodgkin lymphoma is cure. Palliation is thus not normally necessary. Quality of life and symptom control are vital, but the overarching goal is the cure the disease.

15. An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph

node. The patient denies any recent infectious diseases. What is the nurses most appropriate response to the patients complaint?

A) Call 911.

B) Promptly refer the patient for medical assessment.

C) Facilitate a radiograph of the patients neck and have the results forwarded to the patients primary

care provider.

D) Encourage the patient to track the size of the lymph node and seek care in 1 week.

Ans: B

Feedback:

Hodgkin lymphoma usually begins as an enlargement of one or more lymph nodes on one side of the neck. The individual nodes are painless and firm but not hard. Prompt medical assessment is necessary if a patient has this presentation. However, there is no acute need to call 911. Delaying care for 1 week could have serious consequences and x-rays are not among the common diagnostic tests.

17. Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult patient who

is otherwise healthy. The patient and the care team have collaborated and the patient will soon begin induction therapy. The nurse should prepare the patient for which of the following?

A) Daily treatment with targeted therapy medications

B) Radiation therapy on a daily basis

C) Hematopoietic stem cell transplantation

D) An aggressive course of chemotherapy

Ans: D

Feedback:

Attempts are made to achieve remission of AML by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks. Induction therapy is not synonymous with radiation, stem cell transplantation, or targeted therapies.

18. A patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on

the oncology unit. What nursing action should be prioritized in the patients care plan?

A) Protective isolation and vigilant use of standard precautions

B) Provision of a high-calorie, low-texture diet and appropriate oral hygiene

C) Including the family in planning the patients activities of daily living

D) Monitoring and treating the patients pain

Ans: A

Feedback:

Induction therapy causes neutropenia and a severe risk of infection. This risk must be addressed directly in order to ensure the patients survival. For this reason, infection control would be prioritized over nutritional interventions, family care, and pain, even though each of these are important aspects of nursing care.

20. A 60-year-old patient with chronic myeloid leukemia will be treated in the home setting and the nurse is

preparing appropriate health education. What topic should the nurse emphasize?

A) The importance of adhering to the prescribed drug regimen

B) The need to ensure that vaccinations are up to date

C) The importance of daily physical activity

D) The need to avoid shellfish and raw foods

Ans: A

Feedback:

Nurses need to understand that the effectiveness of the drugs used to treat CML is based on the ability of the patient to adhere to the medication regimen as prescribed. Adherence is often incomplete, thus this must be a focus of health education. Vaccinations normally would not be administered during treatment and daily physical activity may be impossible for the patient. Dietary restrictions are not normally necessary.

22. A patient has been found to have an indolent neoplasm. The nurse should recognize what implication of

this condition?

A) The patient faces a significant risk of malignancy.

B) The patient has a myeloid form of leukemia.

C) The patient has a lymphocytic form of leukemia.

D) The patient has a major risk factor for hemophilia.

Ans: A

Feedback:

Indolent neoplasms have the potential to develop into a neoplasm, but this is not always the case. The patient does not necessary have, or go on to develop, leukemia. Indolent neoplasms are unrelated to the pathophysiology of hemophilia.

24. A patient who is undergoing consolidation therapy for the treatment of leukemia has been experiencing

debilitating fatigue. How can the nurse best meet this patients needs for physical activity?

A) Teach the patient about the risks of immobility and the benefits of exercise.

B) Assist the patient to a chair during awake times, as tolerated.

C) Collaborate with the physical therapist to arrange for stair exercises.

D) Teach the patient to perform deep breathing and coughing exercises.

Ans: B

Feedback:

Sitting is a chair is preferable to bed rest, even if a patient is experiencing severe fatigue. A patient who has debilitating fatigue would not likely be able to perform stair exercises. Teaching about mobility may be necessary, but education must be followed by interventions that actually involve mobility. Deep breathing and coughing reduce the risk of respiratory complications but are not substitutes for physical mobility in preventing deconditioning.

26. After receiving a diagnosis of acute lymphocytic leukemia, a patient is visibly distraught, stating, I have

no idea where to go from here. How should the nurse prepare to meet this patients psychosocial needs?

A) Assess the patients previous experience with the health care system.

B) Reassure the patient that treatment will be challenging but successful.

C) Assess the patients specific needs for education and support.

D) Identify the patients plan of medical care.

Ans: C

Feedback:

In order to meets the patients needs, the nurse must first identify the specific nature of these needs. According to the nursing process, assessment must precede interventions. The plan of medical care is important, but not central to the provision of support. The patients previous health care is not a primary consideration, and the nurse cannot assure the patient of successful treatment.

27. A patient has completed the full course of treatment for acute lymphocytic leukemia and has failed to respond appreciably. When preparing for the patients subsequent care, the nurse should perform what action?

A) Arrange a meeting between the patients family and the hospital chaplain.

B) Assess the factors underlying the patients failure to adhere to the treatment regimen.

C) Encourage the patient to vigorously pursue complementary and alternative medicine (CAM).

D) Identify the patients specific wishes around end-of-life care.

Ans: D

Feedback:

Should the patient not respond to therapy, it is important to identify and respect the patients choices about treatment, including measures to prolong life and other end-of-life measures. The patient may or may not be open to pursuing CAM. Unsuccessful treatment is not necessarily the result of failure to adhere to the treatment plan. Assessment should precede meetings with a chaplain, which may or may not be beneficial to the patient and congruent with the familys belief system.

36. An adult patients abnormal complete blood count (CBC) and physical assessment have prompted the

primary care provider to order a diagnostic workup for Hodgkin lymphoma. The presence of what assessment finding is considered diagnostic of the disease?

A) Schwann cells

B) Reed-Sternberg cells

C) Lewy bodies

D) Loops of Henle

Ans: B

Feedback:

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. It is the pathologic hallmark and essential diagnostic criterion. Schwann cells exist in the peripheral nervous system and Lewy bodies are markers of Parkinson disease. Loops of Henle exist in nephrons.

38. The clinical nurse educator is presenting health promotion education to a patient who will be treated for

non-Hodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions?

A) Avoiding direct sun exposure in excess of 15 minutes daily

B) Avoiding grapefruit juice and fresh grapefruit

C) Avoiding highly crowded public places

D) Using an electric shaver rather than a razor

Ans: C

Feedback:

The risk of infection is significant for these patients, not only from treatment-related myelosuppression but also from the defective immune response that results from the disease itself. Limiting infection exposure is thus necessary. The need to avoid grapefruit is dependent on the patients medication regimen. Sun exposure and the use of razors are not necessarily contraindicated.

40. A nurse is caring for patient whose diagnosis of multiple myeloma is being treated with bortezomib. The

nurse should assess for what adverse effect of this treatment?

A) Stomatitis

B) Nephropathy

C) Cognitive changes

D) Peripheral neuropathy

Ans: D

Feedback:

A significant toxicity associated with the use of bortezomib for multiple myeloma is peripheral neuropathy. Stomatitis, cognitive changes, and nephropathy are not noted to be adverse effects of this medication.

19. Which laboratory test will the nurse use to determine whether a prescribed myeloid growth factor is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?

a. Platelet count

b. Reticulocyte count

c. Total lymphocyte count

d. Absolute neutrophil count

ANS: D

Myeloid growth factors increase the neutrophil count in neutropenic patients. The absolute neutrophil count is used to evaluate the effects of myeloid growth factors.

21. A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). Which approach would the nurse take?

a. Discuss the need for insurance to cover post-HSCT care.

b. Inquire whether there are questions or concerns about HSCT.

c. Emphasize the positive outcomes of a bone marrow transplant.

d. Explain that a cure is not possible with any treatment except HSCT

ANS: B

Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

23. Which intervention would the nurse plan for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/L during chemotherapy?

a. Test all stools for occult blood.

b. Encourage fluids to 3000 mL/day.

c. Provide oral hygiene every 2 hours.

d. Check the temperature every 4 hours.

ANS: A

Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

30. Which patient requires the most rapid assessment and care by the emergency department nurse?

a. The patient with hemochromatosis who reports abdominal pain

b. The patient with neutropenia who has a temperature of 101.8F

c. The patient with thrombocytopenia who has oozing gums after a tooth extraction

d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours

ANS: B

A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

35. Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)?

a. Administering injections of myeloid growth factor

b. Assessing the patient for signs and symptoms of infection

c. Teaching the patient the purpose of neutropenic precautions

d. Developing a discharge teaching plan for the patient and family

ANS: A

Administration of subcutaneous medications such as myeloid growth factor is included in LPN/VN education and scope of practice. Patient teaching, assessment, and developing the plan of care require RN level education and scope of practice.

37. After receiving change-of-shift report for several patients with neutropenia, which patient would the nurse assess first?

a. A 23-yr-old who reports severe fatigue

b. A 56-yr-old with frequent explosive diarrhea

c. A 33-yr-old with a fever of 100.8F (38.2C)

d. A 66-yr-old who has white pharyngeal lesions

ANS: C

Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not have symptoms of potentially life-threatening problems.

41. Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic would the nurse include in patient teaching?

a. Potential impact of chemotherapy treatment on fertility

b. Application of soothing lotions to treat residual pruritus

c. Use of maintenance chemotherapy to maintain remission

d. Need for follow-up appointments to screen for malignancy

ANS: D

The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. Chemotherapy will not impact the fertility of a 55-yr-old woman. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma but would not be a concern after treatment.

A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about

a. blood transfusion

b. bone marrow biopsy.

c. filgrastim (Neupogen) administration.

d. erythropoietin (Epogen) administration.

ANS: B

Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?

a. Platelet count

b. Reticulocyte count

c. Total lymphocyte count

d. Absolute neutrophil count

d. Absolute neutrophil count

Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastm

A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?

a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation."

b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy."

c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do."

d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly."

b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy."

Acute myelogenous leukemia (AML) is a cancer of the blood and bone marrow — the spongy tissue inside bones where blood cells are made. The word "acute" in acute myelogenous leukemia denotes the disease's rapid progression

This response uses therapeutic communication by addressing the patient's question and giving accurate information.

Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma?

a. Monitor fluid intake and output.

b. Administer calcium supplements.

c. Assess lymph nodes for enlargement.

d. Limit weight bearing and ambulation.

ANS: A

Multiple myeloma is cancerous cells that proliferate in the bone marrow and destroy bone. Usually detected in late stages with a poor prognosis.

A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

a. Assessing the patient for signs and symptoms of infection

b. Teaching the patient the purpose of neutropenic precautions

c. Administering subcutaneous filgrastim (Neupogen) injection

d. Developing a discharge teaching plan for the patient and family

ANS: C

Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?

a. Serum calcium level is 15 mg/dL.

b. Patient reports no stool for 5 days.

c. Urine sample has Bence-Jones protein.

d. Patient is complaining of severe back pain.

a. Serum calcium level is 15 mg/dL.

Normal Total Calcium range: 9.0- 10.5mg/dL

Myeloma, also called multiple myeloma, is a cancer of the plasma cells. Plasma cells are white blood cells that make antibodies that protect us from infection. In myeloma, the cells grow too much, crowding out normal cells in the bone marrow that make red blood cells, platelets, and other white blood cells.

Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider, but are not life threatening

Patient EHR and Assessment shows:

History: Fatigue, that has increased over last 30 days. Frequent constipation.

Physical Assessment: conjunctiva pale pink and moist. Multiple bruises, Clear lung sounds.

Lab results: Hct 33, WBC 500/uL, Platelets 70,000/uL

Which information is most important to report to the HCP?

a. Bruising

b. Neutropenia

c. Increasing fatigue

d. Thrombocytopenia

b. Neutropenia

The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia.

Normal Values:

Hct (total packed RBCs) M- 0.42- 0.52, F- 0.37- 0.47

WBC 5000- 10,000/mm3

Platelets (thrombocytes; coagulation) 140- 140x10^3/uL

Which action will the admitting nurse include in the care plan for a patient who has

neutropenia?

a. Avoid intramuscular injections.

b. Check temperature every 4 hours.

c. Omit fruits or vegetables from the diet.

d. Place a "No Visitors" sign on the door.

ANS: B

The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although

unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or

cooked are acceptable. Injections may be required for administration of medications such as

filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable

diseases should be avoided, but a "no visitors" policy is not needed.

DIF: Cognitive Level: Apply (application) REF: 632

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which action will the nurse include in the plan of care for a patient admitted with multiple

myeloma?

a. Monitor fluid intake and output.

b. Administer calcium supplements.

c. Assess lymph nodes for enlargement.

d. Limit weight bearing and ambulation.

ANS: A

A high fluid intake and urine output helps prevent the complications of kidney stones caused

by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal

tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph

nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the

patient's calcium level and are not used.

DIF: Cognitive Level: Apply (application) REF: 646

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient who has acute myelogenous leukemia develops an absolute neutrophil count of

850/μL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse

is most appropriate?

a. Discuss the need for hospital admission to treat the neutropenia.

b. Teach the patient to administer filgrastim (Neupogen) injections.

c. Plan to discontinue the chemotherapy until the neutropenia resolves.

d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.

ANS: B

The patient may be taught to self-administer filgrastim injections. Although chemotherapy

may be stopped with severe neutropenia (neutrophil count <500/μL), administration of

filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at

higher risk for infection when exposed to other patients in the hospital. HEPA filters are

expensive and are used in the hospital, where the number of pathogens is much higher than in

the patient's home environment.

DIF: Cognitive Level: Apply (application) REF: 633

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with

rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most

rapid action by the nurse?

a. Anorexia

b. Vomiting

c. Oral ulcers

d. Lip swelling

ANS: D

Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The

nurse should stop the infusion and further assess for anaphylaxis. The other findings may

occur with chemotherapy but are not immediately life threatening.

DIF: Cognitive Level: Analyze (analysis) REF: 642

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity