MSN Exam for Acute Leukemia

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1) A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen is to:

1. Prevent metabolic breakdown of xanthine to uric acid
2. Prevent uric acid from precipitating in the ureters
3. Enhance the production of uric acid to ensure adequate excretion of urine
4. Ensure that the chemotherapy doesn’t adversely affect the bone marrow

2) A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient?

1. 3-10 years.
2. 25-35 years.
3. 45-55 years.
4. over 60 years.

3) The client with leukemia is receiving busulfan (Myleran) and allopurinol (Zyloprim). The nurse tells the client that the purpose if the allopurinol is to prevent:

1. Nausea
2. Alopecia
3. Vomiting
4. Hyperuricemia

4) An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?

1. The abdomen
2. The thorax
3. The earlobes
4. The soles of the feet

5) A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?

1. The client collects stamps as a hobby.
2. The client recently lost his job as a postal worker.
3. The client had radiation for treatment of Hodgkin’s disease as a teenager.
4. The client’s brother had leukemia as a child.

6) A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?

1. “Have you noticed a change in sleeping habits recently?”
2. “Have you had a respiratory infection in the last 6 months?”
3. “Have you lost weight recently?”
4. “Have you noticed changes in your alertness?”

7) Francis with leukemia has neutropenia. Which of the following functions must frequently assessed?

1. Blood pressure
2. Bowel sounds
3. Heart sounds
4. Breath sounds

8) The treatment protocol for a client with acute lymphatic leukemia includes prednisone, methotrexate, and cimetadine. The purpose of the cimetadine is to:

1. Decrease the secretion of pancreatic enzymes
2. Enhance the effectiveness of methotrexate
3. Promote peristalsis
4. Prevent a common side effect of prednisone

Answers and Rationales

1. A. Prevent metabolic breakdown of xanthine to uric acid . The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. Allopurinol doesn’t act in the manner described in the other options.
2. A. 3-10 years. The peak incidence of ALL is at 4 years (range 3-10). It is uncommon after the mid-teen years. The peak incidence of chronic myelogenous leukemia (CML) is 45-55 years. The peak incidence of acute myelogenous leukemia (AML) occurs at 60 years. Two-thirds of cases of chronic lymphocytic leukemia (CLL) occur after 60 years.
3. D. Hyperuricemia . Allopurinol decreases uric acid production and reduces uric acid concentrations in serum and urine. In the client receiving chemotherapy, uric acid levels increase as a result of the massive cell destruction that occurs from the chemotherapy. This medication prevents or treats hyperuricemia caused by chemotherapy. Allopurinol is not used to prevent alopecia, nausea, or vomiting.
4. D. The soles of the feet . Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae.
5. C. The client had radiation for treatment of Hodgkin’s disease as a teenager. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.
6. B. “Have you had a respiratory infection in the last 6 months?”  The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations
7. D. Breath sounds . Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it won’t help detect pneumonia.
8. D. Prevent a common side effect of prednisone . A common side effect of prednisone is gastric ulcers. Cimetadine is given to help prevent the development of ulcers.
9. C. Bleeding and pallor . The child with leukemia has low platelet counts, which contribute to spontaneous bleeding.
10. D. leukocytes . Leukemia is manifested by an abnormal overpopulation of immature leukocytes in the bone marrow.
11. A. A history of hepatitis C five years previously. Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis (gall bladder disease), diverticulosis, and history of Crohn’s disease do not preclude blood donation.
12. D. Check for signs of bleeding, including examination of urine and stool for blood. A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the initiation of bleeding precautions, including monitoring urine and stool for evidence of bleeding. Monitoring for fever and requiring protective clothing are indicated to prevent infection if white blood cells are decreased. Transfusion of red cells is indicated for severe anemia.
13. A. Instituting infection control precautions . Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in immunosuppression and increasing the risk of infection, a leading cause of death in children with ALL. Therefore, the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection. Iron-rich foods help with anemia, but dietary iron is not an initial intervention. The prognosis of ALL usually is good. However, later on, the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion. Injections should be discouraged, owing to increased risk from bleeding due to thrombocytopenia.
14. A. Potential for injury. Question: What nursing diagnosis is seen with acute lymphocytic leukemia and thromocytopenia? Needed Info: Thromocytopenia: decreased platelet count increases the patient’s risk for injury, normal count: 200,000-400,000 per mm3. Leukemia: group of malignant disorders involving overproduction of immature leukocytes in bone marrow. This shuts down normal bone marrow production of erythrocytes, platelets, normal leukocytes. Causes anemia, leukopenia, and thrombocytopenia leading to infection and hemorrhage. Symptoms: pallor of nail beds and conjunctiva, petechiae (small hemorrhagic spot on skin), tachycardia, dyspnea, weight loss, fatigue. Treatment: chemotherapy, antibiotics, blood transfusions, bone marrow transplantation. Nursing responsibilities: private room, no raw fruits or vegs, small frequent meals, O2, good skin care.
    • Potential for injury — CORRECT: low platelet increases risk of bleeding from even minor injuries. Safety measures: shave with an electric razor, use soft tooth brush, avoid SQ or IM meds and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage.
    • Self-care deficit — may feel weak, doesn’t address condition
    • Potential for self-harm — implies risk for purposeful self-injury, not given any info, assumption
    • Alteration in comfort — patient is not comfortable, and comfort measures would address problem
15. B. Risk for injury related to thrombocytopenia . The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem.
16. A. leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lyphoma but is also used to treat secondary progressive MS. Patients need to have laboratory tests ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity.
17. D. gastric distension . Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.
18. B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”. Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the health care provider. The other manifestations are expected side effects of chemotherapy.
19. C. We will bring in fresh flowers to brighten the room. During induction chemotherapy, the leukemia patient is severely immunocompromised and at risk of serious infection. Fresh flowers, fruit, and plants can carry microbes and should be avoided. Books, pictures, and other personal items can be cleaned with antimicrobials before being brought into the room to minimize the risk of contamination.
20. B. Avoid fresh vegetables that are not cooked or peeled 
21. A. The patient is under local anesthesia during the procedure . Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia.
22. A. 4 to 12 years. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
23. D. “Does it help you to joke about your illness?” This non-judgmentally on the part of the nurse points out the client’s behavior.
24. D. Use a soft toothbrush and electric razor . Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.
25. C. stool for Clostridium difficile test. Immunosuppressed clients — for example, clients receiving chemotherapy, — are at risk for infection with C. difficile, which causes “horse barn” smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. The ELISA test is diagnostic for human immunodeficiency virus (HIV) and isn’t indicated in this case. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren’t diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide useful information about bowel function but isn’t indicated in the case of “horse barn” smelling diarrhea.
26. B. to a private room so she will not be infected by other patients and health care workers. 
    • Question: What are the needs of the patient with acute lymphocytic leukemia and thrombocytopenia?
    • Needed Info: Lymphocytic leukemia, disease characterized by proliferation of immature WBCs. Immature cells unable to fight infection as competently as mature white cells. Treatment: chemotherapy, antibiotics, blood transfusions, bone marrow transplantation.
    • Nursing responsibilities: private room, no raw fruits or vegs, small frequent meals, O2, good skin care.
      • to a private room so she will not infect other patients and health care workers — poses little or no threat
      • to a private room so she will not be infected by other patients and health care workers — CORRECT: protects patient from exogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection
      • to a semiprivate room so she will have stimulation during her hospitalization — should be placed in a room alone
      • to a semiprivate room so she will have the opportunity to express her feelings about her illness — ensure that patient is provided with opportunities to express feelings about illness