Leukemia, Acute Nursing Care Plan & Management

EXPLANATION

✔Correct answer:

"I will call the doctor if she has ongoing vomiting and diarrhea." Ongoing vomiting and diarrhea are critical signs that warrant immediate medical attention in a child undergoing chemotherapy for acute lymphoid leukemia (ALL). Persistent vomiting and diarrhea can lead to dehydration, electrolyte imbalances, and malnutrition, which are particularly dangerous in immunocompromised patients like those with ALL. Chemotherapy can damage rapidly dividing cells in the gastrointestinal tract, causing mucositis, nausea, and diarrhea, but when these symptoms are prolonged or severe, they can signal significant complications that may require intervention such as IV fluids, antiemetics, or adjustments to the treatment plan.

Moreover, in a child undergoing chemotherapy, vomiting and diarrhea could also indicate an infection or the toxic effects of chemotherapy on the digestive system. Since children with ALL are often neutropenic (low white blood cell count) after chemotherapy, they are at increased risk of infections, which could present with gastrointestinal symptoms. Recognizing these symptoms and contacting the physician promptly is crucial to prevent complications.

Imagine the body as a plant. If the plant keeps losing water (vomiting and diarrhea), it can wilt and weaken quickly (dehydration and nutrient loss). Just like you would need to water the plant right away, the child needs fluids and care to avoid becoming too weak.

In educating the mother about when to seek medical attention, Nurse Lucy should emphasize the importance of recognizing serious symptoms related to chemotherapy, including:

• Monitor for signs of dehydration, such as dry mouth, decreased urine output, or lethargy.
• Teach the mother to contact the physician if vomiting or diarrhea persists for more than 24 hours or becomes severe.
• Educate about the risk of infection due to immunosuppression, and inform the mother to watch for signs such as fever, lethargy, or persistent GI symptoms.

✘Incorrect answer options:

"I should contact the physician if she has trouble sleeping." Trouble sleeping is common in children undergoing cancer treatment due to the stress of illness, pain, or anxiety, but it is not an immediate cause for concern that requires contacting the physician. Fatigue and sleep disturbances can be managed with comfort measures or supportive care, unless they are related to severe symptoms like pain or respiratory distress.

"I should reach out to the physician if she is irritable and unhappy." While irritability may be a sign of discomfort or emotional distress, it is not as urgent as persistent vomiting and diarrhea. Irritability can be addressed through supportive care, such as providing emotional support, play therapy, or ensuring the child’s physical comfort.

"If her hair loss continues, I need to inform the doctor." Hair loss (alopecia) is a well-known side effect of chemotherapy and, while distressing, is not a medical emergency. It typically resolves after chemotherapy ends, so it does not require immediate contact with the physician. Nurse Lucy should reassure the mother that hair loss is expected and help provide resources for coping with the emotional aspects of this side effect.

EXPLANATION

✔Correct answer:

Avoid fresh vegetables that are not cooked or peeled. One of the critical infection prevention strategies for children undergoing chemotherapy is to avoid fresh vegetables that are not cooked or peeled. Fresh, uncooked produce can harbor bacteria, fungi, or other pathogens that could pose a serious risk to immunocompromised children, who are more susceptible to infections. By peeling or cooking vegetables, the risk of introducing harmful microorganisms is significantly reduced, making these foods safer for the child to consume. This is especially important for children with leukemia whose immune systems are weakened by both the disease and chemotherapy.

Think of uncooked vegetables like clothes straight off the clothesline—they might look clean, but they could still carry dust or bugs that aren’t visible. Cooking or peeling them is like washing the clothes to remove anything harmful before wearing them.

Nurse Carla should instruct the parents on various measures to reduce infection risk at home, including:

• Provide only thoroughly washed, peeled, or cooked fruits and vegetables.
• Ensure that all food preparation surfaces and utensils are sanitized before use.
• Instruct the family to practice strict hand hygiene, especially before meals and after using the bathroom.
• Avoid exposure to large crowds or sick individuals to minimize infection risk.

✘Incorrect answer options:

Provide a diet low in protein and high in carbohydrates. A low-protein, high-carbohydrate diet is not recommended. Children undergoing chemotherapy need balanced nutrition, including adequate protein, to support healing, recovery, and overall health. A diet low in protein could impair the child’s ability to recover and maintain strength.

Notify the doctor if the child’s temperature exceeds 101°F (39°C). The threshold for contacting the doctor in an immunocompromised child should be lower than 101°F. Typically, parents are advised to notify the doctor if the child’s temperature exceeds 100.4°F (38°C), as even a low-grade fever can indicate infection, which can progress rapidly in immunocompromised children.

Increase the use of humidifiers throughout the house. Humidifiers can actually increase the risk of mold and bacterial growth if not cleaned properly, which can introduce harmful pathogens into the air. This would increase the child’s risk of infection, making humidifiers a less ideal option unless specifically recommended and properly maintained.

EXPLANATION

✔Correct answer:

Stop the metabolic conversion of xanthine into uric acid. Allopurinol is commonly administered during chemotherapy for leukemia to prevent tumor lysis syndrome (TLS), a potentially life-threatening complication. During remission induction therapy, chemotherapy causes the rapid destruction of cancer cells, leading to the release of intracellular contents, including purines, which are broken down into uric acid. Excessive uric acid can accumulate in the blood, potentially leading to hyperuricemia and kidney damage. Allopurinol works by inhibiting the enzyme xanthine oxidase, which is responsible for converting purines into uric acid. This decreases the production of uric acid, reducing the risk of crystallization in the kidneys and subsequent renal damage.

Imagine a busy kitchen where food waste (purines) is being generated rapidly. If this waste isn’t properly managed, it clogs the sink (kidneys). Allopurinol acts like a filter, preventing the buildup of large waste items (uric acid) that can block the sink, ensuring the kitchen can keep running smoothly.

Nurses should be aware of the signs and symptoms of tumor lysis syndrome (TLS), such as hyperkalemia, hyperphosphatemia, and hyperuricemia, to monitor patients closely. Proper hydration and the administration of medications like allopurinol are crucial in preventing TLS and protecting kidney function.

• Ensure adequate fluid intake to promote excretion of uric acid and prevent kidney damage.
• Monitor kidney function (serum creatinine and urine output) and electrolyte levels.
• Educate the patient and family about the purpose of allopurinol and the importance of hydration during chemotherapy.

✘Incorrect answer options:

Prevent uric acid crystals from forming in the ureters. While preventing the formation of uric acid crystals in the kidneys is a key goal of allopurinol therapy, this answer incorrectly specifies the ureters. Uric acid crystals tend to form primarily in the kidneys, not the ureters. The medication's function is more systemic, as it reduces overall uric acid levels in the blood.

Increase uric acid levels to promote proper urine output. This option is incorrect because the goal of allopurinol is to decrease uric acid levels, not increase them. Elevated uric acid levels can lead to kidney damage, and allopurinol is used to prevent this from occurring.

Safeguard the bone marrow from the harmful effects of chemotherapy. Allopurinol does not protect the bone marrow from chemotherapy’s effects. Its primary role is to manage uric acid levels. Chemotherapy agents like methotrexate or cyclophosphamide affect the bone marrow, but allopurinol is not involved in protecting against this toxicity.

EXPLANATION

✔Correct answer:

To prevent hyperuricemia. Allopurinol is prescribed in leukemia patients receiving chemotherapy (such as busulfan) to prevent hyperuricemia, a condition where high levels of uric acid accumulate in the blood. Chemotherapy causes rapid cell breakdown, particularly of malignant cells, which leads to the release of intracellular contents, including purines. These purines are metabolized into uric acid, which can overwhelm the body's ability to excrete it, leading to hyperuricemia. If left untreated, this can result in kidney damage due to the formation of uric acid crystals. Allopurinol helps prevent this by inhibiting the enzyme xanthine oxidase, which is responsible for converting purines into uric acid, thereby reducing the risk of kidney complications.

Think of your body as a city, where chemotherapy generates a lot of trash (uric acid) that needs to be processed. Without allopurinol, the trash can build up too quickly, causing blockages (kidney damage). Allopurinol acts like a waste management system, reducing the amount of trash produced so the city's disposal system can keep up.

Nurse Kim should emphasize the importance of hydration in conjunction with allopurinol to help flush uric acid from the body and monitor for signs of tumor lysis syndrome, a serious complication associated with chemotherapy.

• Monitor the patient's uric acid levels, kidney function (e.g., serum creatinine), and fluid balance regularly.
• Encourage adequate hydration to assist with uric acid excretion.
• Educate the patient and family about the role of allopurinol in preventing kidney complications and the importance of adhering to prescribed treatment.

✘Incorrect answer options:

To prevent nausea. Allopurinol does not prevent nausea. Nausea is a common side effect of chemotherapy and is often managed with antiemetic medications such as ondansetron or metoclopramide.

To prevent hair loss. Hair loss (alopecia) is a common side effect of chemotherapy, but allopurinol does not have any impact on this. Hair loss occurs due to the effects of chemotherapy on rapidly dividing cells, including hair follicles.

To prevent vomiting. While vomiting is a common chemotherapy side effect, allopurinol does not prevent this. Antiemetic medications are used to manage chemotherapy-induced nausea and vomiting, not allopurinol.

EXPLANATION

✔Correct answer:

"Does joking about your illness help you cope with it?" The most therapeutic response is "Does joking about your illness help you cope with it?" because it is nonjudgmental, open-ended, and encourages the patient to reflect on and express his emotions in a safe, non-confrontational way. This question shows empathy while inviting the patient to share his thoughts and feelings about his condition. It acknowledges that humor may be his way of coping with the stress and fear of leukemia, without making assumptions or forcing him to confront his emotions prematurely. This approach fosters a trusting therapeutic relationship, where the patient feels comfortable discussing his emotions when ready.

By asking an open-ended question, Nurse Riley creates an opportunity for the patient to explore his coping mechanisms, which may include humor as a defense strategy. The nurse remains supportive, rather than accusatory, and allows the patient to guide the conversation, which is essential in therapeutic communication.

Think of the patient’s humor like a shield he uses to protect himself from feeling vulnerable. Instead of forcing him to drop the shield, the nurse gently asks why he’s holding it, giving him the choice to share what’s behind it when he feels ready.

Effective therapeutic communication involves using techniques that promote emotional expression and trust-building. Nurse Riley should:

• Use open-ended questions that allow the patient to express his emotions and coping strategies.
• Maintain a nonjudgmental and empathetic tone to ensure the patient feels safe discussing his feelings.
• Monitor the patient’s psychological well-being and offer additional support or counseling if needed.

✘Incorrect answer options:

"Your laughter is a way to hide your fear." This response is confrontational and makes assumptions about the patient's emotional state. It might cause the patient to feel defensive or misunderstood, which can hinder open communication and trust.

"They say people who laugh on the outside are crying inside." While this statement attempts to address the patient’s underlying emotions, it is presumptive and lacks empathy. It can make the patient feel as though the nurse is trivializing his coping mechanism or making assumptions about his true feelings.

"Why do you always seem to be laughing?" This question is closed-ended and somewhat accusatory in tone, which may cause the patient to feel criticized or defensive. It does not invite the patient to explore his feelings in a safe, open manner, and it focuses more on the behavior rather than the emotions behind it.

EXPLANATION

✔Correct answer:

Risk for injury. The most accurate nursing diagnosis for a patient with acute lymphocytic leukemia (ALL) and thrombocytopenia (low platelet count) is Risk for injury. This is primarily due to the increased risk of bleeding and bruising associated with thrombocytopenia. Platelets are essential for blood clotting, and with a reduced platelet count, the patient is at a higher risk of spontaneous bleeding, both internally (e.g., gastrointestinal or intracranial bleeding) and externally (e.g., nosebleeds, bleeding gums, or prolonged bleeding from minor cuts). Additionally, ALL leads to bone marrow suppression, which further impairs the body's ability to produce sufficient platelets and other blood components.

The patient's symptoms—fatigue, weight loss, pallor, and bruising—are common in both leukemia and thrombocytopenia, reflecting the body's inability to maintain healthy blood cell levels. In this situation, it is critical to focus on preventing injury to minimize the risk of bleeding, which could quickly become life-threatening. This diagnosis helps prioritize safety interventions, such as limiting invasive procedures, applying gentle pressure to any injection sites, and avoiding activities that could result in trauma.

Think of platelets like small plugs that stop leaks in the body’s blood vessels. When there aren’t enough plugs (due to thrombocytopenia), even small bumps or injuries can cause leaks (bleeding) that are hard to stop. Therefore, it's essential to prevent situations where these leaks could occur.

Based on the nursing diagnosis of Risk for injury, the following interventions are essential to prevent bleeding and injury in a patient with acute leukemia and thrombocytopenia:

• Assess for signs of bleeding, such as petechiae, ecchymosis, hematuria, or gastrointestinal bleeding (e.g., melena).
• Institute bleeding precautions, including avoiding invasive procedures (e.g., injections, blood draws) unless absolutely necessary.
• Advise the patient to use a soft-bristle toothbrush and avoid shaving with sharp razors to prevent gum and skin injuries.
• Monitor platelet counts regularly and prepare for platelet transfusions if the count falls to critically low levels.
• Encourage the patient to avoid activities that may increase the risk of falls or trauma, such as contact sports or strenuous activities.
• Apply prolonged pressure to any puncture sites (e.g., after venipuncture) to prevent bleeding.

✘Incorrect answer options:

Self-care deficit. While fatigue and weakness may impair the patient’s ability to carry out daily activities, self-care deficit is not the most immediate concern. Preventing injury from bleeding should take precedence in the care plan, as the patient’s platelet count puts him at higher risk for serious complications.

Risk for self-harm. There is no indication in this case that the patient is experiencing psychological distress or has a history of self-harm. The physical complications from leukemia and thrombocytopenia, such as bleeding, are the primary concern.

Alteration in comfort. The patient may be experiencing discomfort due to symptoms like fatigue, pallor, or bruising. However, alteration in comfort is not the most critical issue at this time. Managing the risk of injury and bleeding takes priority, as these complications are more likely to result in life-threatening outcomes if not addressed promptly.

EXPLANATION

✔Correct answer:

Between 3 and 10 years old. Acute lymphoblastic leukemia (ALL) is the most common type of leukemia in children. It typically affects children between the ages of 3 and 10 years, with a peak incidence around 4 to 5 years of age. ALL is a fast-growing cancer of the bone marrow and blood that results from an overproduction of immature white blood cells (lymphoblasts). While it can occur in adults, the majority of cases are seen in pediatric patients, and early childhood is considered the most vulnerable age group for this diagnosis.

ALL arises from a genetic mutation in the bone marrow cells that leads to uncontrolled proliferation of lymphoblasts, which crowd out normal cells, leading to symptoms like anemia, infection, and bleeding. Pediatric patients are especially susceptible due to the rapid cell growth and turnover characteristic of early childhood development.

Think of the bone marrow as a factory that produces workers (blood cells) in a balanced way. In children with ALL, the factory starts overproducing unskilled workers (immature white blood cells) who flood the workspace, preventing skilled workers (normal blood cells) from doing their job, which leads to problems like infection and fatigue.

In pediatric patients with ALL, the nurse should focus on managing the side effects of treatment, monitoring for signs of infection due to immunosuppression, and providing age-appropriate emotional support for both the patient and their family.

• Monitor blood counts and assess for signs of anemia, bleeding, or infection.
• Administer chemotherapy as prescribed, while monitoring for side effects like nausea, vomiting, and bone marrow suppression.
• Provide family education about the disease process, treatment plan, and coping strategies for the child.
• Ensure emotional support for the child by involving play therapy and child-life specialists to help them understand their condition and treatment.

✘Incorrect answer options:

Between 25 and 35 years old. While ALL can occur in adults, it is far less common in this age group compared to childhood. Acute lymphoblastic leukemia is typically a pediatric condition, and adult-onset ALL often has a more complicated prognosis and different treatment approaches.

Between 45 and 55 years old. This age group is not typical for the onset of ALL. Leukemias in this age range tend to be more of the chronic types, such as chronic lymphocytic leukemia (CLL) or chronic myeloid leukemia (CML), rather than ALL.

Over 60 years old. Leukemia in older adults tends to be more chronic in nature, like CLL or CML. ALL is rare in the elderly population and is much more aggressive when it does occur in this group. ALL is primarily seen in pediatric populations rather than in those over 60.

EXPLANATION

✔Correct answer:

Whether the client received radiation therapy for Hodgkin’s disease during adolescence. One of the well-known risk factors for developing acute leukemia is a history of radiation therapy. Specifically, patients who received radiation therapy, especially in childhood or adolescence for conditions like Hodgkin’s disease, are at an increased risk of developing secondary malignancies, including acute leukemia, later in life. Radiation exposure can cause damage to the bone marrow, potentially leading to mutations in the hematopoietic (blood-forming) cells, which can result in leukemia. Thus, in this case, it would be important for Nurse Laura to ask if the patient has a history of radiation therapy, as it is a significant risk factor for acute leukemia.

Imagine bone marrow cells as a computer's software. Radiation can act like a virus that disrupts the code, causing errors over time. Some of these errors may eventually lead to problems like leukemia. Inquiring about past radiation treatment is like checking whether the software was exposed to harmful bugs in the past.

When assessing patients at risk for leukemia, it is important to inquire about any previous radiation therapy, as well as other exposures that may increase their risk for hematological malignancies.

• Take a detailed history regarding any prior treatments for cancer, especially childhood cancers, as these can increase the likelihood of secondary malignancies.
• Educate the patient on potential late effects of cancer treatments received in childhood or adolescence.
• Assess for signs and symptoms of leukemia, such as fatigue, bruising, infections, and unexplained weight loss.

✘Incorrect answer options:

Whether the client enjoys collecting stamps as a hobby. While hobbies can provide insight into a patient’s lifestyle, collecting stamps is not a relevant factor or risk for leukemia. This question would not help Nurse Laura assess the patient’s risk of leukemia.

Whether the client recently lost his job as a postal worker. Job-related stress or unemployment can certainly affect mental health and overall well-being, but losing a job as a postal worker does not have a direct link to the development of leukemia.

Whether the client’s brother had leukemia during childhood. Family history can sometimes play a role in certain types of cancer, but acute leukemia is not strongly linked to genetic factors like some other cancers. While it's important to be aware of family history, the radiation therapy exposure would be a much more significant risk factor for this patient compared to a sibling's past medical history of leukemia.

EXPLANATION

✔Correct answer:

"Do you have any known allergies to medications?" When admitting a patient with acute leukemia to the oncology unit, one of the most critical questions Nurse Jenna should ask is whether the patient has any known allergies to medications. This is a priority because patients with acute leukemia often require complex treatment regimens, including chemotherapy, antibiotics, blood transfusions, and supportive medications (e.g., allopurinol for hyperuricemia or growth factors). Knowing about any medication allergies upfront is essential to prevent adverse reactions, anaphylaxis, or other complications during treatment. It allows the healthcare team to tailor the treatment plan safely and avoid contraindicated drugs.

Think of starting a journey with a map in hand. Before the trip, it’s crucial to mark off dangerous routes (allergies) so you can avoid them and travel safely. In the same way, identifying medication allergies is essential to avoiding harmful "routes" during leukemia treatment.

Once medication allergies are identified, the nurse should:

• Document the allergies in the patient's medical record and notify the healthcare team.
• Ensure the patient wears an allergy alert bracelet if necessary.
• Monitor for any signs of allergic reactions when new medications are administered.
• Provide education to the patient and family regarding potential drug interactions and the importance of reporting any past allergic reactions.

✘Incorrect answer options:

"Have you noticed any recent changes in your bowel movements?" While assessing bowel movements can be relevant, especially when monitoring side effects of chemotherapy (e.g., constipation or diarrhea), this is not a priority question during the initial assessment for acute leukemia. Bowel habits are important, but medication allergies are a more urgent concern when planning treatment.

"How many hours of sleep do you get at night?" Sleep patterns are important for overall health, but this question is not as critical in the initial assessment of a patient with acute leukemia. Sleep disturbances may arise from illness or treatment, but ensuring safe medication administration takes precedence.

"Have you experienced any recent chest pain or discomfort?" Although chest pain can be a serious symptom, this question is not the top priority in the context of acute leukemia unless the patient presents with cardiovascular concerns. Leukemia-related symptoms often include fatigue, bleeding, infections, and bone pain, making medication safety (such as allergies) more relevant for the initial assessment.

EXPLANATION

✔Correct answer:

Implementing infection control precautions. In a child diagnosed with acute lymphocytic leukemia (ALL), the most immediate priority is to implement infection control precautions. ALL leads to bone marrow suppression, which severely compromises the immune system by reducing the production of functional white blood cells (neutropenia). This leaves the child at high risk for infections, which can be life-threatening due to their inability to mount an adequate immune response. Protecting the child from infections is critical, as even minor infections can rapidly progress to sepsis or other serious complications in immunocompromised patients.

Given this elevated risk, infection control strategies such as hand hygiene, visitor restrictions, and protective isolation (if needed) are essential. Neutropenic precautions should be a focus, including avoiding exposure to potential sources of infection like raw foods, fresh flowers, and people with respiratory illnesses. The child’s safety is the top priority, and preventing infections will help maintain their health during treatment.

Think of the immune system like a security team that protects a building (the body). When leukemia suppresses the immune system, the security team is reduced to only a few members, making it easier for "intruders" (infections) to get inside and cause harm. By putting up barriers (infection control measures), we protect the building from these threats.

Infection control is critical in the care of children with ALL. The following actions should be implemented to minimize infection risks:

• Ensure strict hand hygiene for all healthcare personnel, family members, and visitors.
• Use protective equipment such as masks, gloves, and gowns as necessary for the child, particularly in cases of severe neutropenia.
• Limit the child’s exposure to crowded or public areas to reduce contact with potential pathogens.
• Monitor the child’s temperature regularly to detect early signs of infection.
• Administer prophylactic antibiotics or antifungals as prescribed to prevent infection.
• Educate the family on proper hygiene practices and infection prevention measures at home.

✘Incorrect answer options:

Encouraging the child to consume iron-rich foods. While nutrition is important in leukemia care, particularly if the child develops anemia, increasing iron intake is not the most immediate concern. Iron-rich foods would not directly address the child’s compromised immune status or prevent infection, which is the primary risk in the acute phase of leukemia.

Supporting the child in coping with chronic illness. Psychosocial support is essential in managing leukemia, as the diagnosis can be overwhelming for both the child and their family. However, in the early stages of care, the physical protection from infections is the more pressing concern. Psychosocial interventions can be introduced once the child’s immediate health is stabilized.

Administering medications through intramuscular injections. Intramuscular injections should generally be avoided in leukemia patients, especially those with thrombocytopenia (low platelet count), due to the risk of bleeding. Injections can cause bleeding or hematomas, and alternative routes (such as oral or intravenous) are preferred for medication administration.

EXPLANATION

✔Correct answer:

"We will bring in fresh flowers to brighten the room." Bringing fresh flowers into the room of a leukemia patient, especially one undergoing the induction phase of chemotherapy, is not safe and indicates the need for further education. Patients with leukemia, particularly during the induction phase, are often severely immunocompromised due to chemotherapy-induced neutropenia (low white blood cell count). Fresh flowers, soil, and plants can harbor bacteria, mold, and fungi, which pose a significant risk of infection in immunocompromised patients. Leukemia patients are highly susceptible to infections, which can be life-threatening, making strict infection prevention measures critical.

Think of a leukemia patient’s room like a sterile greenhouse where delicate plants (the patient’s immune system) are trying to grow. If you introduce fresh flowers, it’s like bringing in outside pests or fungi that could attack the fragile plants. Even though the flowers seem harmless and beautiful, they carry hidden risks that could harm the sensitive environment. In the same way, bringing fresh flowers into the room of an immunocompromised patient could introduce bacteria or mold, leading to infections.

Nurse Emily should reinforce the importance of infection control practices, such as:

• Explain to the family why fresh flowers, plants, and other organic materials are restricted in hospital rooms for immunocompromised patients.
• Encourage alternative ways to brighten the room, such as bringing in pictures, cards, or artificial flowers that do not pose a risk of infection.
• Educate the family on proper hand hygiene before entering the room and handling the patient’s personal items.
• Remind the family to avoid bringing in outside food unless it has been approved by hospital staff to ensure food safety.

✘Incorrect answer options:

"We will bring in books and magazines for entertainment." Books and magazines are safe for the patient and are a great way to provide entertainment during long hospital stays. There is no infection risk associated with these items, so no further education is needed for this statement.

"We will bring in personal care items for comfort." Personal care items, such as lotions, pillows, or blankets, are typically safe to bring from home, as long as they are clean and free from contaminants. These items can improve the patient’s comfort during treatment and pose no infection risk if handled properly.

"We will bring in family pictures and get well cards." Family pictures and get well cards are excellent ways to create a comforting and supportive environment for the patient. These items are safe and help boost the patient’s emotional well-being, so this statement does not require further education.

EXPLANATION

✔Correct answer:

Risk for injury related to thrombocytopenia. The priority nursing diagnosis for a client with acute leukemia is Risk for injury related to thrombocytopenia, as this condition places the patient at high risk for bleeding. Thrombocytopenia (low platelet count) is a common complication of leukemia due to the disruption of normal bone marrow function, which reduces the production of platelets. Platelets are essential for clotting, and a low platelet count increases the risk of both minor and major bleeding, including spontaneous internal bleeding, hemorrhage, and prolonged bleeding from even minor trauma.

This risk takes precedence because bleeding can lead to life-threatening complications such as intracranial hemorrhage or gastrointestinal bleeding. For this reason, preventing injury and monitoring for signs of bleeding (such as petechiae, ecchymosis, hematuria, and melena) are critical in protecting the patient’s safety. Thrombocytopenia management often involves implementing bleeding precautions, minimizing invasive procedures, and potentially administering platelet transfusions if the platelet count falls to dangerous levels.

Platelets are like tiny “band-aids” that stop bleeding in the body. With fewer platelets (due to thrombocytopenia), even small injuries can cause serious bleeding, like leaving a cut without a band-aid. Preventing injury becomes a priority to avoid dangerous bleeding episodes.

To manage the risk for injury associated with thrombocytopenia, the following actions should be included in the care plan:

• Monitor for signs of bleeding (e.g., bruising, petechiae, bleeding gums, blood in stool or urine).
• Implement bleeding precautions, such as avoiding invasive procedures like injections or blood draws unless absolutely necessary.
• Use a soft toothbrush and avoid sharp objects to prevent mucosal bleeding.
• Advise the patient to avoid activities that could lead to trauma, such as contact sports.
• Administer platelet transfusions if ordered to maintain a safer platelet count and reduce the risk of hemorrhage.
• Ensure that blood pressure cuffs and other devices are used with caution to avoid bruising or skin damage.

✘Incorrect answer options:

Altered oral mucous membrane related to chemotherapy. Although chemotherapy can cause mucositis (inflammation of the mucous membranes), which is a significant issue in leukemia treatment, this does not pose as immediate a risk as bleeding. While mucositis affects comfort and nutrition, it is not life-threatening in the same way that thrombocytopenia-related bleeding is.

Fatigue related to the disease process. Fatigue is a common symptom of leukemia and its treatments, including chemotherapy and bone marrow suppression. However, it is a lower priority compared to preventing bleeding, which poses a more immediate risk to the patient's safety.

Interrupted family processes related to the life-threatening illness of a family member. This diagnosis focuses on the psychosocial impact of the disease, which is important for long-term care planning and support. However, psychosocial concerns are not as critical as the immediate physical risk of bleeding and injury due to thrombocytopenia.

EXPLANATION

✔Correct answer:

Check for signs of bleeding, including blood in urine and stool. A platelet count of 25,000/microliter is critically low, placing the patient at high risk for bleeding due to thrombocytopenia (low platelet count). Normal platelet levels range from 150,000 to 450,000/microliter, and when they drop below 50,000/microliter, there is a significant risk of spontaneous bleeding. At levels below 30,000–50,000/microliter, close monitoring for signs of bleeding is essential, and at levels as low as 25,000/microliter, patients can bleed spontaneously, even without injury or trauma. Therefore, a key priority in the nursing care plan is to assess for bleeding, which includes checking for blood in the urine (hematuria), stool (melena), gums, or under the skin (petechiae or ecchymosis).

Thrombocytopenia-related bleeding can occur internally (e.g., gastrointestinal bleeding) or externally, so vigilant monitoring is critical to prevent life-threatening hemorrhage. This can involve watching for nosebleeds (epistaxis), gum bleeding, or prolonged bleeding from minor cuts, and monitoring vital signs for indicators of hemorrhagic shock.

Think of platelets as the body’s repair workers who patch up small leaks (bleeding). When there aren’t enough workers (platelets), even tiny leaks (small injuries or spontaneous bleeds) can grow larger and cause major problems. With fewer platelets available, it’s crucial to check for any signs of leaks (bleeding).

Since the patient is at risk of bleeding due to thrombocytopenia, specific interventions should be prioritized to prevent and detect bleeding:

• Perform frequent assessments for any signs of bleeding, including hematuria, melena, and petechiae.
• Monitor vital signs for indications of blood loss, such as tachycardia or hypotension.
• Educate the patient to avoid activities that might lead to injury, such as using a soft toothbrush and avoiding sharp objects or contact sports.
• Administer platelet transfusions if ordered by the healthcare provider to increase the platelet count and reduce bleeding risk.
• Apply gentle pressure for a prolonged period after any needle sticks or invasive procedures to prevent bleeding.

✘Incorrect answer options:

Monitor the patient’s temperature for fever every 4 hours. While monitoring for fever is essential in leukemia patients with bone marrow suppression due to neutropenia (low white blood cell count), this intervention is more related to infection risk rather than the immediate concern of thrombocytopenia and bleeding. Fever management is critical, but the patient’s platelet count suggests bleeding should take priority.

Require visitors to wear masks and protective clothing. This intervention is more appropriate for patients with severe neutropenia to prevent infection. While protecting a patient with a compromised immune system is important, the question specifically addresses thrombocytopenia (low platelet count), where bleeding risk is the more pressing concern.

Consider transfusing packed red blood cells. Transfusing packed red blood cells (PRBCs) is appropriate if the patient is anemic, but the question highlights a low platelet count, not low hemoglobin. Platelet transfusions, not red blood cell transfusions, are indicated to address the patient’s bleeding risk due to thrombocytopenia.

EXPLANATION

✔Correct answer:

The patient will be under local anesthesia during the procedure. The statement that the patient will be under local anesthesia during the bone marrow transplant procedure is inaccurate and requires clarification. While local anesthesia may be used for a bone marrow biopsy or aspiration, bone marrow transplantation is a much more involved process that often requires general anesthesia or sedation, especially when the marrow is harvested from a donor or when large volumes of marrow are collected. The procedure is typically more complex and uncomfortable than a biopsy, which makes general anesthesia preferable to ensure the patient's comfort and immobility.

For the patient receiving the transplant (the recipient), the process involves infusing the harvested bone marrow or stem cells intravenously after they have undergone conditioning therapy, which includes high-dose chemotherapy (such as cyclophosphamide) and/or radiation. The transplant itself is not painful, but anesthesia is more relevant to the donor rather than the recipient.

Think of a bone marrow transplant like planting seeds in a garden. For the person "planting the seeds" (the donor), it might require a lot of digging, which could be painful without good pain control (general anesthesia). For the "garden" (the recipient), the seeds (bone marrow) are simply added, without much discomfort during the process itself.

Nurse Taylor should clarify this aspect of the procedure and provide accurate information, including:

• Explain the difference between bone marrow aspiration/biopsy (which may use local anesthesia) and bone marrow transplantation (which often requires general anesthesia for the donor).
• Reassure the patient that during the actual transplantation, they will receive the bone marrow or stem cells through a central line or IV, and the process will be similar to a blood transfusion, without the need for anesthesia.
• Review the full procedure and expectations for both the recipient and, if relevant, the donor, including potential side effects and recovery considerations.

✘Incorrect answer options:

The aspirated bone marrow is combined with heparin. This statement is accurate. Bone marrow that is aspirated for transplantation is typically combined with heparin to prevent clotting during the collection process. Heparin ensures the viability of the harvested stem cells or marrow until it can be infused into the recipient.

The aspiration site is typically from the anterior or posterior iliac crest. This statement is also accurate. The iliac crest (either anterior or posterior) is the most common site for bone marrow aspiration and collection, as it provides a large quantity of marrow and is relatively accessible. Occasionally, the sternum or other sites may be used, but the iliac crest is preferred.

The patient will be administered cyclophosphamide (Cytoxan) for four days leading up to the transplant. This statement is accurate. Cyclophosphamide is a chemotherapy agent often used as part of the conditioning regimen before a bone marrow transplant. This treatment helps eliminate the patient’s existing bone marrow cells to make space for the transplanted cells and reduce the risk of rejection. The conditioning regimen may also include radiation therapy or other chemotherapeutic agents.

EXPLANATION

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Breath sounds. Neutropenia, a condition characterized by a low neutrophil count, places patients at high risk for serious infections, particularly respiratory infections like pneumonia. Neutrophils are a key part of the immune response, and without adequate levels, the body is less able to fight infections. Monitoring breath sounds frequently allows early detection of any signs of lung infection, such as pneumonia, which can manifest as abnormal sounds like crackles, wheezes, or diminished breath sounds.

Think of your immune system as a security system that helps keep intruders (infections) out. When the security system (neutrophils) is weakened, it becomes easier for intruders to enter your lungs (a common target), so regularly checking for any signs of trouble (breath sounds) is crucial to prevent serious damage.

In neutropenic patients, the following interventions are important to prevent and detect complications early:

• Conduct frequent lung assessments and monitor breath sounds for any abnormalities, such as crackles or decreased air entry.
• Monitor for early signs of infection, including fever, as even a slight temperature increase could indicate a serious infection in neutropenic patients.
• Teach the patient about neutropenia-related infection risks, emphasizing the importance of hand hygiene, avoiding crowds, and promptly reporting any respiratory symptoms like cough or shortness of breath.
• Encourage appropriate preventive measures, such as wearing a mask in public areas or limiting visitors, to reduce the risk of respiratory infections.

✘Incorrect answer options:

Blood pressure. While monitoring blood pressure is important, it is not the primary concern for neutropenia. Blood pressure changes, like hypotension, may occur later in cases of sepsis, but abnormal breath sounds would provide earlier signs of infection.

Bowel sounds. Assessing bowel sounds is important in gastrointestinal issues but is not directly related to neutropenia. Respiratory tract infections, particularly pneumonia, are the most common complications in neutropenic patients.

Heart sounds. Heart sounds can provide useful information regarding cardiovascular status but are not the primary concern in the context of neutropenia. Respiratory infections are a more immediate risk, making breath sounds more relevant for monitoring.

EXPLANATION

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Leukocytes. In acute leukemia, the bone marrow produces a large number of immature white blood cells, known as blast cells or leukoblasts. These immature leukocytes crowd out the production of normal blood cells, leading to the characteristic symptoms of leukemia such as anemia, thrombocytopenia, and increased susceptibility to infection. Nurse Thomas should be particularly vigilant for an elevated count of blast cells (immature leukocytes) in the bone marrow biopsy results, as this is a hallmark of acute leukemia.

Acute leukemia is classified into two main types based on the lineage of the immature white blood cells: acute lymphoblastic leukemia (ALL), which involves immature lymphoid cells, and acute myeloid leukemia (AML), which involves immature myeloid cells. Both types result in the accumulation of immature leukocytes, disrupting normal hematopoiesis (blood cell production).

Imagine the bone marrow as a school. Normally, it graduates mature and well-trained students (mature blood cells) ready for different jobs in the body. However, in leukemia, the school is flooded with untrained, immature students (blast cells) who cannot perform any jobs properly, and they push out the well-trained students. This leads to problems all over the body as these immature cells take up space without doing useful work.

Early identification and prompt intervention are crucial when managing patients with suspected or confirmed leukemia. Nurses should:

• Monitor lab results for high levels of blast cells in bone marrow biopsies, as this confirms the diagnosis of acute leukemia.
• Prepare the patient for further diagnostic tests, such as flow cytometry or cytogenetic analysis, which help in subtyping the leukemia (e.g., ALL or AML).
• Educate the patient and their family about the nature of acute leukemia, including treatment options such as chemotherapy or bone marrow transplantation.
• Assess for signs of infection, bleeding, or anemia due to the impaired production of normal blood cells.
• Collaborate with the healthcare team to initiate appropriate therapies based on the leukemia type and the patient’s overall health.

✘Incorrect answer options:

Lymphocytes. While lymphocytes are a type of white blood cell, mature lymphocytes are not diagnostic of acute leukemia. In acute lymphoblastic leukemia (ALL), the key diagnostic feature is the presence of immature lymphoid cells (lymphoblasts), not mature lymphocytes.

Thrombocytes. Thrombocytes, or platelets, are involved in blood clotting. While thrombocytopenia (low platelet count) is a common complication in leukemia due to bone marrow suppression, an overproduction of immature thrombocytes does not suggest leukemia. Leukemia primarily involves the overproduction of immature white blood cells.

Reticulocytes. Reticulocytes are immature red blood cells, and while reticulocytosis may occur in response to anemia, it is not a diagnostic feature of leukemia. In leukemia, the overproduction of immature white blood cells is the primary issue, rather than immature red blood cells.

EXPLANATION

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Bleeding and noticeable pallor. In pediatric patients with acute leukemia, bleeding and pallor are priority signs that indicate significant bone marrow suppression. Leukemia disrupts the normal production of blood cells in the bone marrow, leading to a reduction in red blood cells, white blood cells, and platelets. Pallor is a hallmark of anemia due to the decreased production of red blood cells, while bleeding is a critical sign of thrombocytopenia, a result of low platelet count. Both signs suggest that the child’s hematologic function is severely compromised, which can lead to life-threatening complications like severe hemorrhage or hypoxia.

Acute leukemia leads to the overproduction of immature white blood cells (blasts), crowding out the bone marrow and impairing the production of red blood cells (causing pallor) and platelets (resulting in bleeding). Monitoring for these signs is essential because they reflect the core dysfunction caused by leukemia. If left untreated, low platelet counts may result in uncontrolled bleeding, and low red blood cell levels can lead to significant oxygen deprivation to tissues.

Imagine the bone marrow as a bakery that produces three types of bread: one for energy (red blood cells), one for protection (white blood cells), and one for repairs (platelets). If the bakery is overrun with spoiled ingredients (leukemia cells), it can't make enough good bread. This leads to low energy (anemia), vulnerability to harm (bruising or bleeding), and a weakened ability to fix damage (poor clotting).

Nurses must take proactive measures to address the critical complications of bleeding and anemia in leukemia patients. The following actions are key in managing the child’s condition:

• Regularly assess for signs of active bleeding, such as nosebleeds, gum bleeding, or blood in the stool or urine.
• Monitor hemoglobin and hematocrit levels to detect worsening anemia, and consider blood transfusions if necessary.
• Ensure that the child avoids injury-prone activities due to their increased risk of bleeding from low platelet counts.
• Implement safety precautions, such as using soft toothbrushes and avoiding invasive procedures, to prevent trauma-induced bleeding.
• Administer prescribed platelet transfusions as needed to reduce the risk of spontaneous bleeding episodes.
• Encourage frequent rest to manage fatigue associated with anemia and oxygen deprivation.

✘Incorrect answer options:

Abdominal pain and loss of appetite. These symptoms can occur due to organ enlargement (hepatosplenomegaly) or gastrointestinal side effects of chemotherapy, but they are not as urgent or life-threatening as bleeding and pallor, which are direct consequences of leukemia’s impact on blood cell production.

Fatigue and the appearance of bruises. While fatigue and bruising are indeed symptoms of leukemia, they are usually early indicators of anemia and thrombocytopenia. However, bleeding and pallor are more critical signs that indicate the condition has progressed to a more severe state, requiring immediate attention to prevent complications.

Petechiae and the development of mucosal ulcers. Petechiae, tiny pinpoint spots caused by capillary bleeding, and mucosal ulcers may occur in leukemia, particularly in advanced thrombocytopenia and neutropenia. However, they are not as commonly prioritized as major bleeding and noticeable pallor, which signal more immediate and severe hematologic compromise.

EXPLANATION

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Between 4 and 12 years old. Acute lymphocytic leukemia (ALL) is most commonly diagnosed in children, with the peak age range for diagnosis occurring between 2 and 5 years old. While the answer option is "between 4 and 12 years old," it reflects the common demographic for pediatric ALL. ALL is the most frequent type of leukemia in children and accounts for approximately 75% of all childhood leukemia cases. The majority of diagnoses occur in early childhood, making it the most common cancer in children.

Although ALL can occur in adults, it is far more prevalent in children. In adults, the disease tends to have a poorer prognosis and may present differently than in pediatric cases. For educational purposes, Nurse Claire would highlight that the peak incidence of ALL is in early childhood, and it's crucial for nurses to recognize symptoms like fatigue, pallor, fever, bone pain, and bruising in young patients.

Think of ALL like a condition that most often affects young children who are just starting school. Just as kids grow quickly during those years, leukemia cells grow quickly in the body, making this age range especially vulnerable to the disease.

Understanding the peak age range of ALL helps nurses focus on early recognition and timely intervention, especially in pediatric settings. Key actions include:

• Monitor for signs of leukemia in young children, such as recurrent infections, unexplained fevers, and bruising.
• Educate parents about the early symptoms of ALL and the importance of regular pediatric check-ups.
• Collaborate with pediatric oncology specialists for prompt diagnosis and treatment in this vulnerable population.

✘Incorrect answer options:

Between 20 and 30 years old. While young adults may develop ALL, it is much less common than in children. The peak incidence for ALL is in early childhood, not in young adulthood. Adults who develop ALL often have a different prognosis compared to pediatric patients.

Between 40 and 50 years old. The incidence of ALL decreases significantly in middle-aged adults. Other types of leukemia, such as chronic lymphocytic leukemia (CLL), are more common in this age group.

Between 60 and 70 years old. This age group is more commonly affected by acute myeloid leukemia (AML) or chronic lymphocytic leukemia (CLL) rather than ALL. Although ALL can occur in older adults, it is far less common compared to pediatric cases.

EXPLANATION

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A stool test for Clostridium difficile. The most critical diagnostic test in this scenario is a stool test for Clostridium difficile (C. difficile). Mr. Harris is exhibiting classic symptoms of C. difficile infection (CDI), which include severe abdominal pain, fever, and foul-smelling diarrhea that is often described as having a "horse barn" odor. C. difficile is a potentially life-threatening bacterial infection that often occurs in immunocompromised patients, like those undergoing chemotherapy for leukemia, due to the disruption of normal gut flora from both chemotherapy and antibiotic use. Prompt identification and treatment are essential to prevent complications such as toxic megacolon, sepsis, or bowel perforation.

A stool test, typically involving a PCR assay or enzyme immunoassay for C. difficile toxins, is the most appropriate and immediate test to confirm the presence of the infection. Early diagnosis will allow for timely treatment with antibiotics like vancomycin or fidaxomicin, which are crucial in managing CDI.

Think of the digestive system as a balanced ecosystem. Chemotherapy can disrupt this balance, allowing harmful bacteria like C. difficile to grow unchecked. Testing the "ecosystem" (stool sample) helps confirm whether this harmful bacteria is causing the symptoms, so it can be treated before the imbalance causes more damage.

Nurse Amy should take immediate steps to manage the infection and prevent its spread:

• Isolate the patient using contact precautions to prevent transmission of C. difficile, as it is highly contagious.
• Monitor the patient’s vital signs and assess for signs of dehydration or sepsis, both potential complications of severe diarrhea and infection.
• Encourage hydration and replace electrolytes as needed to counteract fluid losses from diarrhea.
• Administer prescribed antibiotics specific for C. difficile infection and monitor the patient’s response to treatment.

✘Incorrect answer options:

An ELISA test for immune function. An ELISA test can be used to assess immune function, but it is not the most urgent test given Mr. Harris’s symptoms of severe abdominal pain, fever, and diarrhea, which suggest an active infection rather than an immune deficiency alone.

A full electrolyte panel and hemogram. A full electrolyte panel and hemogram (complete blood count) are important for assessing dehydration, electrolyte imbalances, and overall health status, especially given the risk of fluid loss from diarrhea. However, these tests are not specific to diagnosing the underlying cause of Mr. Harris’s symptoms, which is most likely C. difficile infection.

An abdominal flat plate X-ray. An abdominal X-ray could be helpful if there were signs of a bowel obstruction or perforation, but it is not the first diagnostic test to consider in this situation. The primary concern is confirming C. difficile infection through stool testing to guide appropriate treatment.

EXPLANATION

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A private room to protect her from infections brought by others. The most appropriate room placement for Mrs. Davis, who has thrombocytopenia and is undergoing treatment for acute lymphocytic leukemia (ALL), is a private room to protect her from infections that could be brought in by others. Leukemia and its treatments, such as chemotherapy, often lead to immunosuppression, which places patients at significant risk for infections. Additionally, thrombocytopenia increases the risk of bleeding, making infection prevention and careful monitoring even more critical.

A private room helps minimize exposure to other patients, visitors, and healthcare workers who may carry infectious agents. This is particularly important because infections in immunocompromised individuals can lead to serious complications, including sepsis or uncontrolled bleeding, due to their reduced ability to fight infections and low platelet counts.

Think of Mrs. Davis’s immune system like a delicate garden that is vulnerable to harmful bugs. A private room is like putting up a protective fence around the garden to keep bugs (infections) from causing damage, especially when the garden is fragile.

In addition to providing a private room, Nurse Kelly should implement other protective measures to reduce Mrs. Davis’s risk of infection and bleeding:

• Ensure that all healthcare workers and visitors practice strict hand hygiene before entering the room.
• Implement neutropenic precautions, including wearing masks, limiting the number of visitors, and avoiding contact with anyone showing signs of infection.
• Monitor Mrs. Davis closely for any signs of infection, such as fever, and initiate prompt treatment if needed.
• Educate the patient and family about the importance of minimizing exposure to potential sources of infection.

✘Incorrect answer options:

A private room to prevent her from infecting others. Mrs. Davis is not at risk of spreading an infection to others; rather, she is at risk of contracting infections due to her weakened immune system. The focus is on protecting her from outside infections, not preventing her from spreading illness to others.

A semiprivate room to provide social stimulation during her stay. While social support is important, the priority for immunocompromised patients like Mrs. Davis is infection prevention. A semiprivate room increases her risk of exposure to pathogens from another patient or their visitors, which could result in serious complications.

A semiprivate room to encourage sharing her feelings about her illness. Although emotional support is vital, the primary concern in this situation is protecting Mrs. Davis from infection and bleeding risks. Socialization should be secondary to physical protection, and a private room is necessary to minimize exposure to infectious agents.

EXPLANATION

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Gastric distension. Gastric distension is the least likely cause of the patient's symptoms of nausea and headaches. While gastric issues such as bloating or distension can cause discomfort and nausea, they do not typically cause headaches. Gastric distension is more commonly associated with conditions like constipation, overeating, or gastrointestinal obstructions and would not directly explain the concurrent headaches in this patient. In the context of acute lymphocytic leukemia (ALL), more specific systemic or neurological causes are likely to explain the patient’s symptoms.

Think of the stomach like a balloon. If it gets too full, it might make you feel uncomfortable or sick (nauseous), but it doesn’t typically affect your head. Headaches are usually linked to issues elsewhere, like the brain or blood vessels.

In this case, Nurse Olivia should explore other more likely causes of the patient’s nausea and headaches in a leukemia context.

✘Incorrect answer options:

Effects of radiation. Radiation therapy is commonly used in leukemia treatment, especially for CNS involvement, and can cause nausea and headaches as side effects. Radiation targeting the brain or spinal cord can cause meningeal irritation or increased intracranial pressure, which would explain headaches, while nausea can occur as a general side effect of radiation therapy.

Side effects from chemotherapy. Chemotherapy drugs are known to cause both nausea and headaches. Chemotherapy often induces nausea due to irritation of the gastrointestinal tract, while headaches may be related to systemic toxicity or dehydration, which can accompany chemotherapy treatment. In ALL, these are common side effects, especially during intensive treatment phases.

Meningeal irritation. In some cases of leukemia, particularly acute lymphocytic leukemia (ALL), leukemic cells can infiltrate the central nervous system (CNS), causing meningeal irritation. This can lead to symptoms such as headaches, nausea, vomiting, and neck stiffness. Leukemic meningitis is a potential complication of ALL and would be a significant cause of the patient's symptoms.

EXPLANATION

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Use a soft-bristle toothbrush and an electric razor. Bone marrow depression in leukemia patients results in pancytopenia, a reduction in all blood cell types: red blood cells, white blood cells, and platelets. This condition puts the patient at significant risk for bleeding due to thrombocytopenia (low platelet count), as well as infection due to neutropenia (low white blood cell count). Nurse Jenna should encourage the patient to use a soft-bristle toothbrush and an electric razor to help minimize the risk of injury and bleeding, which can be difficult to control when platelets are low. These measures help protect the patient from trauma to delicate tissues like the gums and skin, where even minor injuries could result in excessive bleeding.

The use of a soft-bristle toothbrush reduces the likelihood of gum bleeding, while an electric razor is safer than a traditional razor, as it lowers the risk of cuts or nicks that could lead to significant bleeding in someone with thrombocytopenia.

Think of the patient's platelets as the body’s "band-aids" that help stop bleeding. When there aren’t enough "band-aids," it’s best to avoid situations where injuries might happen—like using gentle tools (soft toothbrush and electric razor) to prevent harm.

Nurse Jenna should reinforce these precautions and also include additional safety measures to protect the patient from injury and infection:

• Avoid activities that could cause injury or bruising, such as contact sports or lifting heavy objects.
• Ensure the patient practices good hand hygiene and avoids exposure to people with infections.
• Encourage regular monitoring of lab values (e.g., platelet count, white blood cell count) to assess risk levels.

✘Incorrect answer options:

Increase activity levels and walk frequently. While moderate activity is beneficial, increasing activity levels, especially walking frequently, could put a leukemia patient with bone marrow depression at risk for falls or injuries. With thrombocytopenia, even minor injuries or trauma can lead to bleeding complications.

Sleep with the head of the bed slightly raised. Elevating the head of the bed may help patients with respiratory or gastroesophageal reflux issues, but it is not directly related to the prevention of complications from bone marrow depression. The priority here is preventing bleeding and infection, not improving sleep posture.

Drink citrus juices regularly for extra nourishment. While citrus juices are a good source of vitamin C, they can be acidic and may irritate the mucous membranes, potentially leading to mouth sores in patients undergoing chemotherapy. This is less important than preventing bleeding and injury, which is the primary concern in patients with thrombocytopenia due to bone marrow depression.

EXPLANATION

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The soles of the feet. Petechiae are small, pinpoint, red or purple spots caused by bleeding under the skin, which can be difficult to detect in individuals with darker skin tones. In African American patients or those with deeply pigmented skin, petechiae may be less visible in areas of high pigmentation. To improve visibility, nurses should assess petechiae in areas where the skin is lighter in color, such as the soles of the feet or the palms of the hands. These regions tend to have less pigmentation, making it easier to observe subtle changes, such as petechiae or bruising.

Think of checking for small red dots (petechiae) on a dark surface versus a light one. It’s much easier to spot them on the light surface. For patients with darker skin, areas like the palms or soles are like the lighter surface where these changes are easier to detect.

When assessing African American patients or individuals with darker skin, nurses should use good lighting and focus on less pigmented areas like the palms, soles, mucous membranes (e.g., the oral mucosa), and conjunctiva to evaluate for petechiae or other skin abnormalities, such as pallor or jaundice.

• Focus assessments on areas with lighter pigmentation (palms, soles, conjunctiva, and mucous membranes).
• Use palpation as part of the skin assessment to detect warmth or swelling in the areas of concern, especially in darker skin tones where color changes may be less apparent.
• Educate patients and families on signs of bleeding to report, such as sudden appearance of petechiae, bruising, or nosebleeds, especially during chemotherapy for leukemia.

✘Incorrect answer options:

The abdominal area. The abdominal area in people with darker skin tones can still have significant pigmentation, which may make petechiae more difficult to detect.

The thoracic region. Like the abdominal area, the thoracic region often has more pigmentation, making it less optimal for observing petechiae in darker-skinned individuals.

The earlobes. While earlobes can sometimes be used to assess color changes, they are not the best location for assessing petechiae in individuals with darker skin. Areas like the palms, soles, and mucous membranes provide a better contrast to detect subtle changes in pigmentation.

EXPLANATION

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To prevent a typical side effect caused by prednisone. Cimetidine, an H2 receptor antagonist, is often included in treatment regimens to reduce the risk of gastrointestinal irritation and ulcers, which are common side effects of corticosteroids like prednisone. Prednisone can increase the production of stomach acid, leading to gastritis, peptic ulcers, or gastrointestinal bleeding. Cimetidine helps by reducing the secretion of gastric acid, thereby protecting the stomach lining from the harmful effects of prednisone and preventing these complications.

Think of prednisone as a hot, acidic drink that can burn the stomach lining. Cimetidine acts like a protective lid on the cup, keeping the acid from spilling and causing harm, thereby protecting the stomach.

When a patient is receiving corticosteroids such as prednisone, nurses should focus on preventing gastrointestinal complications. This can include:

• Administer cimetidine as prescribed to help reduce gastric acid production and protect the gastrointestinal tract.
• Monitor the patient for any signs of gastrointestinal distress, such as nausea, abdominal pain, or tarry stools, which could indicate ulceration or bleeding.
• Encourage the patient to take prednisone with food to reduce the risk of irritation to the stomach lining.
• Provide education on the importance of adhering to both the prednisone and cimetidine regimen to prevent potential complications.

✘Incorrect answer options:

To reduce the secretion of pancreatic enzymes. Cimetidine does not play a role in regulating pancreatic enzymes. Its action is related to reducing stomach acid production by blocking histamine receptors in the stomach lining. Drugs like octreotide or enzyme supplements may be used to affect pancreatic enzyme activity.

To improve the effectiveness of methotrexate. Cimetidine does not enhance the effectiveness of methotrexate. While methotrexate is an important chemotherapy agent in leukemia treatment, cimetidine is primarily used to prevent gastrointestinal issues rather than to potentiate the action of other drugs.

To promote bowel movements. Cimetidine does not affect bowel motility or promote bowel movements. If constipation were a concern, other medications like stool softeners or laxatives would be considered. Cimetidine’s role is focused on protecting the gastrointestinal tract from acid-related injury.

EXPLANATION

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A history of hepatitis C five years ago. A history of hepatitis C permanently disqualifies an individual from donating blood, even if the infection was treated and the person has been symptom-free for years. Hepatitis C is a viral infection that affects the liver, and because it can be transmitted through blood, the risk of transmitting the virus to a recipient is too high, even if the donor has no active symptoms. Blood donation guidelines are very strict about hepatitis C, as blood safety is paramount, especially for immunocompromised patients like those with leukemia.

Even with antiviral treatment and possible clearance of the virus, former hepatitis C carriers are not permitted to donate blood, as there is a risk that the virus could still be latent or that traces could exist in the blood. This precaution ensures that transfusion recipients, who may already be vulnerable, are not exposed to bloodborne infections.

Think of donating blood like lending someone water from your well. If the well was once contaminated with a virus (like hepatitis C), even if the water looks clean now, there’s a chance the contamination might still linger, so it’s safer not to use that well at all.

Nurse Claire should ensure that the donor is thoroughly screened and educated about eligibility criteria for blood donation. Here are key steps to follow:

• Evaluate the medical history of potential donors, particularly for any history of bloodborne infections like hepatitis B, hepatitis C, or HIV.
• Ensure that all potential donors undergo serologic testing for bloodborne pathogens as part of the blood donation process.
• Explain to donors why certain medical conditions, such as hepatitis C, permanently disqualify them from donating, emphasizing patient safety.
• Provide alternative ways for the disqualified relative to support the patient, such as emotional support or participation in other care activities.

✘Incorrect answer options:

Cholecystitis was treated with cholecystectomy one year ago. A history of cholecystitis (inflammation of the gallbladder) that was treated with surgery (cholecystectomy) does not disqualify a person from donating blood. This condition is not related to any bloodborne pathogens or other risks that would impact the safety of the blood supply.

Asymptomatic diverticulosis. Diverticulosis is a condition where small pouches form in the colon, but it is generally not a reason to disqualify someone from donating blood, especially when asymptomatic. It does not involve systemic infections or bloodborne diseases, making it safe for blood donation.

Crohn’s disease that is currently in remission. Crohn’s disease, a type of inflammatory bowel disease, does not disqualify someone from donating blood as long as it is in remission and the person is not taking immunosuppressive medications. Crohn's disease does not directly affect the blood or pose an infection risk for recipients.