Nursing Care of the Client with Cancer Cancer Background Definition Family of complex diseases Affect different organs

and organ systems Normal cells mutate into abnormal cells that take over tissue Eventually harm and destroy host Historically, cancer is a dreaded disease Oncology Study of cancers Oncology nurses specialize in the care, treatment of clients with cancer Incidence and Prevalence Cancer accounts for about 25% of death on yearly basis Males: 3 most common types of cancer are prostate, lung and bronchial, colorectal Females: 3 most common types of cancer are breast, lung and bronchial, and colorectal Risk factors for cancer: (some are controllable; some are not) Heredity: 5 10% of cancers; documented with some breast and colon cancers Age: 70% of all cancers occur in persons > 65 Lower socio-economic status Stress Leads to greater wear and tear on body in general Diet: certain preservatives in pickled, salted foods; fried foods; high-fat, low fiber foods; charred foods, high fat foods, diet high in red meat Occupational risk: exposure to know carcinogens, radiation, high stress Infections, especially specific organisms and organ (e.g. papillomavirus causing genital warts and leading to cervical cancer) Tobacco Use: Lung, oral and laryngeal, esophageal, gastric, pancreatic, bladder cancers Alcohol Use: also tied with smoking Sun Exposure (radiation) e.g. skin cancer Nursing role includes health promotion to lower the controllable risks Routine medical check up and screenings Client awareness to act if symptoms of cancer occur Screening examination recommendations by American Cancer Society; specifics are made according to age and frequencies Breast Cancer: self-breast exam, breast examination by health care professionals, screening mammogram Colon and Rectal Cancer: fecal occult blood, flexible sigmoidoscopy, colonoscopy Cervical, Uterine Cancer: Papanicolaou (Pap) test Prostate Cancer: digital rectal exam, Prostate-specific antigen (PSA) test Physiology of Cancer Background Normal Cell Growth includes two events Replication of cellular DNA Mitosis (cell division) Cell cycle is under control of cyclins, and suppresor gene products which control process by working with enzymes;cyclins promote cell division suppresor gene products limit cell division Forms the basis of how some chemotherapeutic agents work against cancers Theories of Carcinogenesis (what causes cancer to occur) Cellular Mutation Cells begin to mutate (change the DNA to unnatural cell reproduction) Oncogenes/Tumor Suppressor Genes Abnormalities Oncogenes are genes that promote cell proliferation and can trigger cancer Tumor suppressor genes normally suppress oncogenes but are damaged Exposure to Known Carcinogens Act by directly altering the cellular DNA (genotoxic) Act by affecting the immune system (promotional) Viruses viruses break the DNA chain and mutates the normal cells DNA Epstein-Barr virus Human papilloma virus Hepatitis virus Drugs and Hormones Sex hormones often affect cancers of the reproductive systems (estrogen in some breast cancers; testosterone in prostate cancer) Glucocorticoids and steroids alter immune system Chemical Agents Industrial and chemical Can initiate and promote cancer Examples: hydrocarbons in soot ; arsenic in pesticides; chemicals in tobacco Physical Agents Exposure to radiation Ionizing radiation found in x-rays, radium, uranium UV radiation Sun, tanning beds

Immune function Protects the body from cancerous cells Increased rate of cancer in immunocompromised pts Neoplasms: also called tumors (mass of new tissue that grows independently of surrounding organs Types of neoplasms Benign Localized growths respond to bodys homeostatic controls Encapsulated Stop growing when they meet a boundary of another tissue Can be destructive Malignant Have aggressive growth, rapid cell division outside the normal cell cycle Not under bodys homeostatic controls Cut through surrounding tissues causing bleeding, inflammation, necrosis (death) of tissue Malignant neoplasms can recur after surgical removal of primary and secondary tumors and other treatments Malignant neoplasms vary in differentiation. Highly differentiated are more like the originating tissue Undifferentiated neoplasms consist of immature cells with no resemblance to parent tissue and have no useful function Malignant cells progress in deviation with each generation and do no stop growing and die, as do normal cells Malignant cells are irreversible, i.e. do not revert to normal Malignant cells promote their own survival by hormone production, cause vascular permeability; angiogenesis; divert nutrition from host cells Effects of Cancer Disturbed or loss of physiologic functioning, from pressure or obstruction a. Anoxia and necrosis of organs b. Loss of function: bowel or bladder obstruction c. Increased intracranial pressure d. Interrupted vascular/venous blockage e. Ascites f. Disturbed liver functioning G. Motor and sensory deficits Cancer invades bone, brain or compresses nerves Respiratory difficulties Airway obstruction Decreased lung capacity Hematologic Alterations: Impaired function of blood cells Secondary to any cancer that invades the bone marrow (leukemia) May also be caused by the treatment a. Abnormal wbcs: impaired immunity b. Diminished rbcs and platelets: anemia and clotting disorders Infections: fistula development and tumors may become necrotic; erode skin surface Hemorrhage: tumor erosion, bleeding, severe anemia Anorexia-Cachexia Syndrome: wasting away of client a. Unexplained rapid weight loss, anorexia with altered smell and taste b. Catabolic state: use of bodys tissues and muscle proteins to support cancer cell growth Paraneoplastic Syndromes: ectopic sites with excess hormone production a. Parathyroid hormone (hypercalcemia) b. Ectopic secretion of insulin (hypoglycemia) c. Antidiuretic hormone (ADH: fluid retention) d. Adrenocorticotropic hormone (ACTH) 7. Pain: major concern of clients and families Types of cancer pain 1. Acute: symptom that led to diagnosis 2. Chronic: may be related to treatment or to progression of disease Causes of pain 1. Direct tumor involvement including metastatic pain 2. Nerve compression 3. Involvement of visceral organs Physical Stress: body tries to respond and destroy neoplasm a. Fatigue b. Weight loss c. Anemia d. Dehydration e. Electrolyte imbalances 9. Psychological Stress a. Cancer equals death sentence b. Guilt from poor health habits c. Fear of pain, suffering, death d. Stigmatized Collaborative Care Diagnostic Tests: used to diagnose cancer Determine location of cancer

a. Xrays b. Computed tomography c. Ultrasounds d. Magnetic resonance imaging e. Nuclear imaging f. Angiography Diagnosis of cellular type of can be done through tissue samples from biopsies, shedded cells (e.g. Papanicolaou smear) washings a. Cytologic Examination: tissue examined under microscope b. Identification System of Tumors: Classification Grading -- Staging Classification: according to the tissue or cell of origin, e.g. sarcoma, from supportive Grading: a. Evaluates degree of differentiation and rate of growth b. Grade 1 (least aggressive) to Grade 4 (most aggressive) Staging a. Relative tumor size and extent of disease b. TNM (Tumor size; Nodes: lymph node involvement; Metastases) Tumor markers: specific proteins which indicate malignancy a. PSA (Prostatic-specific antigen): prostate cancer b. CEA (Carcinoembryonic antigen): colon cancer c. Alkaline Phosphatase: bone metastasis 4 Direct Visualization a. Sigmoidoscopy b. Cystoscopy c. Endoscopy d. Bronchoscopy e. Exploratory surgery; lymph node biopsies to determine metastases Other non-specific tests a. CBC, Differential b. Electrolytes c. Blood Chemistries: (liver enzymes: alanine aminotransferase (ALT); aspartate aminotransferase (AST) lactic dehydrogenase (LDH) Treatment Goals: depending on type and stage of cancer Cure 1. Recover from specific cancer with treatment 2. Alert for reoccurrence 3. May involve rehabilitation with physical and occupational therapy Control: of symptoms and progression of cancer 1. Continued surveillance 2. Treatment when indicated (e.g. some bladder cancer, prostate cancer) Palliation of symptoms: may involve terminal care if clients cancer is not responding to treatment Treatment Options (depend on type of cancer) alone or with combination Chemotherapy 1. Effects are systemic and kills the metastatic cells 2. Often combinations of drugs in specific protocols over varying time periods Much more effective then a single agent Consider the timing of the nadir of each drug The time when the bone marrow activity and WBC counts are at their lowest levels after chemo Different times for different drugs 3. Cell-kill hypothesis: with each cell cycle a percentage of cancerous cells are killed but some remain; repeating chemo kills more cells until those left can be handled by bodys immune system Classes of Chemotherapy Drugs Alkylating agents 1. Action: create defects in tumor DNA 2. Examples: Nitrogen Mustard, Cisplatin Antimetabolites 1. Action: similar to metabolites needed for vital cell processes Counterfeit metabolites interfere with cell division 2. Examples: Methotrexate; 5 fluorouracil 3. Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia Antitumor Antibiotics 1. Action: interfere with DNA 2. Examples: Actinomycin D, Bleomycin 3. Toxic Effect: damage to cardiac muscle Antimiotic agents 1. Action: Prevent cell division 2. Examples: Vincristine, Vinblastine 3. Toxic Effects: affects neurotransmission, alopecia, bone marrow depression Hormone agonist 1. Action: large amounts of hormones upset the balance and alter the uptake of other hormones necessary for cell division 2. Example: estrogen, progestin, androgen

Hormone Antagonist 1. Action: block hormones on hormone-binding tumors (breast, prostate, endometrium; cause tumor regression Decreasing the amount of hormones can decrease the cancer growth rate Does not cure, but increases survival rates 2. Examples: Tamoxifen (breast); Flutamide (prostate) 3. Toxic Effects: altered secondary sex characteristics 7. Hormone inhibitors Aromatase inhibitors (Arimidex, Aromasin) Prevents production of aromatase which is needed for estrogen production Used in post menopausal women Side effects Masculinizing effects in women Fluid retention Effects of Chemotherapy a. Tissues (fast growing) frequently affected b. Examples: mucous membranes, hair cells, bone marrow, specific organs with specific agents, reproductive organs (all fetal toxic, impair ability to reproduce). Administration of chemotherapeutic agents Trained and certified personnel, according to established guidelines Preparation 1. Protect personnel from toxic effects Drugs absorbed through skin and mucous membranes Protective clothing and extreme care 2. Extreme care for correct dosage; double check with physician orders, pharmacists preparation Proper management clients excrement Types of vascular access devices 1. PICC lines (peripherally inserted central catheters) 2. Tunnelled catheters (Hickman, Groshong) 3. Surgically implanted ports (accessed with 90o angle needle Managing side effects of chemotherapy A. Nausea and vomiting 80% of patients will develop it Antiemetics such as Zofran, Tigan, Compazine as well as Ativan to control the symptoms Monitor for dehydration and need for IV fluids B. Bone marrow suppression Decreased number of RBC Leads to hypoxia, fatigue Hgb 9.5-10 gm/dl require oral iron supplements Hgb below 8 gm/dl require transfusion May use Epogen to stimulate RBC production Decrease number of WBC (normal 4,500-11,000 mm3) especially neutrophils (normal 3,000-7,000 cells/cc) Neutropenia-count below 2000 Pt at extreme risk for infection May order granulocyte colony stimulating factor (leukine) to stimulate bone marrow to increase WBC count Neutropenic precautions Private room Good handwashing Monitor temp q 4 hours, monitor for chills, UTI, pneumonia Limit visitors to healthy adults No flowers or plants Monitor neutrophil count Thrombocytopenia Drop in platlet count (normal 150,000-400,000/mm3) below 100,000 Test pt for bleeding in stool and urine Avoid punctures for IV or IM Handle pt gently Use electric razor Avoid placing foley or rectal thermometers Avoid oral trauma with soft bristle brushes, avoid flossing, avoid hard candy Watch for ALOC, pupil changes that might indicate intracranial bleeds Stool softeners to avoid straining Mucocitis Inflammation and ulceration of mucous membranes and entire GI tract Rinse mouth with normal saline and peroxide every 12 hours Topical analgesic medication Avoid mouthwashes with alcohol Avoid spicy or hard food Watch nutritional status Alopecia Hair loss 2-3 weeks after treatment is started Affects all the hair, including eyebrows, eyelashes Within 4-8 weeks after treatment hair begins to grow back

Before hair loss, have the pt pick out a wig that is similar to hair color Peripheral neuropathy Numbness and tingling to fingers and toes in a glove and sock pattern May cause gait and possible fall problems Provide emotional and spiritual support to patient and families Surgery 1. Diagnosis, staging, and sometimes treatment of cancer 2. May be prophylaxis or removal of at risk tissue or organ prior to development of cancer (breast cancer) 3. Involves removal of body part, organ, sometimes with altered functioning (e.g. colostomy) 4. Debulking (decrease size of) tumors in advanced cases 5. Reconstruction and rehabilitation (e.g. breast implant post mastectomy) 6. Palliative surgery to improve the quality of life Removal of tumor tissue that is causing pain or obstruction 5. Psychological support to deal with surgery as well as cancer diagnosis Radiation Therapy Treatment of choice for some tumors to kill or reduce tumor, relieve pain or obstruction Destroy cancer cells with minimal exposure to normal cells Cells die or are unable to divide Delivery a. Teletherapy (external): radiation delivered in uniform dose to tumor Beam radiation b. Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it in the form of seeds Radiation source within the patient so pt emits radiation for a period of time and is a hazard to others c. Combination Goals a. Maximum tumor control with minimal damage to normal tissues b. Caregivers must protect selves by using shields, distancing and limiting time with client, following safety protocols Private room Caution sign on the door for radioactive material Dosimeter film badge by staff No pregnant staff Limit visitors to hour per day and keep them at least 6 ft from the source Treatment Schedules a. Planned according to radiosensitivity of tumor, tolerance of client b. Monitor blood cell counts Side Effects a. Skin (external radiation): blanching, erythema, sloughing, breakdown Use mild soak Dry skin with a patting motion, not rubbing Dont use powders or lotions unless prescribed by radiologist Wear soft clothing over the site Avoid the sun and heat b. Ulcerated mucous membranes: pain, lack of saliva (xerostoma) c. Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation d. Radiation pneumonitis 1-3 months after treatment Cough, SOB, fever Treated with steroids to decrease inflammation Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against tumor for human) Antibodies target specific substances needed by the cancer cell for growth (Herceptin for breast cancer) Gene therapy experimental May insert gene into the tumor cells to make them more susceptible to being killed by antiviral agents May insert genes for cytokines that increase their effectiveness in killing cancer cells Angiogenesis inhibitor drugs prevent new blood vessels from forming and delivering blood to the tissue Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation 1. Stimulation of nonfunctioning marrow or replace bone marrow 2. Common treatment for leukemias Pain Control 1. Includes pain directly from cancer, treatment, or unrelated 2. Necessary for continuing function or comfort in terminally ill clients 3. Goal is maximum relief with minimal side effects

4. Multiple combinations of analgesics (narcotic and non-narcotic) and adjuvants such as steroids or antidepressants; includes around the clock (ATC) schedule with additional medications for break-through pain 5. Multiple routes of medications 6. May involve injections of anesthetics into nerve, surgical severing of nerves radiation 7. May need to progress to stronger pain medications as pain increases and client develops tolerance to pain medication Nursing Diagnoses for Clients with Cancer Anxiety 1. Therapeutic interactions with client and family; community resources such as American Cancer Society, I Can Cope 2. Availability of community resources for terminally ill (Hospice care in-patient, home care) Disturbed Body Image 1. Includes loss of body parts (e.g. amputations); appearance changes (skin, hair); altered functions (e.g. colostomy); cachexic appearance, loss of energy, ability to be productive 2. Fear of rejection, stigma Anticipatory Grieving 1. Facing death and making preparations for death: will be consideration 2. Offer realistic hope that cancer treatment may be successful Risk for Infection Risk for Injury 1. Organ obstruction 2. Pathological fractures Altered Nutrition: less than body requirements 1. Consultation with dietician, lab evaluation of nutritional status 2. Managing problems with eating: anorexia, nausea and vomiting 3. May involve use of parenteral nutrition Impaired Tissue Integrity 1. Oral, pharyngeal, esophageal tissues (due to chemotherapy, bleeding due to low platelet counts, fungal infections such as thrush) 2. Teach inspection, frequent oral hygiene, specific non-irritating products, thrush control Oncologic Emergencies Pericaridal Effusion and Neoplastic Cardiac Tamponade 1. Concern: compression of heart by fluid in pericardial sac, compromised cardiac output 2. Treatment: pericardiocentesis Superior Vena Cava Syndrome 1. obstruction of venous system with increased venous pressure and stasis; facial and neck edema with slow progression to respiration distress Late signs are cyanosis, decreased cardiac output and hypotension 2. Treatment: respiratory support; decrease tumor size with radiation or chemotherapy Sepsis and Septic Shock 1. Early recognition of infection Patients at risk secondary to low WBC and impaired immune system 2. Treatment: prompt intervention with antibiotics and vasopressors D. DIC disseminated intravascular coagulation Triggered by severe illness, usually sepsis in cancer patients Abnormal clotting uses up existing clotting factors and platelets quickly then the pt hemorrhages Mortality rate is 70% Prevention of sepsis is key Spinal Cord Compression 1. Pressure from expanding tumor or vertebral collapse can cause irreversible paraplegia 2. Back pain initial symptom with progressive paresthesia and paralysis Paralysis is usually permanent 3. Treatment: early detection High dose corticosteroid to decrease the swelling radiation or surgical decompression Obstructive Uropathy 1. Concern: blockage of urine flow; undiagnosed can result in renal failure 2. Treatment: restore urine flow Hypercalcemia 1. High calcium (normal 9-10.5) usually from bone metastases 2. May also come from cancer of the lung, head, neck, kidney and lymph nodes that secrete parathyroid hormone that causes the bone to release calcium 2. Symptoms include fatigue, muscle weakness, polyuria, constipation, progressing to coma, seizures 3. Treatment restore fluids with intravenous saline which also increases the excretion of calcium loop diuretics increase calcium excretion

Calcium chelators such as mithracin Inhibit calcium resorption from the bone with calcitonin, diphosphonate Tumor Lysis Syndrome 1. Occurs with rapid necrosis of tumor cells with chemotherapy When tumor cells die they release potassium and purines Potassium (norm 3.5-5.5) elevation causes cardiac arrhthymias, muscle weakness, twitching, cramps Purines convert to uric acid which causes renal failure, flank pain, gout when elevated above 10 mg/dl Hyperphosphatemia with secondary to hypocalcemia causes heart block, HTN, renal failure Treatment Hydration Instruct pt to increase fluid intake before and after chemo May need IV hydration Diuretics to increase urine flow Allopurinol to increase uric acid excretion May need dialysis SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) 1. Ectopic ADH production from tumor leads to excessive hyponatremia 2. holds onto too much fluid which decreases sodium level (normal 135-145) 3. Symptoms Weakness, muscle cramps, fatigue, ALOC, headache, seizures 2. Treatment: restore sodium level Fluid restriction Increase sodium Antibiotic demeclocycline works in opposition to ADH Limits ADH effect on distal renal tubules so they can excrete water

CARE OF PATIENTS WITH CANCER A. Characteristics of Normal Cells The Biology of Normal Cells 1) Have limited cell division 2) Undergo Apoptosis 3) Show specific morphology 4) Perform specific differentiated functions 5) Adhere tightly together 6) Non migratory 7) Grow in orderly and well regulated manner 8) Are euploid * Normal cell growth (cell cycle) consists of 5 intervals or phases * Differentiation refers to the process whereby cells develop specific structures and functions in order to specialize in certain tasks * Cellular adaptation a. Hypertrophy refers to an increase in size of normal cells b. Atrophy refers to the shrinkage of cell size c. Hyperplasia refers to an increase in the number of normal cells d. Metaplasia refers to a conversion from the normal patters of differentiation of one type of cell into another type of cell not normal for that tissue e. Dysplasia refers to an alteration in the shape, size, appearance and distribution of cells f. Anaplasia refers to disorganized, irregular cells that have nor structure and have loss of differentiation; the result is always malignant B. Evolution of Cancer Cells 1. Cancer refers to a disease whereby cells mutate into abnormal cells that proliferate abnormally Neoplasia refers to an abnormal cell growth or tumor - a mass of new tissue functioning independently and serving no useful purpose 2. Invasion occurs when cancer cells infiltrate adjacent tissues surrounding the neoplasm 3. Metastasis occurs when malignant cells travel through the blood or lymph system and invade other tissues and organs to form a secondary tumor C. Characteristics of malignant cells 1. Rapid cell division and growth: regulation of the rate of mitosis is lost 2. No contact inhibition: cells do not respect boundaries of other cells and invade their tissue areas 3. Loss of differentiation: cells lose specialized characteristics of function for that cell type and revert back to an earlier, more primitive cell type 4. Ability to migrate (metastasize): cells move to distant areas of the body and establish new site malignant lesions (tumors) 5. Alteration in cell structure: differences are evident between normal and malignant cells with respect to cell membrane, cytoplasm and overall cell shape 6. Self-survival a. may develop ectopic sites to produce hormones needed for own growth b. can develop a connective tissue stroma to support growth c. May develop own blood supply by secreting angiotensin growth factor to stimulate local blood vessels to grow into tumor D. Epidemiology of Cancer 1. Incidence of cancer a. Cancer affects every age group though most cancer and cancer deaths occur in people older than 65 years of age b. Cancer ranks 3rd as the cause of morbidity in the Philippines c. Highest incidence of all cancer is prostate cancer d. Highest cancer incidence in males in order of frequency: prostate cancer, lung cancer and colorectal cancer e. Highest cancer incidence in females in order of frequency: breast cancer, lung cancer and colorectal cancer 2. Common sites of cancer and their sites of metastasis Cancer Type Sites of Metastasis 1. Brain Cancer Central Nervous System 2. Breast cancer Brain Liver Regional lymph nodes Vertebrae 3. Colon cancer Brain Liver Lung Lymph nodes Ovaries 4. Lung cancer Bone Brain

Liver Lymph nodes Pancreas Spinal cord 5. Prostate cancer Bladder Bone Liver External factors causing CANCER 1. Chemical Carcinogens- over 1,000 chemicals are known to be carcinogenic Alcoholic beverages (Liver, esophagus, mouth, breast colon) -- serves as a promoter in cancers of the liver and esophagus - when combined with tobacco, the risks for other cancers are even higher Anabolic Steroid (Liver) Arsenic (Lung; Skin) Asbestos (Lung; peritoneum) Benzene (Leukemia Diesel exhaust (Lung) Hair dyes (bladder) Pesticides (Lungs) Sunlight (Skin; eyes) Tobacco (Lungs; esophagus; mouth; pharynx; larynx smokeless tobacco (snuff and chewing tobacco) increases the risk of oral and esophageal cancers * long-term exposure to secondhand smoke increases the risk for lung and bladder cancers 2. Physical Carcinogens Radiation Chronic Irritation- GERD 3. Viral Carcinogens - some viral infections tend to increase risk of cancer Ex: Epstein Barr Genital herpes Papillomavirus Hepatitis B Human cytomegalovirus 4. Dietary Factors - diets in high fat, low in fiber and those containing nitrosamines found in preserved meats and pickled foods promote certain cancers such as colon, breast, esophageal and gastric Personal factors causing CANCER 1. Immune Functions 2. Age a. Increased risk for people over age of 65 b. Factors attributed to cancer in elderly include hormonal changes, altered immune responses and the accumulation of free radicals c. Age has been identified as the single most important factor related to the development of cancer 3. Gender a. certain cancers are more commonly seen in specific genders ex: breast cancer more common in female colon cancer more common in males 4. Genetic Risk - 15% of cancers may be attributed to a hereditary component Ex: Breast, colon, lung, ovarian and prostate cancers 5. Race can affect any population - African-Americans experience a higher rate of cancer than any other racial or ethnic group CARCINOGENESIS: Transformation of Normal Cells into Cancer Cells 1. Initiation occurs when carcinogen damages DNA - carcinogenesis cause changes in the structure and function of the cell at the genetic or molecular level. This damage may be reversible or may lead to genetic mutations if not repaired; however the mutations may not lead immediately to cancer 2. Promotion occurs with additional assaults to the cell, resulting in further genetic damage 3. These genetic events result in a malignant conversion 4. Progression the cells are increasingly malignant in appearance and behaviour and develop into an invasive cancer with metastases to distant body parts Comparison of the Characteristics of Normal and Cancer Cells Characteristic Normal Cells Cancer Cells Mitotic cell division Mitotic division lead to 2 daughter cells Mitosis leads to multiple daughter cells that may or may not resemble the

parent. Multiple mitotic spindles Appearance 1. Cells of same type homogeneous in size, shape, and growth 2. Cells cohesive, form regular pattern of expansion 3. Uniform size to nucleus 4. Have characteristic pattern of organization 5. Mixture of stem cells (precursors) and welldifferentiated cells 1. cells larger and grow more rapidly than normal; pleomorphic 2. Cells not as cohesive; irregular patterns of expansion 3. Larger, more prominent nucleus 4. Lack characteristic pattern of organization of host cell 5. Anaplastic, lack of differentiated cell characteristics, specific functions Growth pattern 1. do not invade adjacent tissue 2. Proliferate in response to specific stimuli 3. Grow in ideal conditions (ex: nutrients, oxygen, space, correct biochemical environment) 4. Exhibit contact inhibition 5. Cell birth equals or is less than cell death 6. Stable cell membrane 7. Constant or predictable growth rate 8. Cannot grow outside specific environment (ex: breast cells grow only in breast) 1. invade adjacent tissues 2. Proliferation in response to abnormal stimuli 3. Grow in adverse conditions such as a lack of nutrients 4. Do not exhibit contact inhibition 5. Cell birth exceeds cell death 6. Loss of cell control a result of cell membrane changes 7. Growth rate erratic 8. Able to break off cells that migrate through bloodstream or lymphatics or seed to distant sites and grow in other sites Function 1. have specific, 1. serve no useful purpose designated purpose 2. Contribute to the overall well-being of the host 3. Function in specific, predetermined manners (ex: cells in the thyroid secrete thyroid hormone) 2. do not contribute to the well-being of the host; parasitic, actually feed off host without contributing anything

3. If cells function at all, they do not function normally or they may actually cause damage (ex: lung cancer cells secrete ACTH and cause excessive stimulation of adrenal cortex) Other 1. develop specific antigens, characteristic of the particular cell formed 2. Chromosomes remain constant throughout cell division 3. Complex metabolic and enzyme pattern 4. Cannot invade, erode, or spread 5. cannot grow in present of necrosis or inflammation 1. develop antigens completely different from a normal cell 2. chromosomal aberrations 3. have more primitive and simplified metabolic and enzyme pattern 4. invade, erode and spread 5. grow in presence of necrosis and inflammatory cells such as lymphocytes and macrophages 6. exhibit periods of latency that vary from tumor to tumor 7. have own blood supply and supporting stroma Metastasis - ability of cancer cells to spread from the original site of the tumor to distant organs Stages: 1. Detachment * tumor cell loses cohesiveness and it has increasing motility * tumor cell detaches from the primary tumor and create defects in the basemement membranes with resulting stromal invasion and spread into the circulation 2. Migration * Cancer cells migrate via the lymph or blood circulation or by direct extension * the lymphatic system provides the most common pathway for the initial spread of malignant cancer cells * The blood vessels carry cancer cells from the primary tumor to the capillary beds of the lungs, liver and bones * Direct tumor extension of tumors to adjacent tissues also occurs 3. Dissemination * Cancer cells are established at the secondary site which may result from entrapment due to the size of the tumor clump, adherence to cells at the new site through specific interactions, or by binding to exposed basement membrane 4. Angiogenesis * Vascularization of the tumor The Immune System and Cancer Two critical components of the immune response 1. the ability to recognize a pathogen as foreign 2. the ability to mount a response to eliminate the pathogen * T-cell lymphocyte, macrophages, and antigens recognize cancers cells as non-self and destroy them Immune Surveillance Theory proposes that immune responses, particularly cell-mediated responses, provide a defense against cancer cells by recognizing the antigens on the surface of some neoplastic cells as foreign - they are killed by cytotoxic T cells that have receptors for specific tumor antigens and by interferon-activated natural killer (NK) lymphocytes and macrophages - macrophages phagocytize the pathogen and present it as antigen to T and B lymphocytes

 Failure of Immune Defenses - the immune system may be unable to recognize cancer cells as foreign or to mount an immune response due to the following: a. its immature, old or weak b. malnutrition or chronic ailment c. cancer cells escape detection because they resemble normal cells. Others produce substances that shield them from recognition or they may be coated with fibrin d. use of immunosuppressive drugs which can suppress immune system Classification of Neoplasms 1. Benign from latin word benigunus- kind 2. Malignant Comparision of the characteristics of Benign and Malignant neoplasm Characteristic Benign Neoplasm Malignant Neoplasm Speed Growth Grows slowly Usually continues to grow throughout life unless surgically removed May have periods of remission Usually grows rapidly Tends to grow relentlessly throughout life Rarely, neoplasm may regress spontaneously Mode of Growth Grows by enlarging and expanding Always remains localized; never infiltrates surrounding tissues Grows by infiltrating surrounding tissues May remain localized (in situ) but usually infiltrates other tissues Capsule Almost always contained within a fibrous capsule Capsule does not prevent expansion of neoplasm but does prevent growth by nfiltrations Capsule advantageous because encapsulated tumor can be removed surgically Never contained within a capsule Absence of capsule allows neoplastic cells to invade surrounding tissues Surgical removal of tumor difficult Cell characteristics Usually well differentiated Mitotic figures absent or scanty Anaplastic cells absent Cells function poorly in comparison with normal cells from which they arise If neoplasm arises in glandular tissue, cells may secrete hormones Usually poorly differentiated Large numbers of normal and abnormal mitotic figures present Cells tend to be anaplastic Cells too abnormal to perform any physiologic functions Occasionally a malignant tumor arising in glandular tissue secretes hormnes Recurrence Unusual when surgically removed Common following surgery because tumor cells spread into surrounding

tissues Metastasis Never occur Very common Effect of Neoplasm Not harmful to host unless located in area where it compresses tissue or obstructs vital organs Does not produce Always harmful to host Causes death unless removed surgically or destroyed by radiation or chemotherapy cachexia (weight loss, debilitation, anemia, weakness, wasting) Causes disfigurement, disrupted organ function, nutritional imbalances May result in ulcerations, sepsis, perforations, hemorrhage, tissue slough Almost always produces cachexia, which leaves person prone to pneumonia, anemia, and other conditions Prognosis Very good Tumor generally removed surgically Depends on cell type and speed of diagnosis Poor prognosis if cells are poorly differentiated and evidence of metastatic spread exists Good prognosis indicated if cells still resemble normal cells and there is no evidence of metastasis Classification of cancer according to tissue of origin 1. Carcinoma - refers to a tumor that arises from epithelial tissue; the name of the cancer identifies the location example: basal cell carcinoma 2. Sarcoma - refers to a tumor arising from supportive tissues; the name of the cancer identifies the specific tissue affected example: osteosarcoma Tissue of Origin Benign Neoplasms Malignant Neoplasms Connective Tissue Bone Fibrous tissue Adipose tissue Osteoma Fibroma Lipoma Osteosarcoma Fibrosarcoma Liposarcoma Epithelial Tissue Glandular Surface Adenoma Papilloma Adenocarcinoma Squamous cell carcinoma Hematopoietic Erythrocytes Granulocytes Lymphatic tissue Erythroleukemia Leukemia Hodgkins disease, malignant lymphoma Lymphocytes Plasma cells Lymphocytic leukaemia Multiple myeloma Cancer Prevention and Control 1. Prevention involves measures to avoid or reduce exposure to carcinogens - activities are aimed at interventions before pathologic change has

begun 2. Screening helps to identify high-risk populations and individuals 3. Early Detection involves finding a precancerous lesion or a cancer at its earliest, most treatable stage - also called secondary prevention - methods a. inspection b. palpation c. use of tests or procedures Approaches to Cancer prevention 1. Education 2. regulation prohibit the sale of tobacco and alcohol to minors, limiting smoking in public places, imposing excise taxes, regulating the use of manufactured carcinogens such as asbestos, and prohibiting carcinogens in foods 3. host modification - aims to alter the bodys internal environment to decrease the risk of or to reverse a carcinogenic process Cancer Prevention 1. Skin: Avoid exposure to sunlight 2. Oral: Annual oral examination 3. Breast: Monthly BSE from age 20 4. Lungs: Avoid cigarette smoking; annual chest x-ray 5. Colon: DRE for person over age 40. Rectal biopsy, proctosigmoidoscopic examination, Guiac stool examination for persons age 50 and above 6. Uterus: annual Paps smear from age 40 7. Basic: annual physical examination and blood examination Dietary Recommendations against cancer 1. Avoid obesity 2. Cut down on total fat intake 3. Eat more high fiber foods raw fruits and vegetables, whole grain cereal 4. Include food rich in vitamin A and C in daily diet 5. Include cruciferous vegetables in the diet-brocolli, cabbage, cauliflower, brussel sprouts 6. Be moderate in the consumption of alcoholic beverages 7. Be moderate in the consumption of salt-cured, smoked-cured and nitratecured foods Recommendations of the American Cancer Society for Early Cancer Detection 1. For detection of breast cancer a. Beginning at age 20, routinely perform monthly breast self-examination b. Women ages 20-39 should have breast examination by a healthcare provider every 3 years c. Women age 40 and older should have a yearly mammogram and breast self-examination by a healthcare provider 2. For detection of colon and rectal cancer a. all persons age 50 and older should have a yearly fecal occult blood test b. digital rectal examination and flexible sigmoidoscopy should be done every 5 years c. Colonoscopy with barium enema should be done every 10 years 3. For detection of uterine cancer a. yearly papanicolao (Pap) smear for sexually active females and any female over age 18 b. At menopause, high-risk women should have an endometrial tissue sample 4. For detection of prostate cancer a. beginning at age 50, have a yearly digital rectal examination b. beginning at age 50, have a yearly prostate-specific antigen (PSA) test American Cancer Societys seven warning signs of cancer (uses acronym CAUTION): 1. Change in bowel or bladder habits 2. A sore that does not heal 3. Unusual bleeding or discharge 4. Thickening or lump in breast or elsewhere 5. Indigestions or difficulty in swallowing 6. Obvious change in wart or mole 7. Nagging cough or hoarseness Diagnostic tests of Cancer 1. Biopsy/cytology a. Histologic and cytologic examination of specimens are performed by the pathologist on tissues collected by needle aspiration of solid tumors, exfoliation from epithelial surface, and aspiration of fluid from blood or body cavities b. Tissues may be obtained by excisional biopsy, incisional biopsy, and needle biopsy c. By examination of these tissues, the name, grade, and stage of the tumor can be identified 2. Papanicolao Test (Pap Smear)

Class I: Normal Class II: Inflammation Class III: Mild to moderate dysplasia Class IV: Probably malignant Class V: Malignant 3. Ultrasound 4. MRI 5. X-rays 6. CT scan 7. Radiographic techniques 8. Antigen Skin test 9. Laboratory tests a. Alpha-feto-protein b. HCG c. Prostatic Acid Phosphatase (PSA) d. Carcinoembroyenic antigens (CEA) 10. Endoscopic examination 11. Monoclonal antibodies C. Tumor markers 1. Tumor markers are protein substances found in the blood or blody fluids 2. Are released either by the tumor itself, or by the body as a defense in response to the tumor (called host response) 3. Tumor markers are derived from the tumor itself. And include the ff: a. Oncofetal antigens, present normally in fetal tissue, may indicate an anaplastic process in tumor cells; carcinoembyonic antigen (CEA) and alpha-fetoprotein (AFP) are examples of oncofetal antigens. b. Hormones are present in large quantities in the human body; however, high levels of hormones may indicate a hormone-secreting malignancy; hormones that may be utilized as tumor markers include the antidiuretic hormone (ADH), calcitonin, catecholamines, human chorionic gonadotropin (HCG), and parathyroid hormone (PTH) c. Isoenzymes that are normally present in a particular tissue may be released into bloodstream if the tissue is experiencing rapid, excessive growth as the result of tumor; are examples include neuron-specific enolase (NSE) and prostatic acid phosphatase (PAP) d. Tissue-specific proteins identify the type of tissue affected by malignancy; an example of a tissue-specific protein is the protasticspecific antigen (PSA) utilized to identify prostate cancer 4.Host-response tumor makers include the following: a. C-reactive protein b. Interleukin-2 c. Lactic dehydrogenase d. Serum Ferritin e. Tumor necrosis factor Staging 1. The TNM tumor system is utilized for classifying tumors a. T indicates the tumor size 1) T0 indicates no evidence of tumor 2) Tis indicates tumor in situ 3) T1,T2,T3,T4 indicate progressive degrees of tumor size and involvement b. N indicates lymph node involvement 1) N0 indicates no abnormal lymph nodes detected 2) N1a, N2a indicate regional nodes involved with increasing degree from N1a to N2a, no metastases detected 3) N1b, N2b, N3b indicate regional lymph nodes involvement with increasing Degree from N1b to N3b, metastasis suspected 4) Nx indicates inability to assess regional nodes c. M indicates distant metastases 1) M0 indicates no evidence of distant metastasis 2) M1, M2,M3 indicate ascending degrees of distant metastasis and includes distant lymph nodes Different Modalities for Cancer 1. Surgical interventions 2. Chemotherapy 3. Radiation therapy 4. Immunotherapy 6. Bone Marrow transplantation Surgical Intervention 1. Preventive surgery- removal of precancerous lesions or benign tumors 2. Diagnostic surgery- biopsy 3. Curative surgery- removal of an entire tumor 4. Reconstructive surgery improvement of structures and function of an organ 5. Palliative surgery relief of distressin signs and symptoms; retardations of metastasis Common Nursing Techniques and Procedures A. Radiation therapy 1. Is used to kill a tumor, reduce the tumor size, relieve obstruction, or decrease pain

2. Causes lethal injury to DNA, so it can destroy rapidly multiplying cancer cells, as well as normal cells 3. Can be classified as internal radiation therapy (bachytherapy) or external radiation therapy (teletherapy) B. The client undergoing brachytheraphy ( internal radiation) 1. Sources of internal radiation a. Implanted into affected tissue or body cavity b. Ingested as a solution c. Injected as a solution into the bloodstream or body cavity d. Introduced through a catheter into the tumor 2. Side effects of internal radiation a. Fatigue b. Anorexia c. Immunosuppression d. Other side effects similar to external radiation 3. Priority nursing diagnoses: Impaired tissue integrity; fatigue; anxiety; risk for infection; Social isolation; Imbalanced nutrition: less than body requirements 4. Client education a. Avoid close contact with others until treatment is completed b. Maintain daily activities unless contraindicated, allowing for extra rest periods as needed c. Maintain balanced diet; may tolerate food better if consumes small, frequent meals d. Maintain fluid intake ensure adequate hydration (2-3 liters/day) e. If implant is temporary, maintain bedrest to avoid dislodging the implant. f. Excreted body fluids may be radioactive; double-flush toilets after use g. Radiation therapy may lead to bone marrow suppression 5. Nursing management of client receiving internal radiation a. Exposure to small amounts of radiation is possible during close contact with persons receiving internal radiation: understand the principles of protection from exposure to radiation: time, distance, and shielding 1) Time: minimize time spent in close proximity to the radiation source; a common standard is to limit contact time to 30 minutes total per 8-hour shift; minimum distance of 6 feet used when possible 2) Distance: maintain the maximum distance possible from the radiation source 3) Shielding: use lead shields and other precautions to reduce exposure to radiation b. Place client in private room c. Instruct visitors to maintain at least a distance of 6 feet from the client and limit visitors to 10-30 minutes d. Ensure proper handling and disposal of body fluids, assuring the containers are marked appropriately e. Ensure proper handling of bed linens and clothing f. In the event of a dislodged implant, use long-handled forceps and place the implant into a lead container; never directly touch the implant g. Do not allow pregnant woman to come into any contact with radiation sources; screen visitors and staff for pregnancy h. If working routinely near radiation sources, wear a monitoring device to measure exposure i. Educate client in all safety measures 6. Evaluation: client demonstrates measures to protect others from exposure to radiation, identifies interventions to reduce risk of infection, remains free from infection, achieves adequate fluid and nutritional intake, and participates in activities of daily living (ADLs) at level of ability C. The client undergoing external radiation therapy (teletheraphy) 1. The radiation oncologist marks specific locations for radiation treatment using a semipermanent type of ink a. Treatment is usually given 15-30 minutes per day, 5 day per week, for 2-7 weeks b. The client does not pose a risk for radiation exposure to other people 2. side effects of external radiation therapy a. Tissue damage to target area (erythema, sloughing, hemorrhage) b. Ulcerations of oral mucous membranes c. Gastrointestinal effects such as nausea, vomiting, and diarrhea d. Radiation pneumonia e. Fatigue f. Alopecia g. Immunosuppression 3.Priority nursing diagnoses: risk for infection; impaired skin integrity; social isolation; disturbed body image; anxiety; fatigue 4. Client education exam for external radiation a. Wash the marked area of the skin with plain water only and pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders or medications on the site during the duration of the treatment; do not wash off the treatment site marks b. Avoid rubbing, scratching, or scrubbing the treatment site; do not apply

extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor c. Wear soft, loose-fitting over the treatment area d. Protect skin from sun exposure during the treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun-blocking agents with sun protector factor (SPF) of at least 15 e. Maintain proper rest, diet, and fluid intake as essential to promoting health and repair of normal tissues f. Hair loss may occur; choose a wig, hat, or scarf to cover and protect head (refer to care of client with alopecia later in chapter) 5. Nursing management of the client receiving external radiation a. Monitor for adverse side effects of radiation b. Monitor for significant decreases in white blood cell counts and platelet counts c. Client teaching (refer to later sections for management of immunosuppression, thrombocytopenia 6. Evaluation; client identifies interventions to reduce risk of infection, remains free from infection, achieves adequate fluid and nutritional intake, participates in activities of daily living (ADLs) at level of ability, and maintains intact skin. The Client Undergoing a Bone Marrow Transplant (BMT) 1. BMT used in the treatment of leukemias, usually in conjunction with radiation or chemotherapy a. Autologous BMT the client is infused with own bone marrow harvested during remission of disease b. Allogenic BMT the client is infused with donor bone marrow harvested from a healthy individual 2. The bone marrow is usually harvested from the iliac crest, then frozen and stored until transfusion 3. Before receiving the BMT, the client must first undergo a phase of immunosuppressive therapy to destroy the immune system, infection, bleeding, and death are major complications that can occur during this conditioning phase 4. After immunosuppression, the bone marrow is transfused intravenously through a central line 5. Side of BMT a. malnutrition b. infection related to immunosuppression c. bleeding related to thrombocytopenia 6. Priority Nursing Diagnoses a. Risk for infection b. Risk for hemorrhage c. Risk for imbalanced nutrition d. Social isolation e. Anxiety 7. Nursing Management of client undergoing a bone marrow transplant a. Monitor for graft-versus-host disease b. Provide private room for the hospitalized client; client will be hospitalized for 6-8 weeks c. Encourage contact with significant others by using telephone, computer, and other means of communication to reduce feelings of isolation d. Refer to management for imbalanced nutrition, immunosuppression and thrombocytopenia 8. Evaluation: client evaluates understanding of risks and participates in activities that reduce risk of infection, hemorrhage, and malnutrition; client demonstrates effective coping mechanisms The Client Undergoing other therapeutic interventions 1. Immunotherapy/biologic response modifiers (BMR) a. Enhances the persons own immune responses in order to modify the biologic processes resulting in malignant cells b. Currently considered experimental in use c. Monoclonal antibodies: antibodies are recovered from an inoculated animal with a specific tumor antigen, then given to the person with that particular cancer type; the goal is: destruction of the tumor d. Cytokines: normal growth-regulating molecules possessing antitumor abilities 1) Interleukin-2(IL-2) increases immune response effective and destroys abnormal cells 2) Interferons are substances produced by cells to protect them from viral infection and replication; interferon-alpha 2b is most commonly used 3) Hematopoietic growth factors such as granulocyte colonystimulating factor (G-CSF) and erythropoietin, balance the suppression of granulocytes and erythrocytes resulting from chemotherapy e. natural killer cells (NK cells) : exert a spontaneous cytotoxic effect on

specific cancer cells; they also secrete cytokines and provide a resistance to metastasis 2. Gene therapy a. Current use in investigational b. Increases susceptibility of cancer cells to the destruction by other treatments; insertion of specific genes enhances ability of clients own immune system to recognize and destroy cancer cells 3. Photodynamic theory a. Used to treat specific superficial tumors such as those of the surface of bladder, bronchus, chest wall, head, neck and peritoneal cavity b. Photofirin, a photosensitizing compound, is administered intravenously where it is retained by malignant tissue c. Three days after injection, the drug is activated by a laser treatment which continues for 3 more days d. The drug produces a cytotoxic oxygen molecule (singlet oxygen) e. During intravenous administration, monitor for chills, nausea, rash, local skin reactions, and temporary photosensitivity f. Drug remains in tissues 4-6 weeks after injection; direct or indirect exposure to sun activates drug, resulting in chemical sunburn; educate client to protect skin from exposure to sun Oncologic Emergencies: Diagnosis and Management 1. Spinal Cord Compression a. Occurs secondary to pressure from expanding tumors b. Early symptoms include back and leg pain, coldness, numbness, tingling, paresthesias, progression leads to bowel and bladder dysfunction, weakness, and paralysis c. Early detection is essential: investigate all complaints of back pain or neurological changes d. Treatment is aimed at reducing tumor size by radiation and/or surgery to relieve compression and prevent irreversible paraplegia; may receive corticosteroids to reduce cord edema e. Nursing interventions include early recognition of symptoms, neurological checks and medication administration 2. Superior vena cava syndrome a. Compression or obstruction of the superior vena cava (SVC) b. Usually associated with cancer of the lungs and lymphomas c. signs and symptoms are the result of blockage of venous circulations of head, neck, and upper trunk d. Early signs and symptoms are periorbital edema and facial edema e. Symptoms progress to edema of neck, arms, and hands, difficulty swallowing, shortness of breath f. Late signs and symptoms are cyanosis, altered mental status, headache, and hypotension g. Death may occur if compression is not relieved h. Treatment included high-dose radiation to shrink tumor and relieve symptoms i.Nursing interventions include: a. Monitoring vital signs b. providing oxygen support c. preparing tracheostomy if necessary d. initiating seizure precautions e. administering corticosteroids to reduce edema 3. Disseminated intravascular coagulopathy (DIC) a. Severe disorder of coagulation, often triggered by sepsis, whereby abnormal clot formation occurs in the microvasculature; this process depletes the clotting factors and platelets, allowing extensive bleeding to occur tissue hypoxia occurs as a result of the blockage of blood vessels from the clots b. Signs and symptoms are related to decreased blood flow to major organs (tachycardia, oliguria, dyspnea) and depleted clotting factors (abnormal bleeding and hemorrhage) c. Treatment includes anticoagulants to decrease stimulations of coagulation and transfusion of one or more of the following: 1) fresh frozen plasma (FFP) 2) cryoprecipitate 3) platelets 4) packed RBC d. Nursing interventions include assessing client, monitoring for bleeding, applying pressure dressings to venipuncture sites, and preventing risk of sepsis e. Mortality for clients experiencing DIC is greater than 70% despite aggressive treatment 4. Cardiac tamponade a. Pericardial effusion secondary to metastases or esophageal cancer can lead to compression of heart, restricting heart movement and resulting in cardiac tamponade b. Signs and symptoms are related to cardiogenic shock or circulatory collapse: anxiety, cyanosis, dyspnea,hypotension, tachycardia,tachypnea,impaired levels of consciousness, and increased central venous pressure c. Pericardiocentesis is performed to remove fluid from pericardial sac d. Nursing interventions

1) administering oxygen 2) maintaining intravenous line 3) Monitoring vital signs 4) hemodynamic monitoring 5) administration of vasopressor agents COMMON CANCER DISORDERS I. BREAST CANCER - unregulated growth of abnormal cells in breast tissue Etiology and pathophysiology A. cause is unknown but many risk factors influence development 1. Female gender and white Caucasian race 2. family history of mother or sister with breast cancer 3. medical history of cancer of other breast, endometrial cancer or atypical Hyperplasia 4. Menarche before age 12 (early) or menopause after age 50(Late) 5. First birth after 30 years of age, oral contraceptive use (early or prolonged), prolonged use of estrogen replacement therapy 6. Lifestyle factors: high-fat diet, obesity, high socioeconomic status, breast trauma, smoking, ingesting more than 2 alcoholic drinks daily 7. Exposure to radiation through chest x-ray, fluoroscopy B. Begins as a single transformed cells and is hormones-dependent; does not develop in women without functioning ovaries who never received hormones replacement therapy C. Most often occurs in ductal areas of breast D. Noninvasive: does not penetrate surrounding tissues; may be ductal or lobular; usually diagnosed through mammogram or nipple discharge E. Invasive: penetration of tumor into surrounding tissue Manifestations 1. Lump in upper outer quadrant of breast, usually nontender but may be tender 2. dimpling of breast tissue surrounding nipple, or bleeding from the nipple 3. Asymmetry with affected breast being higher 4. Regional lymph nodes swollen and tender Management 1. Radiation therapy 2. Mastectomy a) Segmental mastectomy or lumpectomy; removes the tumor and margin of breast tissue surrounding the tumor b) simple mastectomy removal of the complete breast but no other structures c) Modified radical mastectomy removal of the breast and axillary lymph nodes but chest wall muscles are not resected d) Radical mastectomy removal of the breast, axillary lymph nodes and underlying chest wall muscles e) Breast reconstruction may be performed at the time of mastectomy or may be done at a later time; can be accomplished through submuscular breast implant, placing an implant after using a tissue expander, using muscles with intact blood supply from the back or abdomen, or creating a free muscle flap with the gluteus maximus muscle 3. Medication therapy a. Tamoxifen (Novadex) interferes with estrogen activity for treating advanced breast cancer b. Chemotherapy when axillary nodes are involved Care of patient undergoing mastectomy 1. Maintain usual postoperative assessment 2. Begin emotional support before surgery and continue in postoperative period 3. Turn, cough and deep breathe to prevent respiratory complications; restrictive surgical dressing may decrease chest expansion 4. Position client on back or unaffected side 5. Jackson-Pratt drain or Hemovac may be in place to drain fluids that accumulate when lymph nodes are removed 6. Note signs of bleeding on dressing and reinforce pressure dressing as needed 7. Encourage early range of motion exercise to prevent contractures are lymphedema 8. Use unaffected arm only to provide IV fluids and take blood pressure 9. Discharge instructions a) Use caution when lifting heavy objects with arms on affected side b) Avoid injury and infection on affected side; wear rubber gloves when washing dishes and garden gloves when working outside c) Dont allow procedures, such as blood pressure or venipunctures on the affected side d) Refer client to support group for psychosocial support B. PROSTATE CANCER - unregulated growth of abnormal cells in the prostate gland Etiology/pathophysiology 1. Adenocarcinoma is most common type; high levels of testosterone may play a Role 2. Usually begins in peripheral tissue on back and sides of the gland

3. Metastasis via lymph and venous changes is common; bony tissue is major site of distant metastasis- especially pelvic bones and spine 4. Is seen predominantly over 40 years of age Clinical Manifestations 1. Clients in early stages often show no symptoms; tumor may be found during digital prostate exam 2. Genitourinary: dysuria, frequency, reduced force of stream, hematuria, nocturia,abnormal prostate found on DRE 3. Musculoskeletal: back pain, migratory bone pain, bone or joint pain 4. Neurologic: nerve pain, muscle spasms, bowel or bladder dysfunction, bilateral weakness of lower extremities 5. Systemic: fatique and weight loss Diagnostic and Laboratory tests 1. Prostate-specific antigen (PSA) levels 2. Transurectal ultrasound (obtained if PSA results are abnormal) 3. tissue biopsy 4. bone scan 5. MRI 6. CT scans to detect metastasis Therapeutic Management 1. Hormone therapy 2. Radiation therapy 3. Brachy therapy (Radioactive seeds implanted in the prostate) 4. Prostatic cryosurgery 5. Surgery a) Orchiectomy decreases androgen production b) Radical procedures include removal of gland, capsule,ampulla,vas deferens,seminal vesicles, adjacent lymph nodes, and cuff of bladder neck c) Suprapubic prostatectomy abdominal and bladder incisions to remove prostate tissue d) Retropubic prostatectomy low abdominal incision without opening bladder e) Perineal prostatectomy incision between scrotum and anus (perineal area) f) Homium laser laser treatment; less bleeding, fewer complications and shorted hospital day 6. Medication therapy a. estrogen therapy of luteinizing hormone antagonist (Lupron) given to slow rate of growth and extension of tumor Nursing Management of Patient Undergoing Prostate Surgery 1. Maintain usual postoperative assessment 2. If dressings are present, monitor for drainage and change as needed 3. Monitor vital signs closely for 24 hours, observing for signs of hemorrhage (frank blood in urine, large blood clots, decreased haemoglobin and hematocrit, tachycardia, and hypotension) 4. IN clients who have a urinary catheter following surgery, traction may be applied against the prostatic fossa to prevent bleeding; the balloon at the tip of the catheter exerts pressure to prevent hemorrhage; the surgeon positions the external end of the catheter by anchoring it tightly to the clients inner thigh to maintain traction; the catheter should not be repositioned 5. A client who has a large indwelling catheter may feel the urge to void, which results from stimulation of the micturition center, explain to the client that this is a normal sensations; efforts by the client to void or strain will increase the risk of bleeding and aggravate pain 6. Continuous bladder irrigation (CBI) may be ordered on a client postoperatively a. The purpose of the CBI is to prevent the formation of blood clots b. If blood clots do form, the urinary catheter will become plugged and prevent outflow of urine; the obstruction will also cause bladder spasms and pain c. A key nursing intervention for the client in CBI is to keep the outflow from the catheter light pink or clear; the rate of administration of the irrigating solution is therefore titrated to keep the color of the outflow this color and prevent blood clots from forming; it is essential to calculate intake and output to determine true urine output d. Indications that the rate of the irrigations is inadequate include: decreased outflow from the catheter; bladder spasms; and dark-colored or frankly bloody drainage

7. Monitor client for signs of hemorrhage;bladder spasms and frank bloody output may indicate bleeding 8. The irrigating solution used during and after surgery may be absorbed causing fluid shifts and dilutional hyponatremia, referred to as TURP syndrome; monitor the client for signs of hyponatremia and bradycardia, nausea and vomiting, monitor serum sodium levels and haemoglobin and hematocrit; in addition, other signs of volume excess will also be evident, including hypertension and confusion 9. If manual irrigations are ordered, maintain sterile technique 10. Medicate as needed for pain

1. A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide? a. Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin b. Increase in the number of normal cells in a normal arrangement in a tissue or an organ c. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found d. Alteration in the size, shape, and organization of differentiated cells 2. During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? a. Recommending that the client discontinue chemotherapy b. Providing a solution of hydrogen peroxide and water for use as a mouth rinse c. Monitoring the client's platelet and leukocyte counts d. Checking regularly for signs and symptoms of stomatitis 3. To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard? a. The client is maintained on strict bed rest. b. The head of the bed is at a 30-degree angle. c. The client receives a complete bed bath each morning. d. The nurse checks the applicator's position every 4 hours. 4. A client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis? a. Stool Hematest b. Carcinoembryonic antigen (CEA) c. Sigmoidoscopy d. Abdominal computed tomography (CT) scan 5. The nurse is teaching a male client to perform monthly testicular selfexaminations. Which of the following points would be appropriate to make? a. Testicular cancer is a highly curable type of cancer. b. Testicular cancer is very difficult to diagnose. c. Testicular cancer is the number one cause of cancer deaths in males. d. Testicular cancer is more common in older men. 6. After being in remission from Hodgkin's disease for 18 months, a client develops a fever of unknown origin. The physician orders a blind liver biopsy to rule out advancing Hodgkin's disease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. The nurse suspects that these findings result from: a. bleeding in the liver caused by the liver biopsy. b. perforation of the colon caused by the liver biopsy. c. an allergic reaction to the contrast media used during the liver biopsy. d. normal postprocedural pain, with a change in the level of consciousness resulting from the preexisting fever. 7. A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomy, appendectomy, and lymphadenectomy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse? a. Abdominal pain b. Hypoactive bowel sounds c. Serous drainage from the incision d. Shallow breathing and increasing lethargy 8. A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction? a. "Keep the stoma uncovered." b. "Keep the stoma dry." c. "Have a family member perform stoma care initially until you get used to the

procedure." d. "Keep the stoma moist." 9. A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to: a. helping the client cope with body image changes. b. ensuring adequate nutrition. c. maintaining a patent airway. d. preventing injury. 10. The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover: a. cancerous lumps. b. areas of thickness or fullness. c. changes from previous self-examinations. d. fibrocystic masses. 11. A patient with relapsing Hodgkins disease presents with weight gain, foot ulcers, vision problems, elevated blood sugar, oral candidiasis, and new onset of wildly swinging mood changes. What is the most likely etiology of this patients psychiatric symptoms? (A) Adverse effects of bleomycin (B) Adverse effects of prednisone (C) Adverse effects of vincristine (D) Normal psychiatric response to having cancer 12. -hCG) level -human chorionic gonadotropin ( A 41-year-old pregnant woman sees her obstetrician because of new-onset vaginal bleeding. Although she is only 4 months pregnant, her doctor notes that her uterus is the size usually seen at 6 months of gestation. Maternal blood works shows a >5 times the upper limit of normal. If left untreated, what is a possible consequence of the patients condition? (A) Choriocarcinoma (B) Coma (C) Fetal neural tube defects (D) Ovarian cancer 13. Oncology Nurse Test Questions about Hydrops fetalis that occurs in the setting of a certain type of thalassemia. What is the underlying mechanism leading to this event? -globin chains binding tighter to oxygen (A) Excess -globin chains binding weaker to oxygen (B) Excess -globin chains binding tighter to oxygen (C) Excess (D) Excess gamma-globin chains binding tighter to oxygen 14. A 56-year-old man who is a health care worker presents to his physician with vague abdominal discomfort. A physical examination reveals a tender liver, palpable to 6 cm below the costal margin and scleral icterus. His laboratory studies are significant for an aspartate aminotransferase activity of 200 U/L and an alanine aminotransferase activity of 450 U/L. A CT scan of the abdomen shows a dominant solid nodule in the liver. The marker most likely to be elevated in this patient is also a good indicator of which of the following malignancies? (A) Choriocarcinoma (B) Colorectal carcinoma (C) Melanoma (D) Yolk sac carcinoma 15. A 57-year-old man presents to his physician with a 4-month history of worsening fatigue and generalized weakness. Further questioning reveals that his clothes fit him more loosely now than they had in the past. Physical examination reveals generalized lymphadenopathy and hepatosplenomegaly. Lymph node biopsy specimens are sent to the pathologist with the presumptive diagnosis of lymphoma. Which of the following types of neoplastic cell is most common in non-Hodgkins lymphoma? (A) B lymphocyte (B) Myeloblast (C) Plasma cell

(D) Reed-Sternberg cell 16. A 29-year-old man presents to his primary care physician with a painless testicular mass. Laboratory studies show an elevated serum human chorionic gonadotropin level. Which of the following is the most likely site of nodal metastasis in this tumor? (A) Deep inguinal lymph nodes (B) External iliac lymph nodes (C) Gluteal lymph nodes (D) Para-aortic lymph nodes 17. A 28-year-old woman comes to the physician concerned about an excessive amount of bleeding from her gums when she brushes her teeth. Her laboratory results show an increased partial thromboplastin time and an increased bleeding time, but are otherwise unremarkable. Which of the following treatments will most likely alleviate this patients symptoms? (A) Cryoprecipitate (B) Factor VIII concentrate (C) Fresh frozen plasma( correction : vitamin K) (D) Low-molecular-weight heparin 18. Nurse Questions about a 29-year-old woman, who is 32 weeks pregnant and has been in the hospital for 3 days because of pyelonephritis, starts oozing blood from her intravenous lines and bleeding from her gums. Petechiae are also noted in her skin. Laboratory tests show a platelet count of 98,000/mm3, hematocrit of 38%, WBC count of 8000/mm3, and a prolonged prothrombin time. What other laboratory anomaly would also be expected? (A) Elevated D-dimer levels (B) Elevated factor VII levels (C) Elevated fi brinogen levels (D) Elevated protein C levels 19. A 62-year-old woman presents to the clinic complaining of frequent bleeding while brushing her teeth and easy bruising. She reports she recently had pneumonia and was treated with a broad-spectrum antibiotic. Laboratory tests show: Prothrombin time: 18 seconds Partial thromboplastin time: 37 seconds Platelet count: 231,000/mm3 Hematocrit: 37% WBC count: 4800/mm3 The cofactor that is deficient in this patient is needed for the carboxylation of glutamate residues of which of the following? (A) Factors II, VII, VIII, and X (B) Factors VII, VIII, IX, and XII (C) Proteins C and S and factors IX, X, XI, and XII (D) Proteins C and S, prothrombin, and factors VII, IX, and X 20. A 20-year-old African-American man develops anemia after being treated for a urinary tract infection. A peripheral blood smear shows RBC lysis and precipitates of hemoglobin within the RBCs. Which of the following drug classes most likely caused his hemolytic anemia? (A) Aminoglycosides (B) Fluoroquinolones (C) Macrolides (D) Sulfonamides 21. Several drugs are used to prevent myocardial infarction in patients with acute coronary syndrome. One class of drugs binds to the glycoprotein receptor IIb/IIIa on activated platelets, thereby interfering with platelet aggregation. This prevents renewed formation of clots that could block the lumen of the cardiac vessels. Which of the following is an example of this class of drug? (A) Abciximab (B) Clopidogrel (C) Leuprolide (D) Selegiline 22. A 49-year-old man presents to the emergency department complaining that my skin has turned yellow. Physical examination reveals the man is significantly jaundiced. He has no abdominal pain and has a negative Murphys sign. The physician is concerned that he can feel the patients gallbladder and orders a CT scan. What is the most likely cause of this patients jaundice? (A) Acute hepatitis (B) Choledocholithiasis (C) Cholelithiasis (D) Pancreatic cancer 23. Nurse Questions about a 34-year-old man who comes to the emergency department complaining of the sudden onset of vomiting and epigastric abdominal pain radiating to the back. On physical examination, the patient is afebrile and has abdominal tenderness; decreased bowel sounds are noted, as is diffuse bruising that he describes as having appeared suddenly. He also reports continuous epistaxis. Laboratory tests show a slightly elevated WBC count, thrombocytopenia, increased amylase and lipase activity, increased prothrombin time (PT) and partial thromboplastin time (PTT), and the presence of fibrin split products. An abdominal ultrasound performed at the bedside shows a dilated common bile duct. Which of the following is the most likely etiology of this patients abnormal coagulation profile? (A) Acute hepatitis (B) Acute pancreatitis (C) Appendicitis (D) Perforated gastric ulcer 24. A 70-year-old man comes to his physician for a routine physical examination. Although he is asymptomatic, a blood test shows an abnormal level of immunoglobulin. After further testing, he is diagnosed with monoclonal gammopathy of undetermined significance. Which of the following is the current treatment for monoclonal gammopathy of undetermined significance? (A) Alendronate (B) Anticoagulation (C) High-dose steroids (D) No treatment 25. A 69-year-old man has a tumor removed from the cerebellopontine angle because a CT scan shows a 2-cm sharply circumscribed mass adjacent to the right pons extending into the right cerebellar hemisphere. He reports a 3-month history of dizziness and a 4-year history of progressive hearing loss. Grossly, the tumor specimen appears as a single irregular fragment of tan-pink soft tissue that measures slightly less than 2 cm. A microscopic pathology report indicates that the specimen consists of compact areas of spindle cells with pink cytoplasm that form whirls and palisades. Which of the following types of tumors would most likely result in these findings? (A) Medulloblastoma (B) Meningioma (C) Neurofibroma (D) Schwannoma 1) D - Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia. 2) B - To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen peroxide and water for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer viscous lidocaine or systemic analgesics as prescribed. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain. 3) C - The client shouldn't receive a complete bed bath while the applicator is in place. In fact, she shouldn't be bathed below the waist because of the risk of radiation exposure to the nurse. During this treatment, the client should remain on strict bed rest, but the head of her bed may be raised to a 30- to 45-degree angle. The nurse should check the applicator's position every 4 hours to ensure that it remains in the proper place.

made, the most likely cause is glucocorticoid psychosis. 4) C - Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer. 5) A- Testicular cancer is highly curable, particularly when it's treated in its early stage. Self-examination allows early detection and facilitates the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger men. 6) B - After any invasive procedure, the nurse must stay alert for complications in the affected region in this case, the abdomen. This client exhibits classic signs and symptoms of a perforated colon severe abdominal pain, fever, and a decreasing level of consciousness. After detecting these findings, the nurse must notify the physician immediately the client is experiencing a medical emergency and requires abdominal surgery and bowel resection. There is no reason to suspect bleeding resulting from the liver biopsy, although this condition must be ruled out. Bleeding would cause hypotension and signs of decreasing perfusion to major organs, not severe pain. Liver biopsy doesn't involve the use of contrast media. 7) D - Shallow breathing with a change in the level of consciousness, such as increasing lethargy, may indicate a respiratory complication for example, atelectasis or carbon dioxide retention. To avoid respiratory complications, the nurse should encourage turning, coughing, deep breathing, and ambulation during the early postoperative period. Abdominal pain, hypoactive bowel sounds, and serous drainage from the incision are expected findings during the first few days after this type of surgery. 8) D - The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities. 9) C - Rapid growth of cancer cells in the esophagus may put pressure on the adjacent trachea, jeopardizing the airway. Therefore, maintaining a patent airway is the highest care priority for a client with esophageal cancer. The other options, although appropriate for a client with this disease, are less crucial than maintaining airway patency. 10) C- Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant. 11) B - Correct Rationale: This patient is presenting with some of the classic adverse effects of steroid therapy, which is often part of treatment for Hodgkins disease. These include the physical signs of Cushings syndrome (weight gain, moon facies, thin skin, muscle weakness, and brittle bones), along with cataracts, hypertension, increased appetite, elevated blood sugar, indigestion, insomnia, nervousness, restlessness, and immunosuppression. However, in addition, prednisone is known to produce profound mood changes known as glucocorticoid psychosis. A is Incorrect. Rationale: The typical adverse effects of bleomycin are pulmonary fibrosis, skin changes, and myelosuppression. Bleomycin is part of the ABVD cancer chemotherapy regimen against Hodgkins: Adriamycin (doxorubicin), Bleomycin, Vinblastine, and Dacarbazine. C is Incorrect. Oncology Nurse Test Questions Rationale: Common adverse effects of vincristine are areflexia and peripheral neuritis. Vincristine is part of the MOPP cancer chemotherapy regimen used against Hodgkins disease: Mechlorethamine, vincristine (Oncovin), Procarbazine, and Prednisone. D is Incorrect. Rationale: Wildly swinging mood is suggestive of cyclothymic disorders, which are common in patients with chronic medical illness. However, given that this disorder requires 2 years of symptoms before a definitive diagnosis can be 12) A - Correct Oncology Nurse Test Questions Rationale: -hCG level is much higher than normal. Moles can be either partial or complete and are caused by either fertilization of an egg that has lost its chromosomes or fertilization of a normal egg with two sperm. Partial moles may contain some fetal tissue but no viable fetus, and a complete mole contains no fetal tissue. Hydatidiform moles must be surgically removed because the chorionic villi may embolize to distant sites and because moles may lead to choriocarcinoma, an aggressive neoplasm that metastasizes early but is very responsive to chemotherapy. The patient has a hydatidiform mole. Hydatidiform moles are cystic swellings of the chorionic villi. They usually present in the fourth and fifth months of pregnancy with vaginal bleeding. On exam the uterus is larger than expected for gestational age and the serum B is Incorrect. Rationale: Coma is a possible outcome of eclampsia, not of a hydatidiform mole. Preeclampsia is the triad of hypertension, proteinuria, and edema. Eclampsia occurs when seizures accompany the symptoms of preeclampsia. This patient does not have any of these symptoms. C is Incorrect. -hCG levels are normal in these patients. -fetoprotein levels in amniotic fluid and maternal serum; Oncology Nurse Test Questions Rationale: Neural tube defects are usually detected in utero by increased D is Incorrect. -hCG levels. This patient has a hydatidiform mole, not ovarian cancer. Hydatidiform moles do not predispose patients to ovarian cancer. Rationale: Ovarian cancers are often accompanied by an increase in blood cancer antigen 125 levels, not 13) D - Correct Oncology Nurse Test Questions Rationale: -thalassemia), excess gamma-globin chains accumulate, leading to the formation of tetramers known as hemoglobin Barts. These tetramers bind so strongly to oxygen that the fetal tissues are not oxygenated properly. This severe tissue anoxia leads to hydrops fetalis, an abnormal fluid accumulation in at least 2 fetal compartments. -globin genes are missing (as in the most severe type of When the A is Incorrect. -chains are not expressed until after birth. -Thalassemia usually does not have negative effects on the fetus because -thalassemia minor or major. -globin chains would be expected in -thalassemia. Excess -globin chains in globin genes is deleted, leading to accumulation of other globin chains. For this reason, one would not expect to see accumulation of -Thalassemia occurs when one or more Rationale: B is Incorrect. -thalassemia -chains in Rationale: There is no excess of C is Incorrect. Excess -chains are expressed. -globin chains make tetramers known as HbH. HbH does have a higher affinity for oxygen, and there is usually tissue hypoxia associated with this disease. However, hydrops fetalis is not associated with this condition because the hypoxia occurs in the adult when -globin chains have been deleted. Here, -thalassemia), in which three -globin chains would be seen in the case of hemoglobin H (HbH) disease (another type of Rationale: 14) D - Correct Oncology Nurse Test Questions Rationale: -Fetoprotein is a marker for hepatomas but can also be elevated in patients with germ cell tumors, such as yolk sac tumors. Tumor markers should not be used for primary diagnoses, but for confirmation and to monitor therapy. -1-antitrypsin deficiency, and carcinogens. This vignette suggests a malignancy of the liver. Hepatomas are highly associated with chronic hepatitis B and C infections, which are often found in health care workers due to needle stick injuries. Other risk factors for hepatomas include Wilsons disease, hemochromatosis, alcoholic cirrhosis, A is Incorrect. -human chorionic gonadotropin. This marker is also elevated with hydatidiform moles and gestational trophoblastic tumors. The presence of a hepatoma has no effect on this marker. Rationale: The marker for choriocarcinoma is B is Incorrect. Rationale: The marker for colorectal carcinoma is carcinoembryonic antigen.

This marker is nonspecific and is also produced by pancreatic, gastric, and breast carcinomas. The presence of a hepatoma has no effect on this marker. C is Incorrect. Rationale: The marker for melanoma is S-100. This marker also is elevated with neural tumors and astrocytomas. The presence of a hepatoma has no effect on this marker. 15) A - Correct Oncology Nurse Test Questions Rationale: Neoplastic B lymphocytes are the cells of origin in most non-Hodgkins lymphomas (90% of cases), with the notable exception of lymphoblastic lymphoma, which is typically dominated by T lymphocytes. B is Incorrect. Rationale: Myeloblasts are the neoplastic cells in acute myelogenous leukemia. C is Incorrect. Rationale: Plasma cells are the neoplastic cells in multiple myeloma. Multiple myeloma also affects patients in their 50s and 60s. However, at presentation patients with multiple myeloma usually have pathologic fracture caused by lytic lesions, hypercalcemia because of bone resorption, and repeated infection because of decreased production of normal immunoglobulins. Urine analysis in patients with multiple myeloma shows Bence Jones proteinuria with a monoclonal spike on electrophoresis. D is Incorrect. Rationale: Reed-Sternberg cells are the neoplastic cells in Hodgkins disease. Under light microscopy, Reed-Sternberg cells appear as large binucleate cells with abundant cytoplasm and large owl-eye nucleoli. 16) D - Correct Rationale: The testes begin life high in the abdomen and descend to their final resting place in the scrotum. The lymphatic drainage from the testes, therefore, is to the para-aortic lymph nodes in the lumbar region just inferior to the renal arteries. A is Incorrect. Rationale: The deep inguinal nodes drain the vessels in the spongy urethra and may become enlarged in some sexually transmitted diseases or other causes of urethritis. B is Incorrect. Nurse Questions Rationale: External iliac nodes drain the bladder. C is Incorrect. Rationale: Gluteal lymph nodes drain the deep tissue of the buttocks. 17) A - Correct Nurse Questions Rationale: This woman suffers from von Willebrands disease, the most common inherited bleeding disorder; it results from a defective form or overall deficiency of vWF. vWF has two functions: it serves as the ligand for platelet adhesion to a damaged vessel wall, and it also is the plasma carrier of factor VIII. Due to platelet dysfunction and lack of a carrier for factor VIII, the unique lab finding in this disease consists of an increased bleeding time and an increased partial thromboplastin time. Cryoprecipitate is the precipitate that remains when fresh frozen plasma is thawed. It contains sufficient normal vWF to correct the bleeding dyscrasia. In addition to prolonged bleeding from mucosal surfaces as in this patient, other symptoms include easy bleeding and skin bleeding. B is Incorrect. Rationale: Factor VIII concentrate is used to treat individuals with hemophilia A, an inherited condition that results in factor VIII deficiency. C is Incorrect. Rationale: Fresh frozen plasma (FFP) is used to treat several factor deficiencies, including V, VII, X, and XI. FFP administration will replace several factor deficiencies, although factor concentrations in FFP tend to vary. Unlike cryoprecipitate, FFP does not contain von Willebrand factor or fi brinogen. FFP may be needed for inherited factor XI deficiency or as a source of factor V in severe cases of disseminated intravascular coagulation when platelet concentrates and cryoprecipitate do not correct the factor V, VIII, and fibrinogen consumption defects.( correction : vitamin K can be used to reverse the effects of warfarin, a vitamin K antagonist the inhibits vitamin K dependent clotting factors . It will not correct a vWF deficiency) D is Incorrect. Rationale: LMWH is an anticoagulant that acts predominantly on factor Xa. This patient is in need of a procoagulant rather than an anticoagulant. LMWH can be administered subcutaneously. One advantage of LMWH over heparin is that the partial thromboplastin time does not need to be routinely monitored with this drug.

18) A - Correct Nurse Questions Rationale: DIC can occur in the setting of obstetric complications, sepsis, malignancy, and other conditions. It is described as a thrombohemorrhagic process because there are microthrombi throughout the body, and coagulation factors and platelets are consumed actively. The active conversion of fibrinogen to fibrin as part of the convergence of both clotting cascades leads to decreased levels of fibrinogen. At the same time, anticoagulation factors such as plasmin and protein C are being activated, leading to fibrinolysis and increased levels of D-dimers in the circulation. B is Incorrect. Rationale: DIC leads to consumption of coagulation factors; therefore, a drop in factor VII levels would be expected. C is Incorrect. Rationale: Fibrinogen is actively converted to fibrin in the setting of DIC; therefore, a decrease in the levels of fibrinogen would be expected. D is Incorrect. Rationale: Because the anticoagulation factors are also being activated and consumed during DIC, protein C levels would decrease. 19) D - CorrectNurse Questions Rationale: -carboxylation of glutamate residues of prothrombin; factors VII, IX, and X; and proteins C and S. Vitamin K deficiency is uncommon; however, it can occur in the setting of oral broadspectrum antibiotics, which suppress the flora of the bowel and interfere with the absorption and synthesis of this vitamin. It can also be associated with other conditions related to fat malabsorption and diffuse liver disease, or in the neonatal period when the intestinal flora have not developed and the liver reserves of vitamin K are small. Vitamin K deficiency usually presents with bleeding diathesis, hematuria, melena, bleeding gums, and ecchymoses. The patient has a prolonged prothrombin time, likely indicating a deficiency in one of the factors involved with the extrinsic pathway. Vitamin K is a fat-soluble vitamin that is a cofactor for the A is Incorrect. Rationale: The activity of factor VIII does not depend on vitamin K. B is Incorrect. Rationale: The activities of factors VIII and XII do not depend on vitamin K. C is Incorrect. Rationale: The activities of factors IX and XII do not depend on vitamin K. 20) D - Correct Nurse Questions Rationale: This patient likely has glucose 6-phosphate dehydrogenase deficiency, which is common in African-Americans, and demonstrates characteristic Heinz bodies (precipitates of hemoglobin) within RBCs. Hemolysis can be precipitated by certain drugs, such as sulfonamides, isoniazid, aspirin, ibuprofen, primaquine, and nitrofurantoin A is Incorrect. Rationale: Aminoglycosides are commonly associated with nephro- and ototoxicity. B is Incorrect. Rationale: Fluoroquinolones may cause some gastrointestinal upset, damage to cartilage in children, and tendonitis and tendon rupture in adults. C is Incorrect. Rationale: Macrolide toxicity includes gastrointestinal discomfort, acute cholestatic hepatitis, eosinophilia, and skin rashes.