Nokea
A 15-year-old female presents with 1 month of fatigue and 3 days of chest pain and shortness of breath. Her physical exam is unremarkable. A chest x-ray shows a large mediastinal mass that is greater than 33% of the diameter of her chest cavity. A biopsy shows nodular sclerosing, classic Hodgkin lymphoma (cHL). Metastatic workup at diagnosis, including CT scan of neck, chest, abdomen, and pelvis and PET scan, shows no other site of disease. According to the Ann Arbor staging system, the patient has which stage of cHL?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: A
Rationale: The correct answer is A: Stage I. In the Ann Arbor staging system for Hodgkin lymphoma, Stage I indicates involvement of a single lymph node region or a single extralymphatic organ or site. In this case, the patient's disease is limited to the mediastinum without involvement of other lymph nodes or organs. The large mediastinal mass is considered as a single site of disease. The absence of disease involvement in other areas based on the metastatic workup supports the classification as Stage I. The other choices (B, C, D) are incorrect because they represent more extensive disease involving multiple lymph node regions or extralymphatic organs, which is not the case in this patient.
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You receive a phone call that a 3-year-old patient on long-term warfarin therapy for congenital heart disease has an international normalized ratio (INR) of 5.8. On further history, you learn the patient and several family members have had recent gastrointestinal illnesses, but the patient is recovering. His mother reports he is not experiencing bleeding symptoms. Which of the following interventions would be most reasonable in this clinical scenario?
- A. Hold 1 to 2 doses of warfarin and recheck INR
- B. Administer oral vitamin K therapy
- C. Administer fresh frozen plasma (FFP)
- D. Administer recombinant factor VIIa
Correct Answer: A
Rationale: The correct answer is A: Hold 1 to 2 doses of warfarin and recheck INR. In this scenario, the patient's elevated INR of 5.8 indicates an increased risk of bleeding due to excessive anticoagulation. Since the patient is not experiencing bleeding symptoms and is recovering from gastrointestinal illness, temporarily holding 1 to 2 doses of warfarin is the most reasonable intervention to prevent bleeding complications while allowing the INR to normalize. Rechecking the INR after holding the doses will help assess the patient's response to the intervention. Choices B, C, and D are incorrect because administering oral vitamin K therapy, FFP, or recombinant factor VIIa are more aggressive interventions that are not warranted in this case where the patient is asymptomatic and recovering from a transient illness.
You are seeing a 2-year-old girl with new onset of fever and bronchitis. She has maculopapular rash and hepatosplenomegaly. Blood smear shows leukocytosis (100,000/mm3), anemia, and thrombocytopenia. Ancillary tests include fetal hemoglobin of 80% and normal blood karyotype. What is the most likely diagnosis?
- A. Leukemoid Reaction
- B. Acute lymphoblastic leukemia (ALL)
- C. Chronic myeloid leukemia (CML)
- D. Juvenile myelomonocytic leukemia (JMML)
Correct Answer: D
Rationale: The most likely diagnosis in this case is Juvenile myelomonocytic leukemia (JMML). JMML is a rare myelodysplastic/myeloproliferative neoplasm seen in young children. The clinical presentation of fever, rash, hepatosplenomegaly, leukocytosis, anemia, and thrombocytopenia is consistent with JMML. The presence of fetal hemoglobin of 80% is a key finding in JMML, as it is a distinguishing feature. Additionally, a normal blood karyotype rules out chromosomal abnormalities commonly seen in other leukemias. Leukemoid reaction (Choice A) is characterized by a reactive increase in leukocyte count due to an underlying condition, but it does not explain the other findings in this case. Acute lymphoblastic leukemia (ALL - Choice B) primarily affects lymphoid cells, not myeloid cells as seen in this case. Chronic myeloid leukemia (C
Which of the following statements about myeloablative, myeloablative but reduced toxicity, reduced intensity, and non-myeloablative approaches is not correct?
- A. Myeloablative approaches are needed for high-risk malignancies to maximize depth of remission and decrease the likelihood of relapse.
- B. Reduced intensity regimens can be successfully used for most nonmalignant disorders to minimize risk of late effects.
- C. Reduced intensity regimens can markedly decrease the risk of transplant-related mortality in patients who have underlying significant comorbidities but at the cost of more relapse and possibly more graft-versus-host disease.
- D. Non-myeloablative regimens are used for the very highest risk patients to minimize toxicity and for certain diseases such as aplastic anemia.
Correct Answer: B
Rationale: The correct answer is B because reduced intensity regimens are used to minimize toxicity and late effects, not for most nonmalignant disorders. Myeloablative approaches are needed for high-risk malignancies to maximize remission depth (A), reduced intensity regimens can increase transplant-related mortality in high-risk patients (C), and non-myeloablative regimens are used for the highest risk patients and certain diseases like aplastic anemia (D).
A female patient's hematocrit level is 50% and oxygen saturation is 98% on room air. What should the nurse suspect as being the cause for this patient's hematocrit level?
- A. Dehydration
- B. Chronic renal failure
- C. Bone marrow suppression
- D. Bleeding esophageal varices
Correct Answer: A
Rationale: The correct answer is A: Dehydration. Dehydration can lead to hemoconcentration, resulting in an elevated hematocrit level. When a person is dehydrated, the plasma volume decreases, causing an increase in the proportion of red blood cells in the blood, leading to a higher hematocrit level. In this case, the patient's high hematocrit level of 50% is likely due to dehydration rather than the other options. Oxygen saturation being 98% on room air indicates adequate oxygenation, ruling out chronic renal failure, bone marrow suppression, and bleeding esophageal varices as potential causes for the high hematocrit level in this patient.
A 36-year-old woman presented with weakness, lassitude, and feeling easily tired. Her bone marrow aspirate showed 15% myeloblasts and reduced erythropoiesis. The most likely cause is
- A. Acute myeloid leukemia
- B. Acute lymphoid leukemia
- C. Myelofibrosis
- D. Myelodysplastic syndrome
Correct Answer: D
Rationale: The correct answer is D: Myelodysplastic syndrome. Given the patient's age, symptoms, and bone marrow findings of myeloblasts with reduced erythropoiesis, it aligns with the characteristics of myelodysplastic syndrome. This condition involves abnormal blood cell production leading to cytopenias and an increased risk of progression to acute myeloid leukemia. Acute myeloid leukemia (Choice A) typically presents with higher blast percentages and more aggressive symptoms. Acute lymphoid leukemia (Choice B) is less likely due to the presence of myeloblasts in the bone marrow. Myelofibrosis (Choice C) is characterized by fibrosis in the bone marrow, which is not indicated in this case.