Examination

AUGUST 1985, VOL 42, N O 2

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hxamination HOMESTUDYPROGRAM

Jane was a normal, happy, vital and active 17year-old when she was diagnosed as having acute nonlymphocytic leukemia. She entered the hospital and began the painful process of chemotherapy. With chemotherapy she achieved a remission for a period of 6 months, after which she suffered a relapse. At this time, the option of a bone marrow transplant was discussed with her and her family. She was told of the different types of transplant donors they would consider, her chances for a cure, and the different phases she would go through in her treatment. 1. In addition to acute nonlymphocytic leukemia, bone marrow transplantation is a treatment approach for a) hemolytic anemia b) aplastic anemia c) Frascotti’s anemia d) chronic lymphmytic anemia 2. A bone marrow transplant for Jane will accomplish which of the following. It will a) result in a complete eradication of cells containing the Philadelphia chromosome b) replace her diseased marrow cells with healthy marrow cells c) deplete her bone marrow reserves d) negate the need for highdose chemotherapy and total body irradiation 3. Depending on the source of the bone marrow used for transplantation for Jane, three types of marrow transplantation can be performed: allogeneic, autologous,and syngeneic.Which of the following is true of allogeneic marrow transplantation? It is a) rarely used 206

b) always requires a sibling donor who is HLAcompatible c) applied most successfully in the treatment of acute leukemia d) never used in conjunction with lethal highdose chemotherapy and total body irradiation 4. Which of the following are true of autologous bone marrow transplantation? 1. it involves a special freezing technique to preserve the patient’s own bone marrow 2. there is no risk of HLA-incompatibility with this technique 3. the patient’s marrow need not be free of tumor involvement, because the cryopreservation process will destroy the tumor Cells 4. the patient’s own marrow is stored for reinfusion as an autograft following chemotherapy and radiation treatments that destroy the underlying malignancy a) 1,2, and 4 c) 2, 3, and 4 b) 1,2, and 3 d) 2 and 3 5. Which of the following is true of syngeneic marrow transplantation? a) it requires an identical twin donor b) it requires donor marrow from any HLAcompatible sibling c) tumor contamination of the marrow is sometimes a complication d) it is the most common form of transplantation 6. Jane was told by her physicians and n u m that the toxic effects of bone marrow transplantation are substantial. She was told

AUGUST 1985, VOL 42, NO 2

that the percentage of patients who die because of complications related to the transplant process within the first year is a) 75% b) 25% c) 50% d) 10% The clinical course Jane will undergo for her bone marrow transplant is divided into phases. After a suitable donor is chosen €orthe procedure, she will start with a pretransplant conditioning regimen consisting of highdose cyclophosphamide and total body irradiation. In the next phase the donated bone marrow is infused, and in the last the new bone marrow begins to function. 7. Which of the following side effects of the cyclophosphamidemight Jane experience? 1. nausea and vomiting 2. cataracts 3. mumitis 4. pancytopenia c) 1,2, and 3 a) 1 and 3 d) 2,3, and 4 b) 1 and 4 8. Which of the following side effects of the total body irradiation might Jane experience? 1. diarrhea 2. decrease in saliva 3. increase in tear production 4. parotid gland swelling c) 1, 2, and 4 a) 1,2, and 3 b) 2,3, and 4 d) 1,3, and 4 9. Another of the side effects Jane might experience is hemorrhagic cystitis. Because of this Jane’s nurse will 1. monitor Jane’s vigorous intravenous hydration instituted to induce diuresis 2. realize that the hemorrhagic cystitis is a result of irradiation on the bladder tissue 3. monitor Jane’s urine output for microscopic blood and adequate flow 4. realize that the hemorrhagic cystitis is a result of a reaction between the cyclophosphamide and the bladder epithelium a) 1,2, and 3 c) 1 and 2 only d) 2 and 3 only b) 1,3, and 4 10. Several days after the conditioning regimen, when the chemotherapyhas been metabolized and excreted from the body, Jane is given the donor marrow by

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a) injections into the iliac crests b) infusions through her regular intravenous line c) infusions through a Hickman catheter d) injections into the sternum 11. Over a period of several weeks after Jane has been given her new bone marrow a) the new marrow cells migrate to other areas of her body and eventually into the marrow spaces where they begin forming new blood cells, a phase. referred to as the “blast” phase b) her blood counts continue to fall to extremely low levels from the prior effects of chemotherapy and radiation c) she is supported with blood, platelet, and additional marrow transfusions d) she is highly unlikely to develop bacterial or fungal infections because of the lethal effects of the total body irradiation 12. Graft-versus-host disease (GVHD) is another complicationof bone marrow transplantation. It occurs a) if an identical twin is used as the donor b) as the marrow from the donor engrafts c) because B lymphocytes react against the recipient’s body d) in other types of organ transplantation as well as bone marrow transplantation 13. Which of the following is also true of GVHD? a) it is an immunosuppressive disorder predisposing the patient to interstitial pneumonia b) acute GVHD occurs after the first three months posttransplant in 30% to 50% of patients c) techniques to reduce GVDH include techniques to remove B lymphocytes from the donor marrow before transplantation d) the recipient’s cells attack the transplanted Cells 14. Before the bone marrow harvesting procedure, Jane’s donor is told by the nurse that she a) will be first positioned in a prone position and then turned in a supine position for aspiration of marrow from the iliac crests b) must have general anesthesia c) will have 2 cc to 4 cc of her marrow

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aspirated from each iliac crest d) will remain in the OR until all of the marrow is put through the filtering process to make sure enough marrow has been obtained 15. One week before the harvesting procedure, Jane's donor came into the hospital to donate a unit of her blood. This was done because a) blood may be needed during or after the harvest procedure, even though very little blood is harvested with the marrow b) only the donor's previously stored blood or blood that has been irradiated to destroy B lymphocytes should be administered during the harvest procedure c) Jane may need her donor's HLAcompatible blood later on as well as the bone marrow d) any random donor blood products transfused during the harvest procedure potentially contaminate the harvest with mismatched T lymphocytes 16. Problems unique to the harvesting procedure include 1. hypertension 2. biotin-induced pulmonary complications 3. development of fat emboli from traumatized marrow spaces 4. toxicity of anesthetics on the bone marrow cells c) 1 and 2 a) 1,2, and 3 d) 3 and 4 b) 2,3, and 4 17. During the marrow harvesting procedure 1. the scrub nurse is responsible for heparinizing the aspirating syringebetween uses 2. the circulating nurse is responsible for collecting the contents of each syringe in a large beaker 3. as the syringes become sticky, heparinized tissue culture medium is added to anticoagulate the specimen 4. the marrow is filtered through a series of screens to remove blood clots c) 1 and 3 a) 1, 2, and 3 d) 2 and 4 b) 2,3, and 4 18. For autologous marrow transplantation, it is imperative that strict aseptic technique be maintained and that the OR staff be free of colds or infection because 210

AUGUST 1985, VOL 42, NO 2

1. cryopreservation does not destroy all nosocomial infection causing organisms 2. patients undergoing marrow transplantation frequently have underlying diseases associated with malfunctions in host defense systems 3. these are preventive measures against GVHD 4. these patients frequently have received treatment with immunosuppressive therapies before transplantation c) 1 and 3 a) 1,2, and 3 d) 2 and 4 b) 2,3, and 4 19. In assessing for fat embolus postoperatively, the nurse watches for 1. cyanosis 2. dyspnea 3. decreased respiratory rate 4. increased blood pressure c) 1 and 2 a) 1,2, and 3 d) 3 and 4 b) 2,3, and 4 Bill is a 35-year-old school teacher with chronic myelogeneous leukemia (CML). Bill's physicians and nurses discuss the option of a bone marrow transplant with him and his family. 20. Which of the following is characteristic of Bill's disease? a) excessive numbers of mature granulocytic red blood cells b) it has a 30%cure rate with chemotherapy c) the presence of a chromosomal abnormality d) the majority of patients die within the first six months of diagnosis without total body irradiation 21. After Bill's physicians and nurses discuss his disease with him, he and his family should be aware that before his disease enters a more aggressive phase he needs a) a syngeneic marrow transplant b) an allogeneic marrow transplant c) an autologous marrow transplant d) total body irradiation plus an autologous marrow transplant 22. And that this treatment leads to complete normalization of blood counts and bone marrows in c) 40%of patients a) 98%of patients d) 20% of patients b) 65% of patients