The nurse is analyzing complete blood count (CBC) results to… | 마이메르시 MyMerci
Adult Health
문제

The nurse is analyzing complete blood count (CBC) results to identify findings consistent with acute leukemia diagnosis. Which laboratory finding would be most indicative of acute leukemia?

해설
Blast cells >20% in peripheral blood is the diagnostic hallmark of acute leukemia per WHO criteria. Other CBC findings (anemia, normal platelets, mild leukocytosis) are nonspecific and not diagnostic.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests your ability to identify the most specific and diagnostic laboratory finding for acute leukemia. Acute leukemia is a cancer of the blood and bone marrow characterized by the rapid, uncontrolled proliferation of immature white blood cells called blasts. While a complete blood count (CBC) often shows abnormalities, the definitive diagnosis hinges on identifying these abnormal cells.

Answer Rationale: The correct answer is the presence of blast cells in the peripheral blood. Key Point! In a healthy individual, blasts are confined to the bone marrow where they mature. Their appearance in the peripheral blood (a condition called leukemic blast crisis or circulating blasts) is a hallmark of acute leukemia. According to the World Health Organization (WHO) classification, the presence of ≥20% blasts in the bone marrow or peripheral blood is diagnostic for acute leukemia. This finding is specific, unlike other CBC abnormalities which can be seen in many other conditions.

Distractor Analysis:
Watch out for confusion! Option 1 (Hemoglobin 10.5 g/dL): This indicates anemia (normal is typically >12-13 g/dL). While common in leukemia due to bone marrow infiltration and reduced red blood cell production, anemia is a nonspecific finding seen in countless other conditions (e.g., iron deficiency, chronic disease, hemorrhage).
• Option 2 (Platelet count 150,000/mm³): This is a normal platelet count (normal range ~150,000-400,000/mm³). In acute leukemia, thrombocytopenia (low platelets) is very common, so a normal count does not support the diagnosis and might even argue against it.
• Option 3 (White blood cell count 12,000/mm³): This indicates leukocytosis (elevated WBC count). While patients with leukemia can have high, low, or normal WBC counts, leukocytosis alone is nonspecific and can be caused by infection, inflammation, or stress. More importantly, it's the type of white cell (blasts) that matters, not just the total number.

Related Concepts: The diagnosis of leukemia is confirmed by bone marrow aspiration and biopsy, which quantifies the blast percentage. The two main types are Acute Lymphoblastic Leukemia (ALL) and Acute Myeloid Leukemia (AML). Nursing care focuses on managing complications from bone marrow failure: infection risk from neutropenia, bleeding risk from thrombocytopenia, and fatigue from anemia.

Concept SummaryPathophysiology: Malignant proliferation of immature blast cells crowds out normal hematopoiesis in the bone marrow.
Key Diagnostic Finding: ≥20% blasts in bone marrow/peripheral blood (WHO criteria).
Common CBC Pattern (but not diagnostic): Pancytopenia (anemia, neutropenia, thrombocytopenia). WBC count can be high, low, or normal.
Definitive Test: Bone marrow biopsy with cytogenetic analysis.

Side-by-Side Comparison!
FindingSignificance in Acute LeukemiaSpecificity for Diagnosis
Blasts in Peripheral BloodHallmark; indicates marrow overflow of immature cells.Highly Specific & Diagnostic
Anemia (Low Hgb/Hct)Common due to impaired RBC production.Nonspecific (seen in many conditions)
Thrombocytopenia (Low Platelets)Common due to impaired platelet production.Nonspecific (seen in ITP, chemo, liver disease)
Leukocytosis (High WBC)May occur, but WBCs are often dysfunctional blasts.Nonspecific (often indicates infection)

Anatomy, Physiology & Pharmacology PointsBone Marrow Function: The primary site of blood cell production (hematopoiesis). Leukemia disrupts this factory.
Blast Cells: Immature precursor cells that normally mature into lymphocytes, granulocytes, monocytes, etc. In leukemia, they proliferate without maturing.
Chemotherapy Goal: To achieve remission by eradicating leukemic blast cells, allowing normal bone marrow function to recover.

Memory TipsAcronym: Think "BLAST is a BLAST to find for diagnosis!" (It's the key).
Analogy: The bone marrow is a school. Normal cells are students of all grades. Leukemia is when the kindergarten class (blasts) takes over the entire school, preventing older students (mature RBCs, WBCs, platelets) from graduating into the bloodstream.

High-Frequency NCLEX Topics NCLEX loves to test the specific vs. nonspecific finding distinction. For leukemia, always prioritize the finding that is unique to the disease (blasts) over common complications (infection, bleeding, fatigue signs) which are important for nursing care but not for definitive diagnosis.

Watch Out for Question Variations! • Instead of "most indicative for diagnosis," the question could ask: "The nurse reviews a client's lab report. Which finding should be reported immediately to the provider?" Answer: Presence of blasts.
• A question might give a CBC with pancytopenia and ask for the priority nursing diagnosis. Answer: Risk for Infection (due to neutropenia) often takes priority over Risk for Bleeding.

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are a nurse on an oncology unit. A 45-year-old patient is admitted with profound fatigue, fever, and petechiae. A CBC is drawn, and the differential report shows "25% blasts" noted on the manual review. The hemoglobin is 8.2 g/dL, platelets are 30,000/mm³, and the WBC is 15,000/mm³ with a low absolute neutrophil count (ANC).

Nursing Intervention Strategy:
1. Assessment & Communication: Recognize the critical finding (blasts >20%) and immediately notify the provider. This is a time-sensitive diagnosis requiring prompt hematology consultation for bone marrow biopsy confirmation.
2. Infection Protection (Priority!): Initiate neutropenic precautions. Place the patient in a private room if possible. Enforce strict hand hygiene for everyone. Screen visitors for illness. Monitor for signs of infection (fever is an emergency).
3. Bleeding Precautions: Implement bleeding precautions due to thrombocytopenia. Avoid IM injections, use soft toothbrushes, hold pressure on venipuncture sites for 5-10 minutes, and monitor for bleeding (petechiae, gum bleeding, melena).
4. Supportive Care & Education: Manage fatigue by assisting with activities. Educate the patient and family about the diagnostic process (bone marrow biopsy), the rationale for precautions, and the upcoming treatment plan (likely chemotherapy).

Patient Safety and Precautions:
Fever in Neutropenia: A single temperature of ≥38.3°C (101°F) or ≥38.0°C (100.4°F) sustained over one hour in a neutropenic patient is a medical emergency. It requires immediate blood cultures and empiric broad-spectrum antibiotics.
Transfusion Support: Patients will likely require packed red blood cell (PRBC) transfusions for symptomatic anemia and platelet transfusions for active bleeding or very low counts (e.g.,

핵심 개념

마이메르시로 국가고시 완벽 대비

기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요.

무료로 시작하기

학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.