Correct Answer: A

Rationale: Preventing shivering is crucial in this situation as it can increase the body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat, potentially worsening the fever. Restricting oral fluids (
Choice
B) is not appropriate as fluid intake is important to prevent dehydration, especially in a child who has been vomiting. Measuring output hourly (
Choice
C) and taking vital signs hourly (
Choice
D) are important nursing actions but not as critical as preventing shivering in this scenario.
Therefore, the most important nursing action is to prevent shivering to aid in fever reduction and management.

Correct Answer: A

Rationale: The correct answer is Varicella (chickenpox), choice A. Varicella can lead to the complication of encephalitis, which is the inflammation of the brain. Scarlet fever (choice
B) is caused by Group A Streptococcus bacteria and does not typically lead to encephalitis. Poliomyelitis (choice
C) is a viral infection that affects the nervous system but does not directly cause encephalitis. Whooping cough (choice
D), also known as pertussis, primarily affects the respiratory system and does not commonly result in encephalitis.

Correct Answer: A

Rationale: The correct answer is A: Preventing infection. When caring for a child with acute lymphoblastic leukemia (ALL) undergoing chemotherapy, the top priority is to prevent infection. Chemotherapy suppresses the immune system, making the child more susceptible to infections. By implementing infection control measures such as hand hygiene, aseptic techniques, and environmental cleanliness, the nurse can help protect the child from potentially life-threatening infections. Administering chemotherapy (choice
B) is important but not the priority over preventing infection. Providing nutritional support (choice
C) and monitoring fluid intake (choice
D) are essential aspects of care but take a back seat to preventing infection in this scenario.

Correct Answer: A

Rationale: The priority nursing intervention for a child with acute lymphoblastic leukemia (ALL) receiving chemotherapy is to prevent infection. Chemotherapy compromises the child's immune system, increasing susceptibility to infections. Preventing infection is crucial to avoid potential complications such as sepsis, which can be life-threatening. Administering chemotherapy is essential for treating ALL but preventing infection takes precedence due to the increased risk of infections associated with chemotherapy-induced immunosuppression. Providing nutritional support is important for overall health but preventing infections is more critical in this context. Monitoring fluid intake is significant, but the priority is to prevent infections that can have severe consequences in an immunocompromised child.

Correct Answer: C

Rationale: The correct clinical manifestation that a nurse is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception is a medical emergency where a part of the intestine folds into itself, causing obstruction. Abdominal distension is a common symptom due to the obstruction and the build-up of gases and fluids. While currant jelly stools (
Choice
B) are a classic sign of intussusception, they are typically seen in later stages of the condition and may not be present during the initial assessment. Projectile vomiting (
Choice
A) is more commonly associated with conditions like pyloric stenosis. Constipation (
Choice
D) is not a typical manifestation of intussusception; the condition usually presents with severe colicky abdominal pain and possible passage of blood and mucus in stools.