A 15-year-old has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which of the following signs and symptoms require the most immediate nursing intervention?

Correct Answer: C

Rationale: The correct answer is C: Fever and petechiae. Fever and petechiae are indicative of a potential infection or bleeding, which can be life-threatening for a leukemia patient due to compromised immune system and low platelet count. Immediate nursing intervention would involve assessing the severity of the fever, monitoring for signs of sepsis, and addressing any bleeding issues. A: An enlarged liver and spleen may be common in leukemia but do not require immediate intervention unless associated with other symptoms. B: Fatigue is common in leukemia but not as urgent as signs of infection or bleeding. D: Swollen glands and lethargy are also common in leukemia but do not require immediate intervention unless accompanied by other concerning symptoms.

Correct Answer: D

Rationale: The correct answer is D because in DIC, excessive clotting can lead to bleeding. Therefore, the absence of bleeding indicates successful care. Option A is not specific to DIC management. Option B indicates poor oxygenation, not related to DIC. Option C is insufficient urine output, not a direct indicator of DIC management.

Correct Answer: D

Rationale: The correct answer is D because preschool-aged children typically lack the cognitive capacity to fully understand complex medical conditions like leukemia and its severity. They may not grasp the concept of illness or the implications of a cancer diagnosis. Preschoolers are unlikely to exhibit acceptance (Choice A) as they may struggle to comprehend the situation. They are also not likely to blame themselves for causing the illness (Choice B) as this requires a more advanced understanding of cause and effect. While some children may have a basic understanding of cancer and its treatment (Choice C), they are unlikely to fully comprehend the disease's complexities. Overall, the most likely reaction for a preschooler diagnosed with leukemia is unawareness due to their developmental stage.

Correct Answer: B

Rationale: The correct answer is B: Leukopenia. Leukopenia refers to a decrease in white blood cells, which are essential for fighting infections. In leukemia, the bone marrow produces abnormal white blood cells, leading to a decrease in healthy white blood cells. This compromises the child's immune system, making them more susceptible to infections like pneumonia. A: Anemia is a decrease in red blood cells and would not directly cause pneumonia. C: Thrombocytopenia is a decrease in platelets and is not directly related to pneumonia. D: Eosinophilia is an increase in eosinophils and is not typically associated with pneumonia in this context.

Correct Answer: C

Rationale: The correct answer is C: Obtaining daily weight measurements. Daily weight measurements are crucial in monitoring fluid status in clients with glomerulonephritis, as sudden weight gain can indicate fluid retention and worsening of the condition. This intervention allows for early detection of fluid imbalances, guiding appropriate fluid management and treatment adjustments. Assessing vital signs every four hours (choice A) is important but not the highest priority in this scenario, as monitoring weight is more specific for fluid status changes. Monitoring intake and output every 12 hours (choice B) is also important, but not as immediate as obtaining daily weight measurements. Obtaining serum electrolyte levels daily (choice D) is essential, but weight measurements take precedence in assessing fluid status.