The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the most appropriate initial nursing action?

Choice A rationale:

Hypoparathyroidism is not associated with exophthalmos. Hypoparathyroidism is a condition where the parathyroid glands produce insufficient parathyroid hormone, leading to low calcium levels in the blood. This condition doesn't directly affect the thyroid gland or cause exophthalmos.

Choice B rationale:

Exophthalmos, also known as protruding or bulging eyes, is a classic symptom of hyperthyroidism. Hyperthyroidism is a condition where the thyroid gland produces excessive amounts of thyroid hormones. These elevated hormone levels can lead to a variety of symptoms, including increased metabolism, weight loss, nervousness, and protruding eyes due to inflammation of the eye muscles and tissues behind the eye.

Choice C rationale:

Hyperparathyroidism involves the overactivity of the parathyroid glands, leading to excessive production of parathyroid hormone (PTH) and elevated calcium levels in the blood. While elevated calcium levels can have various effects on the body, exophthalmos is not a typical manifestation of hyperparathyroidism. The condition is more commonly associated with bone and kidney issues.

Choice D rationale:

Hypothyroidism, the underproduction of thyroid hormones by the thyroid gland, is not linked to exophthalmos. Instead, hypothyroidism is known for causing symptoms such as fatigue, weight gain, cold intolerance, and slow heart rate. Exophthalmos is a characteristic sign of hyperthyroidism, not hypothyroidism.

The correct answer is choice C: Oral rehydration solution (ORS).

Choice A rationale:

Clear liquids, 1 to 2 ounces at a time, might not be sufficient to adequately rehydrate a child with severe dehydration. Clear liquids lack the necessary electrolytes and glucose content to effectively combat dehydration and replace lost fluids.

Choice B rationale:

Administration of antidiarrheal medication is not the initial step in managing severe dehydration caused by acute diarrhea and vomiting. Antidiarrheal medications can slow down the gastrointestinal motility, which may exacerbate the problem by delaying the elimination of the causative agent and prolonging the dehydration.

Choice C rationale:

Oral rehydration solution (ORS) is the recommended initial intervention for managing severe dehydration caused by acute diarrhea and vomiting. ORS contains the appropriate balance of electrolytes (sodium, potassium, chloride) and glucose to replace lost fluids and electrolytes, thereby helping to rehydrate the child effectively. It is absorbed even when digestion is impaired due to the illness.

Choice D rationale:

Intravenous fluids might be necessary if the child's condition is very severe and oral intake cannot be maintained. However, it's not the first-line intervention. Oral rehydration is preferred whenever feasible because it is less invasive and can be administered even in mild to moderate dehydration cases.