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?

The correct answer is choice C. Explain in simple terms how it works.

Choice A rationale:

Asking the girl why she wants to know might be appropriate in some contexts, but children are naturally curious and seeking information is a common behavior. Explaining how the blood pressure apparatus works would likely be more beneficial than questioning her motivation.

Choice B rationale:

Determining why she is anxious assumes that the girl is anxious, which might not be the case. Additionally, the question she asked does not necessarily indicate anxiety, but rather a curiosity about the medical equipment.

Choice C rationale:

Explaining in simple terms how the blood pressure apparatus works is the most appropriate nursing action. This approach respects the child's curiosity and provides her with age-appropriate information, fostering a positive and educational interaction.

Choice D rationale:

Telling her that she will see how it works as it is used might not fully satisfy her curiosity or address her immediate question. Children often benefit from clear and concise explanations, especially when it comes to medical equipment.

The correct answers are choices A, C, and D: Tachycardia, Hyperthermia, and Vomiting.

Choice A rationale:

Tachycardia. Tachycardia, an abnormally fast heart rate, is a classic manifestation of thyroid storm. In this life-threatening condition, there is an excessive release of thyroid hormones, leading to increased metabolic rate and subsequent cardiovascular effects such as tachycardia.

Choice B rationale:

Constipation. This choice is incorrect for thyroid storm. Hyperthyroidism typically leads to increased bowel motility and can cause diarrhea rather than constipation.

Choice C rationale:

Hyperthermia. This is a correct choice. Thyroid storm is associated with severe hyperthermia due to the increased metabolic rate caused by excessive thyroid hormones. The body's temperature regulation is disrupted, leading to dangerously high body temperatures.

Choice D rationale:

Vomiting. This is a correct choice. Gastrointestinal symptoms, including vomiting and nausea, can occur in thyroid storm due to the heightened metabolic state. Thyroid storm affects various systems, including the gastrointestinal system, leading to symptoms like vomiting.

Choice E rationale:

Hypotension. This choice is incorrect for thyroid storm. Thyroid storm is more likely to cause hypertension rather than hypotension due to the increased cardiac output and sympathetic stimulation.