A nurse is planning care for an adolescent who has sickle cell anemia. Which of the following immunizations should the nurse include in the plan?

Choice A Reason:

"I cannot confirm or deny that we have a client by that name." This response respects the patient's right to confidentiality under HIPAA (Health Insurance Portability and Accountability Act) regulations. It neither confirms nor denies the patient's presence in the hospital, preserving the patient's privacy and confidentiality.

Choice B Reason:

"I will tell him you called." This response doesn't uphold patient confidentiality. Revealing that the employer called could indirectly confirm the patient's presence in the hospital, potentially breaching confidentiality.

Choice C Reason:

"The client's condition is stable right now." Sharing any information about the patient's condition with someone who hasn't been authorized to receive it breaches patient confidentiality. Even sharing a seemingly benign statement about stability can indirectly disclose the patient's presence in the hospital.

Choice D Reason:

"He is here in the hospital, but I cannot tell you anything else. “While it refrains from divulging more information, it still confirms the patient's presence in the hospital, breaching confidentiality.

Choice A Reason:

Relaxed facial expression is correct. Opioids, when effectively managing pain, can lead to a more relaxed facial expression in infants. It's a common indicator that the pain is being controlled and the infant is experiencing relief.

Choice B Reason:

Increased blood pressure is incorrect. Opioids usually cause a decrease in blood pressure rather than an increase. Elevated blood pressure wouldn't typically signify a therapeutic effect of opioids; it might indicate other factors such as stress, discomfort, or an adverse reaction.

Choice C Reason:

Limb withdrawal is incorrect. Limb withdrawal is a reflex action and might occur in response to a stimulus. It's not a direct indicator of pain relief; rather, it's a reflexive response to a sensation.

Choice D Reason:

Bradycardia is incorrect. Bradycardia, a slowed heart rate, can be a side effect of opioid medications. However, it's not an indicator of the therapeutic effect of pain relief. In fact, bradycardia might signal an adverse reaction or a dose that's too high for the infant.