The nurse is assessing a client experiencing acute pain.
What assessments should validate the client with acute pain? Select all that apply.

This is because the patient may be experiencing serotonin toxicity, a potentially life- threatening condition caused by excessive levels of serotonin in the brain. Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels, and some other medications or supplements may interact with it and cause serotonin toxicity. Some of the symptoms of serotonin toxicity include agitation, increased sweating, and hallucinations.

Choice B is wrong because administering an anti-anxiety medication may worsen serotonin toxicity, especially if the medication is also an SSRI or another serotonergic agent.

Choice C is wrong because placing the patient in loose bilateral arm restraints may increase the risk of injury or agitation, and does not address the underlying cause of the symptoms.

Choice D is wrong because telling the patient that the voices they are hearing are not real may not be helpful or reassuring, and may also increase the patient’s distress or confusion.

This is because acute pain is the most urgent and life-threatening problem for a client with myocardial infarction.

Acute pain indicates ongoing ischemia and tissue damage, which can lead to complications such as heart failure, arrhythmias, or cardiogenic shock. Therefore, relieving pain is the priority nursing diagnosis.

Choice A. Anxiety is wrong because anxiety is not a specific symptom of myocardial infarction and anxiety is due to the discomfort that happens due to activation of the sympathetic pathway which is good for survival.

Choice C. Knowledge deficit is wrong because knowledge deficit is not an immediate problem for a client with myocardial infarction.

Knowledge deficit can be addressed after the acute phase of the condition is over and the client is stable.

Choice D. Nausea and vomiting are wrong because nausea and vomiting are common symptoms of myocardial infarction, but they are not as urgent and life-threatening as acute pain.

Nausea and vomiting can be treated with antiemetics and fluids, but they do not affect the outcome of the condition as much as pain does.