Which assessment requires the nurse to assess the patient further?

A. Irritating cough. Opioid agonists do not typically cause an irritating cough. In fact, opioids like codeine are used as antitussives to suppress cough reflexes.
B. Tachypnea. Opioids depress the central nervous system, leading to respiratory depression rather than an increased respiratory rate (tachypnea). The nurse should monitor for bradypnea instead.
C. Hypertension. Opioids commonly cause hypotension due to vasodilation and central nervous system depression. Hypertension is not a typical adverse effect.
D. Urinary retention. Opioids can increase sphincter tone and suppress the urge to void, leading to urinary retention. This is a known side effect and should be monitored, especially in older adults or those with underlying bladder issues.

A. Falsely low. Using an adult-sized cuff on a child results in an overestimation of the cuff size, causing the cuff to not inflate properly and distribute less pressure, leading to a falsely low blood pressure reading.
B. Indistinct. The reading may be inaccurate, but it will still produce a numerical value rather than being completely indistinct.
C. Accurate. Accuracy depends on using a cuff size appropriate for the child's arm circumference. An adult cuff on a child is too large, leading to an incorrect reading.
D. Falsely high. A too-small cuff would produce a falsely high reading, but an oversized cuff produces a falsely low blood pressure.