An older client who has type 2 diabetes mellitus (DM) and a history of heart failure (HF) tells the home health nurse that his daughter brought him melatonin to help with sleeping problems. Which information should the nurse provide to the client? Select all that apply.

• Tardive dyskinesia is most likely because the client exhibits rhythmic tongue protrusion and involuntary facial and shoulder movements, classic signs after chronic chlorpromazine use. Long-term dopamine blockade causes these irreversible motor symptoms.
• Anaphylaxis typically presents with airway compromise, rash, hypotension, and tachycardia. The client's stable respiratory status and isolated involuntary movements are not consistent with an allergic reaction.
• Postural hypotension would involve symptoms like dizziness or fainting on position changes, which are not described. The client's blood pressure is stable, and there are no signs of orthostatic intolerance.
• Opioid withdrawal usually presents with symptoms such as agitation, sweating, diarrhea, and abdominal cramping. The client’s involuntary muscle movements are neurologic, not signs of opioid withdrawal.
• Give diphenhydramine IV is indicated for acute dystonic reactions, not tardive dyskinesia. Tardive dyskinesia requires different management focused on antipsychotic adjustment, not antihistamine therapy.
• Assess the client's medication history is important because chronic exposure to first-generation antipsychotics like chlorpromazine strongly increases the risk for tardive dyskinesia. Understanding medication use helps confirm diagnosis and guide treatment.
• Give a bolus of IV fluids is unrelated to involuntary motor symptoms. There is no evidence of dehydration or shock, and IV fluids will not address tardive dyskinesia.
• Hold the next dose of chlorpromazine is essential because continued dopamine receptor blockade can worsen the severity and permanence of tardive dyskinesia. Discontinuing or adjusting medication is a priority intervention.
• Initiate fall precautions could be reasonable for overall safety but is secondary to addressing the medication cause. The priority is to stop progression of symptoms by modifying the antipsychotic regimen.
• Mental status should be closely monitored because clients with neurologic side effects may experience confusion, worsening agitation, or other mental changes, especially when medications are adjusted.
• Pulse deficit monitoring is not clinically useful in tardive dyskinesia. It is more relevant in assessing cardiac arrhythmias and is not connected to the client's neurologic symptoms.
• Respiratory rate monitoring is important generally but does not directly assess for the progression or resolution of tardive dyskinesia, which affects motor function rather than breathing.
• Standing blood pressure is useful when evaluating for postural hypotension, but there is no evidence suggesting orthostatic instability in this client’s presentation.
• Extrapyramidal symptoms must be continuously monitored because their worsening or improvement will guide the need for further neurologic evaluation and possible medication adjustments.

A. Administer an additional dose of naloxone: Naloxone has a shorter half-life than many opioids, leading to the recurrence of respiratory depression once its effects wear off. When signs of opioid toxicity return, the immediate priority is to administer another dose of naloxone to reverse life-threatening respiratory depression and restore adequate ventilation.

B. Initiate a second intravenous access site: While maintaining IV access is important in emergency care, establishing a second IV line is not the most urgent priority when the client’s breathing is dangerously slow. Immediate reversal of respiratory depression takes precedence.

C. Prepare to initiate cardiopulmonary resuscitation (CPR): CPR is indicated if the client has no pulse or is not breathing. Since the client is still breathing, although minimally, and has a pulse, the immediate action should be reversing the opioid effects with naloxone, not starting CPR.

D. Determine if results of the drug toxicity screen are available: While knowing the substances involved can guide further treatment, waiting for lab results would delay the critical intervention needed to treat the acute respiratory depression at this moment.