Patient Data

Which actions should the nurse take to assure safety during morphine administration? 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. Propofol: Propofol is a powerful sedative used mainly for anesthesia or sedation during mechanical ventilation. It is not appropriate or expected for routine postoperative pain management with morphine on a surgical floor.

B. Methadone: Methadone is another opioid used for chronic pain management or opioid dependency, not typically prescribed alongside morphine for acute postoperative pain because combining opioids increases the risk of respiratory depression.

C. Docusate sodium: Docusate sodium is a stool softener often prescribed with opioids like morphine to prevent constipation, a common opioid side effect. Promoting bowel movements is an important preventative measure in postoperative patients.

D. Ibuprofen: Ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), may be prescribed to provide additional pain relief through a different mechanism and reduce inflammation. This combination allows lower opioid doses, improving pain management while minimizing opioid side effects.

E. Naloxone: Naloxone is an opioid antagonist kept available as a safety measure in case of opioid-induced respiratory depression. Having naloxone ordered and readily accessible is a critical precaution during opioid therapy.

F. Senna: Senna is a stimulant laxative that can be prescribed along with docusate to prevent or treat opioid-induced constipation by actively stimulating bowel movements, making it a commonly expected medication alongside opioids.