Which action should the nurse take to assess for analgesic tolerance in a client who is unable to communicate?

• 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. Have a manual resuscitation bag at the bedside: Because morphine can cause respiratory depression, it is critical to have emergency resuscitation equipment readily available in case the client requires assisted ventilation during an adverse reaction.

B. Suction the client to clear the airway: Routine suctioning is not necessary unless the client has secretions impairing airway patency. It is not a standard precaution for clients receiving IV morphine without signs of airway obstruction.

C. Ask the client about other medications she takes: Morphine can interact dangerously with other medications, particularly sedatives, benzodiazepines, and other central nervous system depressants. Knowing the client’s full medication list helps prevent additive respiratory depression.

D. Perform a 12-lead electrocardiogram: A 12-lead ECG is not a standard requirement when starting morphine therapy unless there are cardiac symptoms. Continuous cardiorespiratory monitoring is already ordered, and that level of cardiac surveillance is sufficient unless new cardiac concerns arise.

E. Restrain the client with soft restraints: Restraints are not appropriate unless the client becomes a danger to herself or others. Administering morphine does not justify the prophylactic use of restraints and would violate ethical care standards.

F. Take an initial respiratory rate: An initial baseline respiratory rate is critical before starting or continuing morphine, as the drug’s main risk is respiratory depression. Ongoing respiratory assessments will be essential during PCA therapy.