A nurse is preparing to administer olanzapine extended release 210 mg IM to a client. Which of the following actions should the nurse take?
Monitor the client's sodium levels.
Evaluate the client's frequency of panic attacks.
Inform the client that application site rash is common.
Observe the client for 3 hr following administration of medication.
The Correct Answer is D
A. Monitor the client's sodium levels:
This action is not directly related to the administration of olanzapine. Olanzapine does not typically affect sodium levels directly. Monitoring sodium levels is essential for some other medications or conditions, but it is not a specific consideration for olanzapine administration.
B. Evaluate the client's frequency of panic attacks:
Evaluating the frequency of panic attacks is not directly related to the administration of olanzapine. Olanzapine is an antipsychotic medication used to treat conditions like schizophrenia and bipolar disorder. It is not primarily indicated for the treatment of panic attacks. Monitoring panic attacks would be relevant if the client's primary concern was panic disorder, but it's not the priority in this scenario.
C. Inform the client that application site rash is common:
This information is not relevant to the administration of olanzapine in the form of an intramuscular injection. Application site rash is a concern for topical medications or transdermal patches, not for IM injections. Therefore, informing the client about application site rash is not necessary in this context.
D. Observe the client for 3 hours following the administration of medication:
This is the correct action. Olanzapine extended-release IM injection requires close observation for at least 3 hours after administration. This monitoring period is essential due to the potential risk of post-injection delirium/sedation syndrome, which can occur shortly after the injection. Monitoring allows for the early detection of any adverse reactions, ensuring the client's safety and well-being.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The nurse maintains confidentiality unless the client's safety is compromised:
Explanation: Maintaining confidentiality is a fundamental principle in nursing practice. Nurses are ethically and legally obligated to keep client information confidential, ensuring that the client's privacy is respected. Confidentiality builds trust between the nurse and the client, encouraging open communication. However, confidentiality can be breached if the client's safety is at risk, such as if they express suicidal or homicidal thoughts, indicating the need for intervention to ensure their well-being.
B. The nurse seeks to spend extra time specifically with the client each day:
Explanation: While it's important for nurses to spend adequate time with each client, seeking to spend extra time specifically with one client may create imbalances in care distribution. Nurses should strive to provide equitable care to all clients, addressing their needs based on assessments and care plans. Special attention to one client could lead to feelings of favoritism or neglect among other clients, affecting the therapeutic environment.
C. The client sees the nurse as an authority figure:
Explanation: Clients often view nurses as authority figures due to their expertise and role in healthcare. This perception can facilitate a therapeutic relationship, as clients may trust the nurse's guidance and care. However, this should be balanced with empathy and understanding to create a supportive and therapeutic environment.
D. The client regards the nurse as a friend:
Explanation: While a therapeutic nurse-client relationship aims for trust and rapport, it is not a friendship. The nurse maintains professional boundaries to provide objective care without personal bias. Friendship implies a level of personal involvement that can compromise the nurse's ability to make objective clinical decisions. A therapeutic relationship is built on trust, respect, empathy, and clear professional boundaries.
Correct Answer is B
Explanation
A. Clients who are involuntarily committed do not maintain access to legal counsel.
This statement is incorrect. Clients who are involuntarily committed generally do have the right to legal counsel. They can challenge their commitment in a court of law, and legal representation is often provided to them if they cannot afford it.
B. Clients must be informed of the risks of treatment.
This statement is correct. Informed consent is a fundamental principle in healthcare, including mental health treatment. Clients have the right to be fully informed about the risks and benefits of any treatment or procedure before giving consent.
C. Clients who have a severe mental illness cannot request a psychiatric advance directive.
This statement is incorrect. Clients with severe mental illness can, and should, create psychiatric advance directives. These directives allow individuals to specify their preferences regarding mental health treatment in advance, ensuring their wishes are respected even if they are not able to communicate them at a later time due to their mental condition.
D. Clients who are violent can refuse chemical restraint.
This statement is generally incorrect. In emergency situations where a client poses an immediate danger to themselves or others, chemical restraint might be administered without the client's consent to ensure safety. However, there are strict guidelines and regulations surrounding the use of chemical restraints, and they should only be used in specific situations and as a last resort. In non-emergency situations, clients generally have the right to refuse any treatment, including chemical restraint, unless it is court-ordered due to their condition posing an imminent risk.
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