A client is prescribed olanzapine for schizophrenia.
How will the nurse monitor the client for adverse side effects? (Select all that apply).
Weigh the client.
Observe skin turgor.
Ask client about falls.
Obtain blood pressure.
Obtain blood sugar.
Correct Answer : A,E
Olanzapine is an antipsychotic drug that can cause weight gain and increased blood sugar as common side effects.
Therefore, the nurse should monitor the client’s weight and blood sugar regularly to prevent complications such as obesity and diabetes.
Choice B is wrong because olanzapine does not affect skin turgor, which is a measure of hydration status.
Choice C is wrong because olanzapine does not cause falls, although it may cause dizziness or unsteadiness as side effect.
Choice D is wrong because olanzapine does not cause significant changes in blood pressure, although it may cause orthostatic hypotension (a drop in blood pressure when standing up) as a side effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.
Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.
Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.
Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.
Correct Answer is ["B"]
Explanation
Place the call bell in reach and respond promptly when activated.
This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.
Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.
The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.
Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.
The bed should be lowered to a safe position and locked when not in use.
Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.
The client should have adequate lighting in their room and be oriented to their surroundings.
Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.
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