A nurse is planning to administer olanzapine 10 mg IM to a client who has schizophrenia. Which of the following actions should the nurse take?

Administer the medication into the deltoid muscle.

Monitor the client for at least 3 hr after the injection.

Withhold the medication if the client reports hallucinations.

Instruct the client to expect difficulty sleeping

Answer and Explanation

The Correct Answer is B

A. Administer the medication into the deltoid muscle: Olanzapine is typically administered deep into the muscle to ensure proper absorption. However, the deltoid muscle may not be the preferred site for intramuscular injections of medications like olanzapine due to the risk of hitting the underlying radial nerve. The ventrogluteal or vastus lateralis muscles are often preferred sites for IM injections to reduce the risk of nerve damage.
B. Monitor the client for at least 3 hr after the injection: After administering olanzapine IM, the nurse should monitor the client closely for at least 3 hours to assess for any adverse reactions or side effects, such as sedation, hypotension, or extrapyramidal symptoms. This allows for early detection and prompt intervention if needed.
C. Withhold the medication if the client reports hallucinations: Olanzapine is an antipsychotic medication commonly used to treat schizophrenia and other psychotic disorders. Hallucinations are a symptom of schizophrenia, and olanzapine is often prescribed to help manage such symptoms. Withholding the medication solely based on the client reporting hallucinations would not be appropriate without further assessment and consideration of the overall treatment plan.
D. Instruct the client to expect difficulty sleeping: While olanzapine can cause sedation and may affect sleep patterns in some individuals, it is not a universal side effect for everyone. Providing anticipatory guidance about potential side effects is essential, but instructing the client to expect difficulty sleeping without individual assessment may lead to unnecessary anxiety or concerns.

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Correct Answer is C

Explanation

A. "I will feel less hungry during meals while I am taking orlistat": Orlistat works by blocking the absorption of dietary fat in the intestines rather than suppressing appetite. Therefore, it does not typically reduce hunger during meals.
B. "I will eat a no-fat diet to prevent side effects from the medication": Orlistat can cause gastrointestinal side effects such as oily stools, fecal incontinence, and flatulence, particularly when consumed with high-fat meals. While reducing fat intake can help minimize these side effects, it is not necessary to eliminate fat entirely from the diet. The statement is partially correct but not the best response indicating full understanding.
C. "I will stop taking orlistat and call my doctor if my urine gets darker in color": Dark urine can indicate liver problems, which are a potential side effect of orlistat. Therefore, it is crucial for the client to monitor for this symptom and contact their healthcare provider if it occurs. This response indicates that the client understands the potential adverse effects of the medication.
D. "I will take my dose of orlistat every morning an hour before breakfast": Orlistat is typically taken with meals or up to one hour after eating. Taking it on an empty stomach before breakfast is not recommended.

A. Begin active range of motion. B. Remain on bedrest for the first 24 hr. C. Apply ice to the affected area D. Keep the leg in a dependent position.

Correct Answer is C

Explanation

A. Beginning active range of motion immediately after arthroscopic knee surgery may increase the risk of injury or disruption to the surgical site. Typically, passive range of motion exercises are initiated first under the guidance of a physical therapist or healthcare provider.
B. Remaining on bedrest for the first 24 hours after arthroscopic knee surgery is not typically recommended. Early mobilization and ambulation are encouraged to prevent complications such as blood clots and joint stiffness.
C. Applying ice to the affected area is a common postoperative instruction following knee surgery. Ice helps reduce swelling, inflammation, and pain. It is usually recommended for short intervals, such as 20 minutes every few hours, for the first 48 to 72 hours after surgery.
D. Keeping the leg in a dependent position (hanging down) for an extended period after knee surgery can increase swelling and discomfort. Elevating the leg when resting can help reduce swelling and improve circulation.

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A nurse is planning to administer olanzapine 10 mg IM to a client who has schizophrenia. Which of the following actions should the nurse take?

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