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 B

Explanation

Rationale:

A) Administer ibuprofen as needed for pain: Ibuprofen is not typically recommended for pain relief in infants under 6 months old due to the risk of adverse effects, such as gastrointestinal irritation and renal impairment. Additionally, surgical repair of a cleft lip is not typically associated with severe postoperative pain requiring ibuprofen in infants.

B) Encourage the parents to rock the infant: This is the correct intervention. Rocking or gentle movement can provide comfort to infants postoperatively and may help soothe them. It can also promote bonding between the infant and parents, which is important for emotional support during the recovery period.

C) Offer the infant a pacifier: Pacifiers can be soothing for infants and may help provide non-nutritive sucking comfort. However, it's essential to ensure that the pacifier does not interfere with wound healing or exacerbate discomfort related to the cleft lip repair. Therefore, while offering a pacifier may be appropriate, it should be done with caution and under the guidance of the surgical team.

D) Position the infant on her abdomen: Placing the infant on her abdomen (prone position) is not recommended postoperatively, especially after cleft lip repair surgery. The supine position is typically preferred to reduce the risk of aspiration and ensure adequate airway patency. Additionally, the prone position may put pressure on the surgical site and cause discomfort.

A. Rotate assignment of daily caregivers. B. Provide an activity schedule that changes from day to day. C. Limit time for the client to perform activities. D. Talk the client through tasks one step at a time.

Correct Answer is D

Explanation

A. Rotate assignment of daily caregivers: Consistency in caregivers is important for individuals with Alzheimer's disease to build trust and rapport. Rotating caregivers frequently may disrupt the client's routine and lead to increased confusion and anxiety.
B. Provide an activity schedule that changes from day to day: Consistency and routine are beneficial for individuals with Alzheimer's disease as they provide structure and predictability. A consistent activity schedule helps the client feel more secure and can reduce agitation and behavioral issues.
C. Limit time for the client to perform activities: While it may be necessary to pace activities based on the client's abilities and fatigue level, arbitrarily limiting time for the client to perform activities can be counterproductive. Instead, individualizing the pace of activities based on the client's preferences and abilities is more beneficial.
D. Talk the client through tasks one step at a time: Individuals with Alzheimer's disease often experience cognitive impairment, including difficulty with memory, attention, and problem-solving. Breaking tasks down into manageable steps and providing clear, simple instructions can help the client understand and complete activities of daily living more effectively. This intervention supports the client's independence and reduces frustration.

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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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