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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Do you feel you need treatment?"
Asking the client, "Do you feel you need treatment?" assesses their insight into their own mental health condition. Insight refers to the client's awareness and understanding of their illness, including recognizing the need for treatment. A positive response to this question indicates the client's awareness of their condition and willingness to seek help, demonstrating good insight.
B. "Who is the governor of this state?"
This question assesses the client's orientation to time, place, and current events. It is useful for assessing cognitive functioning but does not specifically measure insight into one's own mental health.
C. "What do you get when you subtract 7 from 100?"
This question assesses the client's cognitive functioning, specifically mathematical abilities. It is useful for evaluating cognitive skills but does not address insight into mental health.
D. "How do you get money for your needs?"
This question assesses the client's problem-solving abilities and understanding of practical matters. It is relevant for assessing functional abilities but does not specifically measure insight into their mental health condition.
Correct Answer is B
Explanation
A. Displacement:
Displacement is a defense mechanism where a person redirects their feelings, often negative or hostile ones, from the original source or target to a different, less threatening target. For example, if the client were to express anger at their boss by yelling at their family members instead, it would be an example of displacement.
B. Rationalization:
Rationalization is a defense mechanism in which a person provides logical or reasonable explanations to justify or explain a situation or behavior, even if these explanations are not entirely true or valid. It involves creating justifications or excuses to make an event or one's actions appear more reasonable or acceptable. In this case, the client is rationalizing the job loss by attributing it to their boss not liking them, which may be an oversimplified or inaccurate explanation.
C. Dissociation:
Dissociation is a defense mechanism where a person mentally separates themselves from their own thoughts, feelings, or experiences to cope with overwhelming or traumatic situations. It involves a disconnection from reality. The client's statement doesn't suggest dissociation; rather, they are providing a reason for their job loss.
D. Repression:
Repression is a defense mechanism that involves the unconscious exclusion of painful or anxiety-provoking thoughts, feelings, or memories from awareness. It is not readily visible or expressed in behavior. The client's statement involves a conscious attempt to explain their job loss, so it's not an example of repression.
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