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.

Answer and Explanation

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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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.

A. Reassure staff members that the debriefing is confidential. B. Have staff members discuss their involvement in the event. C. Ask staff members to describe their most traumatic memories of the event. D. Provide stress-management exercises to the staff members.

Correct Answer is A

Explanation

A. Reassure staff members that the debriefing is confidential:
Explanation: Ensuring confidentiality is crucial in creating a safe space for individuals to express their emotions and thoughts freely. It builds trust among the participants, making them more likely to open up about their experiences during the debriefing session. Confidentiality encourages honest communication and helps individuals feel secure in sharing their feelings without fear of repercussions.

B. Have staff members discuss their involvement in the event:
Explanation: After establishing confidentiality, the next step is to encourage participants to discuss their involvement in the traumatic event. This can help individuals process their experiences, share their perspectives, and express their emotions related to the incident. Sharing their involvement can provide context to their reactions and emotions, facilitating a more comprehensive understanding of their experiences.

C. Ask staff members to describe their most traumatic memories of the event:
Explanation: Encouraging individuals to describe their most traumatic memories of the event is a way to help them confront and process specific experiences that might be causing distress. This step allows participants to verbalize and share their emotions and memories related to the incident. Talking about these specific memories can be therapeutic and can contribute to the overall healing process.

D. Provide stress-management exercises to the staff members:
Explanation: Providing stress-management exercises, such as relaxation techniques or breathing exercises, comes after individuals have had the opportunity to share their experiences. These exercises can help participants manage immediate stress and anxiety during the debriefing session. They provide practical tools for coping with overwhelming emotions and can be beneficial for individuals who are feeling distressed or overwhelmed during the process.

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A nurse is preparing to administer olanzapine extended release 210 mg IM to a client. Which of the following actions should the nurse take?

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