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?
A.
Administer the medication into the deltoid muscle.
B.
Monitor the client for at least 3 hr after the injection.
C.
Withhold the medication if the client reports hallucinations.
D.
Instruct the client to expect difficulty sleeping
The Correct answer and Explanation is:
The correct answer is B. Monitor the client for at least 3 hr after the injection.
Explanation:
When administering olanzapine, particularly via intramuscular (IM) injection, monitoring the client for potential adverse effects is crucial. Olanzapine is an atypical antipsychotic used to treat schizophrenia and can have significant effects on the central nervous system, including sedation and potential cardiovascular effects.
- Monitoring Duration: After administering olanzapine IM, it’s essential to monitor the client for at least three hours. This is because the medication can cause sedation, dizziness, or changes in vital signs, which may require prompt intervention. During this period, the nurse should assess the client’s mental status, level of sedation, and any signs of adverse reactions, such as extrapyramidal symptoms or tachycardia.
- Injection Site Consideration: While the deltoid muscle is commonly used for IM injections, it is not always the preferred site for antipsychotic medications due to the potential for higher vascularization and subsequent rapid absorption. Some providers may prefer the ventrogluteal or vastus lateralis muscles for this class of medications. However, the choice of the injection site alone does not negate the importance of monitoring.
- Hallucinations and Medication Administration: The statement about withholding the medication if the client reports hallucinations (Option C) is misleading. Olanzapine is specifically used to address symptoms of schizophrenia, including hallucinations. While a nurse must always evaluate the severity of the symptoms before administration, the presence of hallucinations does not necessarily warrant withholding the medication.
- Sleep Disturbances: Olanzapine can lead to sedation, which may actually help clients sleep rather than cause insomnia. Therefore, instructing clients to expect difficulty sleeping (Option D) would be inaccurate.
In conclusion, monitoring the client post-injection is critical to ensure safety and efficacy. This includes observing for any adverse effects, ensuring the client remains stable, and providing interventions as necessary based on their response to the medication.