A nurse in a long-term care facility notices two residents arguing in the day room over a game they are playing. Which of the following interventions should the nurse use first?
Ask both clients to take a time out in their separate rooms.
Distract the clients by asking them to park.
Send both clients into seclusion.
Physically restrain both clients.
The Correct Answer is B
Choice A rationale
Asking both clients to take a time out in their separate rooms may not be the best first intervention. This approach might not address the root cause of the argument and could potentially escalate the situation if one or both of the residents feel unfairly treated.
Choice B rationale
Distracting the clients by asking them to participate in an activity is the most appropriate first intervention. This approach can help defuse the situation and redirect the residents’ attention away from the argument. It’s a non-confrontational way to de-escalate the situation and can help maintain a peaceful environment in the facility.
Choice C rationale
Sending both clients into seclusion is not an appropriate first intervention. Seclusion should be used as a last resort and only when the residents pose a risk to themselves or others. In this case, the argument does not seem to have escalated to a level that would warrant such a drastic measure.
Choice D rationale
Physically restraining both clients is not an appropriate first intervention. Restraints should only be used as a last resort when there is an immediate risk of harm to the residents or others. In this case, the argument does not seem to have escalated to a level that would warrant physical restraint.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The client must be calm and cooperative. This is the most important criterion for removing physical restraints. Restraints are used to prevent patients from causing harm to themselves or others. Once the patient is calm and cooperative, it indicates that the risk of harm has decreased. The goal is always to use the least restrictive measures and to remove restraints as soon as possible.
Choice B rationale
The provider who prescribed the restraints must be present to assess the client before the restraints can be removed. This is not necessarily true. While a provider’s order is required to initiate restraints, the decision to remove them can often be made by the nurse based on their assessment of the patient.
Choice C rationale
The client must verbalize remorse for their behavior. This is not a requirement for removing restraints. The primary concern is the safety of the patient and others, not whether the patient expresses remorse.
Choice D rationale
The client only verbalizes anger toward the staff. If the client is still expressing anger, it may not be safe to remove the restraints. However, verbalizing anger alone is not a sufficient reason to keep a patient in restraints.
Correct Answer is B
Explanation
Choice A rationale
While it’s important for a child to be taken to the hospital if they develop difficulty breathing, this is more of a tertiary prevention strategy, as it involves managing the symptoms of an existing disease.
Choice B rationale
Testing the child to determine the cause of their illness is a form of secondary prevention. By identifying whether the child has SARS-CoV-2, appropriate measures can be taken to treat the illness and prevent further spread.
Choice C rationale
Immunization is a form of primary prevention, as it aims to prevent the disease from occurring in the first place.
Choice D rationale
Wearing a mask can help prevent the spread of SARS-CoV-2, but it is more of a primary prevention strategy, as it aims to prevent exposure to the virus.
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