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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Minimizing contact with a patient who is angry can create a barrier in the nurse-patient relationship. It’s important for nurses to address the patient’s anger and work through it rather than avoid it.
Choice B rationale
While it’s crucial to explain the importance of treatments, language barriers can make this difficult. The nurse should use a translator or other resources to ensure the patient fully understands.
Choice C rationale
Using clinical terminology can confuse patients who are not familiar with medical jargon. It’s better to use simple, understandable language.
Choice D rationale
Fulfilling promises builds trust and rapport. By allowing a patient to visit with family members, the nurse shows they are reliable and trustworthy.
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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