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
Acute Stress Disorder (ASD) is a mental health condition that can occur in the immediate aftermath of a traumatic event, with symptoms starting within four weeks of the event and lasting for a minimum of three days and up to one month. This client’s statement about experiencing nightmares following a car crash two weeks ago aligns with the diagnosis of ASD.
Nightmares are a common symptom of ASD, often replaying the traumatic event, leading to disrupted sleep and increased distress.
Choice B rationale
This statement is more indicative of Post-Traumatic Stress Disorder (PTSD), a related but distinct condition from ASD. PTSD is characterized by persistent and intrusive memories of the traumatic event, which can include flashbacks, and symptoms must last for more than a month and cause significant distress or functional impairment. The chronic nature of the symptoms described by the client, including frequent flashbacks since childhood, is more consistent with PTSD than ASD.
Choice C rationale
This statement could suggest a condition known as Specific Phobia, Situational Type. This is a type of anxiety disorder characterized by an intense, persistent fear of certain situations. The individual will avoid the situation or endure it with intense fear or anxiety. In this case, the client’s inability to drive following a car crash two years ago could indicate a specific phobia related to driving.
Choice D rationale
The experience described by the client in this statement is indicative of a dissociative symptom, which can be a feature of several different mental health disorders, including but not limited to Dissociative Disorders and PTSD1. The feeling of leaving one’s body is referred to as depersonalization, a type of dissociation that can occur as a response to trauma. However, without more information, it is difficult to align this statement with a specific diag
Correct Answer is A
Explanation
Choice A rationale
The cortico-striato-thalamo-cortical circuit (CSTC) of the brain is associated with feelings of fear. Anxiety disorders are characterized by an overactivation of this circuit, leading to excessive fear responses14.
Choice B rationale
The amygdala-centered (ACC) circuit of the brain is not typically associated with feelings of apprehension. The ACC is more commonly associated with processing emotions and fear learning14.
Choice C rationale
The cortico-striato-thalamo-cortical circuit (CSTC) of the brain is not specifically associated with phobias. While this circuit plays a role in fear responses, it is not specific to phobic responses14.
Choice D rationale
The amygdala-centered (ACC) circuit of the brain is associated with feelings of panic. However, it is not the only brain circuit involved in anxiety. Other circuits, including the CSTC, also play important roles14.
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