Answer to Question 1
B
When patients are inappropriate and intrusive on the unit, the nurse will want to protect the patient (who will probably be embarrassed when his or her thinking clears), other inpatients, and self. The most therapeutic intervention is one that distracts the patient and enlists cooperation for a time-out before escalation of the behavior occurs. As the patient's mental status clears, the nurse's sensitivity to the patient will foster trust in the therapeutic relationship.
Answer to Question 2
A, B, D
The patient is using denial, admits to anxiety, and has self-doubts. These would be appropriate targets for intervention.
The tone of the nurse-patient introduction sets the stage for the patient interview and patient care
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