A nurse who works in the medical-surgical unit is taking care of a patient who has become psychotic while overcoming the effects of anesthesia. Which of the following situations would warrant a call to the psychiatric team for assistance with this patient? Select all that apply.

 

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Correct

- The patient is crying

- The patient is practicing self-mutilation

- The patient’s behavior is escalating toward violence

- The patient is very anxious

- The patient is unable to care for himself

Rationale

A nurse may care for a patient who is suffering from emotional or psychological disturbances but that can be managed with traditional nursing interventions. There are times, though, when a nurse may need to call for further help from the psychiatric team. The nurse would need to call in cases where the patient is hurting himself or others or is unable to care for himself.

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