Practice Quiz

CNOR Operating Room Nursing

Category - Emergencies

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Following surgery, a patient with no previous mental health problems is experiencing hallucinations, trying to crawl out of bed, and is threatening the nurse. Which of the following actions is most appropriate in this situation?
  1. Contact psychiatric services to admit the patient to the mental health unit.
  2. Notify the house supervisor about the need for patient restraints.
  3. Contact the physician for an order for restraints.
  4. Isolate the patient, remove potentially harmful objects, and continue to try and calm the patient.
Explanation
Answer: D-The nurse in this situation should isolate the patient, remove potentially harmful objects, and continue to try and calm the patient. Postoperative psychosis may occur due to decreased oxygenation or fluid and electrolyte imbalances. Depending on the patient’s health history, continued orientation may be necessary while the patient continues to recover. Patient restraints may not be beneficial and should only be used when other measures to help have failed.
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