You are performing your shift assessment of your patient. You find his mental status, level of consciousness, speech, and orientation are intact and at baseline. Your patient tells you he is very anxious. What would you do next?

Question

A) Assess oxygen levels
B) Give anti-anxiety medications
C) Notify the physician
D) Make a social services consult

Answer 1

Ans: A
Feedback: The nurse assesses the patient's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Anti-anxiety medications are not given until the cause of the anxiety is known. The physician is only notified if the reason for the anxiety is serious or if an order for medication is needed. A social services consult is inappropriate at this time.