A Patient Is Self-Admitted to a Mental Health Facility for "Problems

A patient is self-admitted to a mental health facility for "problems related to military service." The nurse is collecting information for the patient's plan of care. Which behavior will prompt the nurse to immediately notify the RN or HCP?

A) Patient adamantly denies thoughts of suicide or self-harm.
B) Patient displays hypervigilant behavior and has hand tremors.
C) Patient begins to shout and cry in response to the nurse's questions.
D) Patient refuses to participate in activities with other patients in the unit.