A nurse is assisting in the admission of a client to an inpatient mental health facility. The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the charge nurse immediately? Select all that apply.

A. Medical history: While limited medical history may affect care planning, the lack of other medical conditions does not pose an immediate safety concern and does not require urgent reporting. B. Heart rate: A heart rate of 121/min indicates tachycardia, which, in the context of recent substance injection and agitation, may signal acute toxicity or cardiovascular stress. This finding requires immediate attention and reporting to the charge nurse. C. Respiratory rate: A respiratory rate of 20/min is within normal limits for an adult and does not indicate immediate compromise. While monitoring is necessary, it does not require urgent reporting. D. Pupils: Dilated pupils can indicate recent stimulant use or other substance effects, suggesting acute intoxication. This finding may correlate with life-threatening complications and should be reported immediately for safety and intervention planning. E. Oxygen saturation: Oxygen saturation of 98% on room air is within normal limits and does not indicate hypoxia, so it is not an urgent concern in this context. F. Orientation: The client is oriented only to person, indicating confusion or impaired cognitive function, possibly due to intoxication or withdrawal. This acute change in mental status is a safety concern and should be reported immediately.