A nurse is assisting with the care of client in a clinic. Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.

A. Blood pressure 122/80 mm Hg: This blood pressure reading is within normal limits for an adolescent and does not suggest acute physiologic instability. It does not indicate an urgent medical or psychological complication requiring immediate intervention. B. Attends school regularly: Continued school attendance and academic performance suggest preserved daily functioning and adaptive coping in at least one domain. While not excluding psychological distress, this finding alone does not signal immediate risk. C. Client experiences nightmares: Recurrent nightmares following exposure to a traumatic event are a core symptom of acute stress disorder and post-traumatic stress disorder. Sleep disturbance reflects intrusive trauma-related recollections and can worsen anxiety, emotional regulation, and daytime functioning. This finding requires prompt mental health evaluation. D. Heart rate 99/min: A heart rate of 99/min is at the upper end of normal for a stressed adolescent and can be explained by anxiety during a clinic visit. It does not independently suggest acute medical or psychiatric instability. E. Startles easily during thunderstorm: The client reports a longstanding fear of thunderstorms, suggesting this response may not be new or trauma-related. While hyperarousal is a PTSD feature, this finding is less concerning given the client’s stated baseline fear. F. Friend reporting client is not themselves: A noticeable change in behavior or affect reported by a peer is a significant red flag for emotional distress. External observations often identify functional or personality changes the client may minimize and warrants immediate psychosocial assessment. G. Smoking marijuana to clear their mind: Substance use as a coping mechanism following trauma increases the risk of dependency, impaired emotional processing, and worsening mental health outcomes. In adolescents, marijuana use can also negatively affect neurodevelopment and judgment. This requires prompt intervention and counseling. H. Witnessing the death of their parents and sibling: Direct exposure to the violent death of immediate family members is a severe traumatic stressor. This level of trauma places the client at high risk for acute stress disorder, PTSD, depression, and complicated grief. Immediate mental health follow-up is essential.