A nurse is caring for a client. Exhibits The nurse is assessing the client. Select the 4 findings that require immediate follow-up.

A. Hallucinations: The client appears to be responding to unseen stimuli, indicating auditory hallucinations. This psychotic feature requires immediate follow-up due to risks of harm to self or others. B. Hygiene: Although the client is unclean, poor hygiene is a common and non-urgent symptom during manic episodes. It does not require immediate intervention compared to issues with psychosis, dehydration, or cardiovascular stability. C. Heart rate: The client’s heart rate is 120/min, which is tachycardia (normal range: 60–100/min). This may reflect dehydration, overstimulation, or a manic state and requires urgent assessment. D. Skin turgor: Poor skin turgor suggests dehydration, possibly from inadequate intake during mania. Dehydration can worsen cognitive status and vital signs and must be addressed quickly. E. Sleep pattern: The client has not slept in 2 days, which is dangerous in manic states. Severe sleep deprivation increases the risk for psychosis, agitation, and physical exhaustion, requiring prompt intervention.