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

A. Heart rate: A heart rate of 120/min is tachycardic and may indicate physiological stress, dehydration, or other medical complications. Immediate follow-up is necessary to assess underlying causes and prevent further cardiovascular compromise. B. Hallucinations: The client is responding to unseen stimuli, which suggests possible psychosis or severe mania. Hallucinations pose a safety risk to the client and others and require urgent psychiatric and medical evaluation. C. Sleep pattern: The client has not slept for 2 days, indicating severe sleep deprivation. Sleep loss can exacerbate agitation, impair judgment, and increase the risk of medical and psychiatric complications, making prompt intervention essential. D. Skin turgor: Poor skin turgor indicates dehydration, which can lead to electrolyte imbalances, hypotension, and other acute complications. Immediate follow-up is needed to initiate fluid replacement and prevent further physiological deterioration. E. Hygiene: Unclean hair and clothing reflect self-care deficits, but while important for overall well-being, hygiene issues do not require immediate intervention compared with vital signs, safety, and acute physiological concerns.