The nurse is assisting in the care of a client in 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. Oxygen saturation: 98% on room air is normal and does not require immediate reporting. B. Heart rate (121/min): This is tachycardia, which may indicate acute intoxication, stimulant overdose, or cardiovascular instability. The combination of tachycardia and hypertension (BP 190/88 mm Hg) is potentially life-threatening and requires immediate reporting. C. Orientation: The client is oriented to person only, which indicates significant cognitive impairment, possibly from acute intoxication or drug effects. This acute change in mental status is an urgent safety concern and must be reported. D. Medical history: The client’s medical history is reportedly unremarkable; nothing urgent is indicated from this information. E. Respiratory rate: 20/min is within normal adult limits (12–20/min). F. Pupils: Pupils are dilated, which is consistent with recent substance use (likely stimulants). While noteworthy, this is expected in the context and not immediately life-threatening unless accompanied by other critical findings.