[Solved]: The nurse is assisting with the care of a client on…

The nurse is assisting with the care of a client on the mental health unit. History and Physical Day 1, 0700: Client is admitted to mental health unit following evaluation in the emergency department. Client history includes cannabis use for 8 years, nicotine use for 10 years, history of hypertension, history of recurrent sexual abuse during teenage years, diagnosis of schizophrenia 6 years ago. Client was brought to the emergency department this morning for wandering up and down the highway with only undergarments on, screaming they are chasing me, “Go, go, away, leave me alone. I see them everywhere. They have the police following my every move.” “They took my car, prison, bars, four walls, confinement, locks, cuffs, chains, police, badges, orange.” Question 1 of 6 The nurse should recognize which of the following findings require immediate follow-up by the nurse? Blood pressure Sleep disturbance Hallucinations Reports of substance use