The nurse has reviewed the Nurses’ Note entry from Day 1 at 1444. Click to highlight the 4 assessment

The nurse has reviewed the Nurses’ Note entry from Day 1 at 1444. Click to highlight the 4 assessment findings that require immediate follow-up by the nurse. 1444: 43-year-old male client presents in the Emergency Department via Emergency Medical Services (EMS) after being found sleeping on a park bench in full sun with diarrhea-soiled clothing. EMS states the client was agitated and reported nausea and shivering. Per EMS, the client is a known homeless veteran with posttraumatic stress disorder (PTSD) who is frequently found in the park under the influence of alcohol. Upon questioning, the client denies recent alcohol consumption, and states he has taken escitalopram “for a long time” and was recently prescribed fluoxetine. Nursing assessment reveals client is alert and oriented. Client has pupil dilation and lower extremity muscle stiffness. Clear lung sounds in all lung fields. Pulse regular +2. Client appears diaphoretic with flushed skin and chills. Vital Signs: heart rate (HR) 118 beats per minute, blood pressure (BP) 164/96 mmHg, respiratory rate (RR) 24 preaths per minute, oxygen saturation (SpOz) 95% on room air, by mouth (PO) temperature 101.3°F (38.5°C).