A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?

A.The client's weight has remained relatively stable (83.9 kg to 83 kg), which does not indicate an immediate health concern compared to the acute behavioral and mental health symptoms observed.

B. While the client's neurostatus (mental status) is affected by the presence of auditory hallucinations, pressured speech, and restlessness, these symptoms are more critical in terms of immediate management than a general assessment of neurologic status.

C. Auditory hallucinations, such as appearing to listen to unseen others, are concerning symptoms indicating possible exacerbation of schizophrenia or medication non-compliance. Immediate assessment and intervention by mental health professionals are needed.

D.Pressured speechis commonly seen in mania or anxiety.Poverty of speechcan be associated with shyness, depression, schizophrenia, or cognitive impairment. Pressured speech noted along with other symptoms can indicate agitation or worsening of mental health symptoms. It suggests the client may be experiencing an acute phase of their illness, requiring evaluation and possibly adjustment of medications.

E. Restlessness, frequently getting out of the chair, and appearing tired and disheveled indicate agitation and potential agitation or anxiety. This could be a sign of increased agitation, anxiety, or distress, which needs immediate attention to prevent escalation.

A. Intellectual impairment

- The correct answer is ID.

- Intellectual impairment is a core feature of ID, which is characterized by significant limitations in intellectual functioning and adaptive behavior that are present before age 18.

- Intellectual impairment can sometimes be a feature of ADHD, but it's not a defining characteristic. ADHD, or Attention Deficit Hyperactivity Disorder, primarily involves difficulties with attention, hyperactivity, and impulsivity. However, some individuals with ADHD may also experience challenges with certain aspects of cognitive function, such as executive function, working memory, and processing speed. These difficulties can sometimes be mistaken for intellectual impairment, but it's important to note that ADHD itself does not necessarily indicate lower intelligence. ADHD is a neurodevelopmental disorder that affects individuals differently, and many people with ADHD have average or above-average intelligence..

B. Losing necessary things

- The correct answer is ADHD.

- Losing necessary things is a common symptom of ADHD, especially in the inattentive subtype. Children with ADHD may have difficulty organizing their belongings, remembering where they put them, or keeping track of them.

- Losing necessary things is not a specific indicator of ID, although children with ID may also have difficulties with memory and organization.

C. Impaired language skills

- The correct answer is ID.

- Impaired language skills are often associated with ID, as language development depends on cognitive abilities and social interactions. Children with ID may have delays or difficulties in acquiring, understanding, or using spoken or written language.

- Impaired language skills are not a typical feature of ADHD, although some children with ADHD may have coexisting language disorders or learning disabilities.

D. Hyperreactivity to sensory input

- The correct answer is ADHD.

- Hyperreactivity to sensory input is a possible manifestation of ADHD, especially in the hyperactive-impulsive subtype. Children with ADHD may be easily distracted by external stimuli, such as noises, lights, or movements, or may seek sensory stimulation by fidgeting, touching, or moving around.

- Hyperreactivity to sensory input is not a characteristic of ID, although some children with ID may also have sensory processing issues or autism spectrum disorder.

E. Interrupting others

- The correct answer is ADHD.

- Interrupting others is another common sign of ADHD, especially in the hyperactive-impulsive subtype. Children with ADHD may have difficulty waiting their turn, following social rules, or respecting others' boundaries. They may blurt out answers, comments, or questions without thinking or listening.

- Interrupting others is not a typical behavior of children with ID, although some children with ID may also have social skill deficits or communication problems.