A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (Select all that apply.)

A. Discuss the client's preferences for determining a repositioning schedule. While it's important to consider the client's comfort, repositioning must follow clinical guidelines (typically every 2 hours) to prevent pressure injuries, especially in clients with limited mobility post-stroke.
B. Raise the side rails on both sides of the client's bed during repositioning. Raising both side rails can be considered a form of restraint if not medically justified. Only one rail should be raised for safety and support unless otherwise indicated by facility policy.
C. Reposition the client without the use of assistive devices. Repositioning a client post-stroke without proper equipment increases the risk of injury to both the client and the nurse. Assistive devices promote safety and proper body mechanics.
D. Evaluate the client's ability to help with repositioning. This is the first and most important step. Assessing the client’s physical capability and level of consciousness ensures that the nurse uses the appropriate technique and equipment for safe repositioning.

A. Heart rate. The client has a heart rate of 120/min, which is tachycardia and may indicate dehydration, mania-related hyperactivity, or a response to poor nutritional status. This requires immediate follow-up to assess for cardiovascular strain or fluid imbalance.
B.Sleep deprivation (has not slept for 2 days) can exacerbate mania, contribute to delirium, and impair judgment. This requires prompt intervention to ensure safety and stabilization.

C. Hallucinations. The client is responding to internal stimuli, indicating active psychosis, which poses a safety risk to the client and others. Hallucinations require immediate intervention to stabilize mental health and prevent harm.
D. Skin turgor. Poor skin turgor suggests dehydration, which is a priority physiological concern, especially when paired with tachycardia and failure to recall last food intake. This finding indicates the need for fluid and electrolyte evaluation and possible replacement.
E. Poor hygiene is important for overall care but is not an immediate threat to the client’s safety or physiological stability. It can be addressed after urgent medical and psychiatric concerns are managed.