A nurse is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as complete?

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.

A. Weak femoral pulses. Coarctation of the aorta is a congenital narrowing of the aorta, which leads to reduced blood flow to the lower extremities, resulting in weak or absent femoral pulses—a hallmark finding of this condition.
B. Increased intracranial pressure. This is not directly associated with coarctation of the aorta. While severe hypertension can lead to neurologic symptoms, increased ICP is not a typical or early finding.
C. Upper extremity hypotension. The condition causes hypertension in the upper extremities and hypotension in the lower extremities due to the location of the narrowing. Upper extremity hypotension would be an unexpected finding.
D. Frequent nosebleeds. While nosebleeds may occur in older children or adults with uncontrolled hypertension, they are not an expected finding in infants with coarctation of the aorta.