A nurse working in a community health center is speaking with a client who has a serious mental illness. The client states that they are unable to find employment and they do not understand why. Which of the following questions should the nurse ask? (Select all that apply.)

Rationale:

A. Increased respiratory rate is a common finding in fluid overload due to pulmonary congestion and edema, which can affect breathing.

B. Increased temperature is not directly associated with fluid overload; it is more indicative of an infection or inflammatory process.

C. Increased heart rate can occur as the heart compensates for the increased blood volume and stress on the cardiovascular system.

D. Increased blood pressure is a typical response to fluid overload due to the higher volume of circulating blood.

E. Increased hematocrit is usually not associated with fluid overload; instead, it is often increased in conditions of dehydration or hemoconcentration.

Rationale:

A. Reviewing the client's history and reading progress notes are important for understanding the client's situation but are secondary to ensuring the nurse's readiness.

B. Reviewing current provider prescriptions is relevant but does not address the immediate need for self-preparation.

C. Performing self-reflection is essential to ensure that the nurse is emotionally prepared and empathetic, which is crucial when dealing with clients experiencing significant grief.

D. Performing self-reflection is the most critical first step as it ensures the nurse is emotionally prepared and able to provide empathetic and non-judgmental support to the client during a difficult time.