The nurse is caring for a 58-year-old client who was admitted to the medical unit with liver cirrhosis. Highlight three findings that require immediate follow up. History and Physical The client is a 58-year-old admitted to the medical unit with a known history of liver cirrhosis secondary to chronic alcohol use. Client reports progressive abdominal swelling over the past several weeks associated with increasing fatigue, early satiety, and generalized weakness. Client reports pruritus that has worsened over the past week and intermittent shortness of breath when lying flat. Family reports increasing confusion at home over the past 2 days, including difficulty concentrating and forgetfulness. On assessment, the client is alert and oriented x3 but appears fatigued. Scleral icterus and generalized jaundice are noted. Abdomen is markedly distended with positive fluid wave consistent with ascites. Lower extremity edema is present. Breath sounds are diminished at the bases with shallow respirations. Skin is dry with scratch marks noted from itching. Nurses' Notes 0920: Client admitted to the medical unit yesterday for severe ascites. Sitting in bed. Alert and oriented x 3 (person, place, situation). No adventitious breath sounds but shallow respirations. S1 and S2 present; no murmurs. Bowel sounds present x 4 but distant. Abdomen very distended due to ascites. Can move all extremities but reports weakness. Cap refill <3 sec. Skin dry with jaundice; icterus present. Reports frequent pruritis. VS: T 99.2°F (37.3°C); HR 96 BPM; RR 24 bpm; B/P 98/58 mmHg; SpO2 94% on 4 L/min 02 via NC.