The nurse is caring for a 79-year-old female client who was…

The nurse is caring for a 79-year-old female client who was brought to the emergency department from a long-term care facility after complaining of lightheadedness and weakness. Use the chart to answer the questions. The chart may update as the scenario progresses. The nurse has completed the client’s history of presenting illness. Which cue is of greatest concern? Select all that apply.