The nurse is assessing the skin of a patient who uses a wheelchair for mobility. The nurse notes an area over the patient’s left ischium that is shiny and pinkish-red with a serous exudate. The area measures 5 cm x 4 cm and depth of the wound is insignificant. Which of the following terms is the most appropriate for the nurse to use when documenting this finding?

The patient’s father is observed pressing the patient’s patient-controlled analgesia (PCA) pump while the patient is asleep. The nurse attempts to arouse the patient, who only opens the eyes after being pinched. Once aroused, the patient is able to raise the hand upon request. When asked what the year is, the patient responds with the previous year. The nurse reports the patient’s condition to the provider with which number on the Glasgow Coma Scale? Enter your response using a whole number.

The patient presents to the emergency department after having a metal beam fall on his head at a work site. He was wearing a helmet which broke with the impact. He was unconscious at the scene but is awake now, and his initial assessment is completely benign. Which finding upon reassessment 30 minutes later is most concerning?