The patient who has severely elevated intracranial pressure following a traumatic brain injury is intubated, sedated, and chemically paralyzed. Which intervention does the nurse include in the plan of care?

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 nurse witnesses a 19-year-old collapse while playing soccer. The individual is arousable but confused and irritable. The skin is warm, dry, and flushed. Which actions are most helpful? Select all that apply.