The patient is brought to the emergency department (ED) after hitting their head during a fall. The patient does not arouse when their name is called, but opens the eyes and attempts to remove the hand that is pinching him. Once aroused, the patient responds with, “Bubble,” when asked what year it is. The nurse records the patient’s mental status using the Glasgow Coma Scale as which number? Enter your response using a whole number.

The patient suddenly begins slurring. The nurse assesses the patient for additional symptoms of which condition?

The nurse is changing the dressing of a patient with a stage IV pressure injury. Upon removal of the gauze dressing, the nurse notes the wound bed appears dry. The wound bed is clear of slough or eschar. The nurse cleans and measures the wound. Which of the following is the best wound care strategy for this patient?