The patient was admitted to the critical care unit following a fall from a balcony. Emergency responders were unable to adequately ventilate the patient until arrival at the emergency department. The patient has been unresponsive since the fall and is now receiving mechanical ventilation and continuous intracranial pressure monitoring. The nurse assesses for signs of which complications in this patient? Select all that apply.

The patient is brought to the emergency department after a motorcycle accident which resulted in head trauma. The nurse observes a hematoma and bruising around the mastoid bone. Which term does the nurse use to document the finding?

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?