[Answered]: NURSING ASSESSMENT & NOTES04/18 0205Pain: 3/10…

NURSING ASSESSMENT & NOTES04/18 0205Pain: 3/10 headache PERRLA: 3 mm bilaterally, react briskly to light Glasgow Coma Scale: 15 Alertness: Drowsy, easy to arouse Emotion: Calm, cooperative with exam. Level of Orientation: Oriented to person, place, and situation. Unsure of time/day. Speech: Clear Facial Symmetry: Symmetrical. Tongue midline Motor strength Bilateral Upper Extremities: 5/5 Motor strength Bilateral Lower Extremities: 5/5 Balance: Normal and baseline per girlfriend.04/18 0210Nursing Note: Client resting on stretcher. Client’s girlfriend at bedside. Girlfriend states she is worried about the client. She reports he sleeps very little, falling asleep around midnight and waking up at 5 am to exercise. He studies until 11 pm each night. She also states he had a cold for the past three days, which contributed to a lower-than-average test score one day ago. She states she thinks the client is under a lot of stress. Question 1 Before answering this question, review the client’s health information in the EHR. Identify the findings that cause the nurse to be concerned. Select all that apply. Question 1Answer Speech Pulse Oximetry Level of Orientation Pain Glasgow Coma Scale Respiratory Rate Alertness Blood Pressure Temperature Pulse