a 12-year-old child has had a traumatic head injury from playing in a football game. he is admitted to the emergency department and transferred to the pediatric intensive care unit. he has an iv of dextrose 5% in water at 21 ml/h and nasal oxygen at 2 l/min. the nurse is assessing the child at the beginning of the shift (2300 hours) and reviews the accompanying glasgow coma scale flow sheet. the nurse notes that the child responds to pain, is making incomprehensible sounds, and has abnormal flexion of the limbs. what should the nurse do first?