A school age client is brought to the emergency department after a fall from playground equipment. The client reports head pain of a level 7 on a 0 to 10 scale and has a tender area on the head, Which assessment finding would prompt the nurse to seek immediate intervention by the health care provider?
a. The sclera of the client's eyes is showing over the top of the iris
b. A palpable jump is forming at the site of tenderness on the client's head.
c. The client states feeling a sense of nausea and a possibility of vomiting
d. The client is unable to remember a brief period of time after the fall occurred.