A 51-year-old male client who sustained a closed head injury was brought to the emergency department (ED) this morning by emergency medical services (EMS). The client was accompanied by his wife who reported that he fell from a ladder while trying to clean the gutters on their house. On arrival to the hospital, the client was alert and responding appropriately to questions wearing a neck collar that was applied by first responders for neck stabilization. Vital signs: temperature = 98.7°F (37°C), apical heart rate = 78 beats/min and regular, respirations = 18 breaths/min, blood pressure (BP) = 126/78 mm Hg. Oxygen saturation is 95% (on room air [RA]). The client reported a mild headache of 3/10 on a 0 to 10 pain intensity scale. Cardiac monitor reading revealed normal sinus rhythm. The client denied nausea or vomiting. Glasgow Coma Scale score = 15 ; PERRLA. In addition to routine lab work, a computed tomography (CT) scan of the brain, and cervical and spinal x-rays were performed. The CT scan of the brain showed regions of hypodensity. Two hours later, the client was transferred to the acute neurological unit. The unit admission assessment was the same as the baseline assessment in the ED. The client was placed on bedrest with the head of the bed elevated, and a lunch tray was requested.

The nurse performs a neurological check on the client about an hour after lunch. Vital signs: temperature = 98.8°F (37.1°C), apical heart rate = 60 beats/min and regular, respirations = 16 breaths/min blood pressure (BP) = 142/68 mm Hg. Oxygen saturation is 92% (on RA). The client reports a headache of 5/10 on a 0 to 10 pain intensity scale and has a new onset of nausea. Glasgow Coma Scale score = 12. The client seems sleepy and confused as to where he is, but he responds to localized painful stimuli and opens his eyes in response to sound. Slight pupil dilation is noted in the right eye.

List the client findings that are of immediate concern to the nurse.