A nurse in the emergency department (ED) is caring for an adolescent. Exhibits Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Nurses' Notes 2 weeks ago, 1000: 16-year-old adolescent is brought to the emergency department (ED) due to a sudden onset of fever, headache, and reports of sensitivity to light. Guardian reports adolescent is refusing to eat or drink due to nausea. Adolescent is lethargic and drowsy, arouses with verbal stimuli, but is irritable when aroused. Pupils equal, round, reactive to light, and accommodation (PERRLA). Hand grasps and pedal pulls and pushes are strong and equal bilaterally. Mucus membranes are dry and pink. Skin is very warm and dry to touch. Capillary refill is 2 seconds. Photophobia is present. Client reports headache pain as 10 on a scale of 0 to 10. Resists flexion of the neck. Cervical lymph nodes are without edema or tenderness. Breath sounds are clear and equal. Abdomen is soft, flat, bowel sounds are heard in all quadrants. Has small pinpoint purpuric rash bilaterally on lower extremities.