The nurse on the clinical unit is assigned to four patients. Which patient should she assess first?

• A. Patient with a skull fracture whose nose is bleeding
• B. Elderly patient with a stroke who is confused and whose daughter is present
• C. A patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0 to 10 scale
• D. A patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

Answer: (C)

The most important concept here is recognizing signs of acute neurological deterioration due to rising intracranial pressure. In meningitis, cerebral edema can cause ICP to climb rapidly, and sudden changes in a patient’s mental status paired with a severe headache are red flags for potential brain compromise. A patient who becomes acutely agitated and reports a 10/10 headache may be tipping toward increased ICP and possible herniation, so this person needs immediate neuro assessment to check level of consciousness, pupil reactivity, and vital signs, and to initiate urgent management if deterioration is confirmed.

The other scenarios also require attention, but they don’t currently show the same abrupt neuro change. A skull fracture with nasal bleeding could involve airway or fracture-related issues, but without signs of acute cerebral decline it isn’t the top priority. An elderly stroke patient who is confused, though needing careful observation, is not demonstrating a sudden deterioration. A craniotomy patient three days post-op with continued vomiting could indicate raised ICP, but the abrupt change in the meningitis patient is the most urgent clue that prompt assessment is warranted first.